Case Report

Foreign Body ( Coin ) in Esophagus

Presentator :
dr. Muhammad Pringgo Arifianto

Moderator :
dr. Ashadi Prasetyo., M.Sc., Sp.T.H.T.K.L

Otorhinolaryngology Head and Neck Surgery Departement

Medical, Public Health and Nursing Faculty of Universitas Gadjah Mada
Dr. Sardjito Hospital Yogyakarta
2018
INTRODUCTION
Foreign bodies can enter to the
nose, ears, throat and esophagus. Foreign
Body in the esophagus is a common
problem in children and adults. Typically,
two types of foreign bodies are
encountered: true foreign bodies (eg,
buttons, coins, pieces of balloon) and
Based on research conducted at THT-KL
RSUP Prof. Dr. R. D. Kandou Manado
during period January 2010-December
2014, obtained that prevalence 52 patients
had diagnose with esophageal foreign
bodies during period. The most common
esophageal foreign bodies in all patient
was dentures with 25 cases (48.1%) and
coins become the second most common
foreign bodies in 18 cases (34.6%).food-
related foreign bodies.1
Ingestion of true foreign bodies
generally occurs in persons less than 40
years old, with the vast majority being
children. Foreign bodies in the oesophagus
are a common occurrence in children
because of their innate curiosity, habitual
insertion of objects into their mouths while
playing and speaking, and the lack of
posterior dentition. In Addition,
coordinating of the swallowing process
and laryngeal sphincter is not mature at the
age of 6 months - 1 year. In the older age
group, the most common foreign body
found is a denture, because of the
decreased sensation of the oral cavity in
denture wearers, a gradual loss of
sensation and poor motor control of the
laryngopharynx.2
Foreign body in the esophagus can
cause a dangerous situation, such as
blockage and pressure to the airway.
Foreign body obstruction symptoms
depend on the location of foreign objects,
the degree of blockage, the nature, shape
and size of the foreign body. In principle,
foreign bodies in the esophagus and the
airway should be immediately evacuated
in the safest conditions and with a
minimum trauma.3
Anatomically normal esophageal
had 4 stricture points, the first stricture is
as high as the vertebral cervikal VI
(approximately 16 cm from the incisors
ginggiva), due to musculus cricofaringeus
(who are always in tonus constriction,
except when the food bolus through
stimulating); the second is as high as
thoracic vertebra IV (approximately 23 cm
from superior incisors ginggiva ) where
there is a cross between the esophagus and
the aortic arch; the third is as high as v.
thoracal V (approximately 27 cm from
superior incisors) where there are crossing
the esophagus with the left main bronchus;
the fourth is as high as v.thoracal X where
the esophagus squeezed by the crura of the
diaphragm who works as sphincter.4
Esophageal foreign body is any
object, either a bolus of food or a corrosive
agent were ingested, intentionally or not
which may cause injury to the esofagus.
Esophageal foreign body can also mean a
sharp object or a dull or foods that are
caught and lodged in the esophagus
because swallowed, intentionally or not
intentionally.4
In children the symptoms may
include inability to swallow food. Child
becomes fussy, refusing to eat or vomit
after a while being swallowed. Older
people almost always know when they
ingest foreign bodies because as soon as
possible they must feel the partial or total
blockage, often times they can show where
the sick. The early symptom is pain in the
neck when a foreign object lodged the
cervical area. When caught at distal
esofagus, the patient will fell discomfort at
the substernal area. Other symptoms
include odinofagia (pain when swallowing
food), vomiting, and hypersalivation.
Foreign object who lodged in
esophagus is often as high as
krikofaringeus. This is the enter way of the
esophagus just below and behind the
larynx. If a foreign object stuck here
patients will complain of uncomforted
sense.4,5
The longer the foreign
remains in the esophagus, the greater the
incidence of respiratory symptoms. Cough,
fever, and congestion are often interpreted
as upper respiratory infections, and stridor
mimics croup. An esophageal foreign body
can cause these respiratory symptoms by
three mechanisms. Cough or stridor
occurring soon after ingestion of an
esophageal foreign body probably results
from direct pressure on the trachea by the
foreign body itself or by secondary
esophageal dilatation.2,3,4
The diagnosis can be established
from the history, both alloanamnesis and
autoanamnesis, physical examination and
additional examination. A simple physical
examination can be done using a head
lamps and a laryng mirror. The additional
examination were usually done is X-ray
photo (cervical and thoracal plain photo
with posteroanterior and lateral positions).
Endoscopy can be performed for
diagnostic and therapeutic purposes. If
foreign objects are not visible by x-ray
plain photo examination, the examination
can be done by adding barium (barium
the
swallow). Barium can envelop foreign
m.
materials and the barriers flow can show
the place where the foreign body.
However, the provision of barium should
be avoided because of enveloping the
esophageal wall, so that will complicate
esofagoskopi.4,5
body
Treatment for foreign bodies in the
esophagus must be performed quickly.
Sharp foreign bodies should be careful in
evacuated because it can make an
esophageal perforation. Foreign objects
that make total obstruction
esophagus should be addressed
immidiately because it can suppress the
respiratory tract, and causing shortness of
breath. The ways of foreign
evacuation in the esophagus can be done
by: esophagoscopy rigid
esophagoscopy flexible tool, catheter and
fluoroscopi folley tool.6,7
CASE REPORT
A 4-year-old man was taken by
her parents to the emergency department
of Dr. Sardjito hospital with a swallow of
coins.
Approximately 2 hours prior to a
hospital patient's mother complained that
the child swallowed a coin.
complaints occur when patients watch TV
with sleeping position and biting 100
rupiah coin. When patient was sleep, the
coin in the patient's mouth was swallowed.
After the coin swallowed, the patient was
coughing and complaining that any object
caught in his throat and pain swallow.
Patients were still can drink, no vomiting,
no tightness, no complaints in the ears and
the nose.
From the examination found that
the general condition were compos mentis
and sufficient nutrition impression. The
vital signs were : Heart Rate: 90x / minute,
Respiration : 24x / minute, Temperature:
36,6 'C. On the physical examination of
in the both ears, canalis akusticus eksternus
within normal limits, tympanic membrane
was intact with cone of light (+).
Examination of anterior rhinoscopy within
body normal limits and posterior rhinoscopy
difficult to assess (the child does not
tool, cooperate ) . Oropharynx examination
within normal limits. Indirect
laryngoscopy examination difficult to
assess ( the child does not cooperate ).
Neck examination within normal limit and
there was no enlargement of lymph nodes.
In the X-ray photos of Cervical and
Thorax PA / Lateral impression, seems a
coins foreign body as high as the thoracal
vertebrae I-II.
These
Patient was diagnosed as coin
foreign body in esophagus. In this patient
have been conducted esophagoscopy and
evacuation of coin foreign bodies in the
esophagus. After esophagoscopy patient
hospitalized one day for observation. After
five days, patient control to ENT with no
complain. We have to educate the parents
to pay more attention to their children
away from the objects that possibily put
into their body.
The problem that will be discussed
in this case report is the choice of therapy
for foreign bodies in the eshopagus.
DISCUSSION
 Treatment of coin foreign bodies in
the esophageal should be done as soon as
possible, although there are no emergency
state. A sharp foreign body should be
taken as soon as possible, while the form
of food can be observed in advance to
allow the esophagus peristaltik. Rigid
esophagoscopy with general anesthesia is
an act of choice for cases of foreign bodies
in esofagus. The aim of evacuation in case
of a foreign body in esophagus is to avoid
complications, which are common
complications that can occur include: the
formation of granulation tissue, mucosal
erosions, esophageal perforation, tracheo-
oesophageal fistula, and mediastinitis.4,6
Many alternative methods
removal of foreign bodies have been
described , such as dislodgement by a
Foley catheter, advancement with bougie,
papain or carbonated fluid treatment,
glucagon therapy, balloon extraction
during fluoroscopy, removal-using
magnet. These are all blind methods of
extraction providing no control of the
foreign body. They can only be used for
blunt foreign bodies of short duration and
with no preexisting esophageal disease.
Their major disadvantage is that if
pathology is present it cannot be assessed.
In addition, any failure of the above
methods still requires rigid
esophagoscopy.6,7
Esophagoscopy rigid is the
traditional method to retrieve foreign
bodies in the hypopharynx and esophagus.
But there are limitations, especially in the
patients with abnormalities in the cervical
vertebrae. The advantage is: seeing clearly,
it can be to take a large foreign object
enough, because it can go through a fairly
large instrument and the view is not
obstructed by secretions if there is
bleeding. Esophagoscopy flexible can be
done when there are limitations of using
esophagoscopy rigid, it can be done by
administering sedation, but can not be used
to retrieve a large foreign bodies, and the
view will be disrupted if there is bleeding
or discharge even it little enough. The use
for
of fluoroscopy folley chateter needs to
consider the various terms as follows: a)
the patient is cooperative, b) a foreign
body is not sharp and not penetrated by x-
ray translucent, c) a foreign body is not
more than 3 days and no more than one, d)
esophagus obstruction is not totally, e)
fluoroscopy facilities are available, f) there
is an expert endoscopy because of the risk
of perforation with the use of this tool is
higher than both the tool above.4,6,7
Sharp esophageal foreign bodies,
such as needles, pins, and hairclips can
perforate the esophagus and lead to
pneumomediastinum, and must also be
removed urgently. Also, smooth foreign
bodies such as coins may become sagitally
oriented and can encroach on the trachea, morbidity rates. Flexible endoscope will be
causing biphasic stridor and requiring more affordable because it is performed on
urgent removal . Patients with retained an outpatient basis, without general
esophageal coins, whether symptomatic or anesthesia, but, when sharp or penetrating
asymptomatic, should undergo immediate foreign bodies are present, rigid
removal.8 esophagoscopy is required. Rigid
endoscopy has the larger lumen and allows
The risk of perforation to be higher
removal of the most objects under direct
in children who had swallowed coins more
vision without withdrawn the endoscope.
than 3 days prior to admission. Impacted
Therefore, we have preferred rigid
esophageal foreign bodies can easily cause
esophagoscope for removal of foreign
mucosal ulceration, esophageal stricture,
bodies.7,8,9
mediastinitis, lung abscess and can also
result in various fatal complications such Surgical treatment must be
as aorticoesophageal fistula.3,4,8 performed in cases of irretrievable foreign
body or esophageal rupture. The surgical
Endoscopy has been the mainstay
approaches may be cervicotomy,
of management of esophageal foreign
thoracotomy or gastrostomy according to
bodies. Additionally rigid esophagoscopy
the location of the foreign body. The
can assist to remove by causing esophageal
esophageal perforation should be sutured
dilatation. Endoscopy does pose its own
in two layers. Although recently
risks of complications, including
encouraging results were reported about
pharyngeal bleeding, bronchospasm,
the sealing of esophageal perforations by
accidental extubation, stridor, hypoxia,
insertion of endoluminal prosthesis.
esophageal perforation and mediastinitis.
surgical repair of esophageal perforations
Therefore, endoscopist should be skilled.
is still considered the treatment of choice.8
Additionally, endotracheal anesthesia
should be used to provide an adequate CONCLUSION
airway and to minimize the incidence of Have been reported, patient, male,
aspiration during the procedure. Muscle 4 year old, who have been diagnosed as
relaxation induced by anesthesia may also coin foreign body in esophagus. The
assist to remove the object.4,7,9 patient have been done esophagoscopy and
evacuation of the foreign body. After five
Rigid and fiberoptic
days, patient control to ENT with no
esophagoscopy have similar success and
complain.
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