A. Epidemiology
- Typically children under 4 years of age
- Reflects natural curiosity of children of this age
- Affects thousands of children every year
- Boys slightly higher incidence than girls
B. Common Objects
- Coins
- Food
- Small metal and plastic toys
- Buttons
- Bones
- Batteries
- Sharps: Pins, safety pins, or thumbtacks
- Wood
- Glass
C. Signs and Symptoms
- Dysphagia
- Drooling
- Vomiting
- Anorexia
- Cough
- Choking, cyanosis
- Wheezing
- Hemoptysis
- Upper respiratory infection or pneumonia
- Cervical or chest pain
- Fever
D. Anatomical Location of Foreign Body
- Proximal esophagus
- Level of cricopharyngeal muscle and thoracic inlet
- Most common location
- Coins oriented in transverse position (widest opening in esophagus)
- Middle esophagus: level of carina and aortic arch
- Distal esophagus: proximal to the gastro-esophageal junction
- Level of pre-existing esophageal stricture from pre-existing condition
E. Diagnostic evaluation
- Obtain chest radiograph
- Repeat film if time has passed since initial evaluation
- Consider esophagraphy to rule-out radiolucent foreign body
F. Removing Foreign Body (objects which don't spontaneously pass)
- Rigid or flexible esophagoscopy
- Balloon catheter extraction under radiologic guidance
- Bougienage
- Awaiting spontaneous passage
- Object must be in distal esophagus with ingestion less than 24 hours ago
- Parents must watch for passage of object in stool
- Invasive removal required if not successful
- Sharp Objects
- Must be removed from esophagus but can be allowed to pass spontaneously once in stomach
- Best technique is direct visualization with rigid or flexible esophagoscope
- Rigid scope allows for removal of the object in protective sheath
- Batteries
- Must be removed from stomach due to corrosive effects of acid environment
- May be followed into intestine with radiographs every 2-3 days to monitor progress
- Abdominal pain may be a reason for surgical exploration
G. Esophagoscopy
- Rigid or flexible
- Most common invasive technique used
- Allows direct visualization
- Variety of types and sizes of extraction tools can be used
- Nearly 100% success but expensive procedure
- Technique
- Child put under general anesthesia
- Neck placed in the sniffing position
- Esophascope introduced through endotracheal tube
- Foreign body visualized with telescope
- Grasper introduced through sheath
- After grabbing object, sheath telescope, and grabber are removed together
- Reintroduction of telescope will assess residual damage to the esophagus
- Flexible esophagoscopy can be done with sedation for objects in:
- Lower esophagus
- Stomach
- Duodenum
H. Balloon Catheter Extraction
- Performed under radiologic guidance
- Lower cost removal method without need for general anesthesia
- No direct esophagus visualization
- Technique
- Child calmed without sedation (allows for airway protection)
- Child put in oblique prone position
- Under flouroscopic guidance, catheter is passed through the nose or mouth
- Inserted to beyond the foreign body
- Balloon inflated with contrast material to the width of the esophagus
- Catheter gently withdrawn bringing foreign body along
- The foreign body is removed through the mouth (McGill forceps may be required)
- Esophagraphy recommended after difficult or bloody extractions
- Alternately can push object into stomach with balloon catheter
I. Bougienage
- Pushing of foreign body into stomach using a bougienage
- Not commonly used
- Effective only for witnessed ingestions of smooth objects
- Only used within 24 hours of ingestion
- Procedure performed while child is in the emergency department
- Technique
- Unsedated child sits upright
- Well-lubricated bougie dilator is passed through the mouth
- Foreign body is pushed into the stomach
- Position is reconfirmed using Chest X-ray
- Parents watch for spontaneous passage in the stool
K. Complications
- Problems arise from foreign body or method used to remove them
- Overall rate is less than 2%
- Persistently lodged foreign bodies, sharp objects or batteries cause the most problems
- Types of injury
- erosion or perforation of the esophagus
- Tracheal compression
- Mediastinitis
- Esophageal-tracheal or esophageal-vascular fistulas
- Extraluminal migration of foreign body
- False esophageal diverticulum
H. References
References
- Bergreen BJ, et. al. 1993. Gastrointestinal Endoscopy. 39:626

- McGahren ED. 1999. Pediatrics in Review. 20:(4):129
