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. mechanisms. Cough or stridor occurring
Esophageal foreign body can also mean a soon after ingestion of an esophageal
sharp object or a dull or foods that are foreign body probably results from direct
caught and lodged in the esophagus because pressure on the trachea by the foreign body
swallowed, intentionally or not itself or by secondary esophageal
intentionally.4 dilatation.2,3,4
In children the symptoms may
The diagnosis can be established
include inability to swallow food. Child
from the history, both alloanamnesis and
becomes fussy, refusing to eat or vomit
autoanamnesis, physical examination and
after a while being swallowed. Older people
additional examination. A simple physical
almost always know when they ingest
examination can be done using a head
foreign bodies because as soon as possible
lamps and a laryng mirror. The additional
they must feel the partial or total blockage,
examination were usually done is X-ray
often times they can show where the sick.
photo (cervical and thoracal plain photo
The early symptom is pain in the neck when
with posteroanterior and lateral positions).
a foreign object lodged the cervical area.
Endoscopy can be performed for diagnostic
When caught at distal esofagus, the patient
and therapeutic purposes. If foreign objects
will fell discomfort at the substernal area.
are not visible by x-ray plain photo
Other symptoms include odinofagia (pain
examination, the examination can be done
when swallowing food), vomiting, and
by adding barium (barium swallow).
hypersalivation. Foreign object who lodged
Barium can envelop foreign materials and
in the esophagus is often as high as m.
the barriers flow can show the place where
krikofaringeus. This is the enter way of the
the foreign body. However, the provision of
esophagus just below and behind the
barium should be avoided because of
larynx. If a foreign object stuck here
enveloping the esophageal wall, so that will
patients will complain of uncomforted
complicate esofagoskopi.4,5
sense.4,5
Treatment for foreign bodies in the
The longer the foreign body remains
esophagus must be performed quickly.
in the esophagus, the greater the incidence
Sharp foreign bodies should be careful in
of respiratory symptoms. Cough, fever, and
evacuated because it can make an
congestion are often interpreted as upper
esophageal perforation. Foreign objects that
respiratory infections, and stridor mimics
make total obstruction in the esophagus
croup. An esophageal foreign body can
should be addressed immidiately because it
cause these respiratory symptoms by three
can suppress the respiratory tract, and
causing shortness of breath. The ways of
foreign body evacuation in the esophagus
can be done by: esophagoscopy rigid tool,
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. These
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
both ears, canalis akusticus eksternus
within normal limits, tympanic membrane
was intact with cone of light (+).
Examination of anterior rhinoscopy within
normal limits and posterior rhinoscopy
difficult to assess (the child does not
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.
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
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
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
of fluoroscopy folley chateter needs to
for
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)
during
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
the oriented and can encroach on the trachea,
causing biphasic stridor and requiring
urgent removal . Patients with retained
esophageal coins, whether symptomatic or
asymptomatic, should undergo immediate present, rigid esophagoscopy is required.
removal.8 Rigid endoscopy has the larger lumen and
allows removal of the most objects under
The risk of perforation to be higher
direct vision without withdrawn the
in children who had swallowed coins more
endoscope. Therefore, we have preferred
than 3 days prior to admission. Impacted
rigid esophagoscope for removal of foreign
esophageal foreign bodies can easily cause
bodies.7,8,9
mucosal ulceration, esophageal stricture,
mediastinitis, lung abscess and can also Surgical treatment must be
result in various fatal complications such as performed in cases of irretrievable foreign
aorticoesophageal fistula.3,4,8 body or esophageal rupture. The surgical
approaches may be cervicotomy,
Endoscopy has been the mainstay of
thoracotomy or gastrostomy according to
management of esophageal foreign bodies.
the location of the foreign body. The
Additionally rigid esophagoscopy can
esophageal perforation should be sutured in
assist to remove by causing esophageal
two layers. Although recently encouraging
dilatation. Endoscopy does pose its own
results were reported about the sealing of
risks of complications, including
esophageal perforations by insertion of
pharyngeal bleeding, bronchospasm,
endoluminal prosthesis. surgical repair of
accidental extubation, stridor, hypoxia,
esophageal perforations is still considered
esophageal perforation and mediastinitis.
the treatment of choice.8
Therefore, endoscopist should be skilled.
Additionally, endotracheal anesthesia CONCLUSION
should be used to provide an adequate Have been reported, patient, male, 4
airway and to minimize the incidence of year old, who have been diagnosed as coin
aspiration during the procedure. Muscle foreign body in esophagus. The patient
relaxation induced by anesthesia may also have been done esophagoscopy and
assist to remove the object.4,7,9 evacuation of the foreign body. After five
days, patient control to ENT with no
Rigid and fiberoptic esophagoscopy
complain.
have similar success and morbidity rates.
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