Guru Ram Dass Institute of Medical Sciences, & Research, Amritsar. Abstract. Although foreign bodies in aerodigestive tract are quite common in children, but ...
An Unusual Impacted Foreign Body Oesophagus in an Infant Karan Sharma, Senior Lecturer, K. K. Duggal, Professor & Head, Department of E.N.T., Govt, Medical College, Amritsar, H. P. S. Miglani, Consultant Paediatric Surgeon, Guru Ram Dass Institute of Medical Sciences, & Research, Amritsar. Abstract
Although foreign bodies in aerodigestive tract are quite common in children, but presence of an impacted, sharp foreign body which needed removal by trans-cervical oesophagotomy is quite rare and is thus being reported. F o r e i g n bodies in the upper aerodigestive tract are quite common in all age groups and commonly being coins in children, fish bones in adults and dentures in old age. Sharp, penetrating or impacted foreign bodies are quite difficult to manage and their removal should always be attempted under general anaesthesia, so as the edges can be rotated safely or advanced into the end of rigid endoscope and then withdrawn. An experienced endoscopist is required, who after making one attempt may recommend surgical removal because of an obvious risk of perforation or that of an additional perforation being created by overzealous attempt at endoscopical removal of the object. IJO & HNS, August 1999 (SpecialNumber, EB.)
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An Anusual Impacted Foreign Body Oesophagus in an Infant-Karan Sharma et al Case Report
Five months old infant with very poor socioeconomic status was brought to the E.N.T. out patient department of Government Medical College, Amritsar with the complaint of swallowing a foreign body i.e. Fastener of the Zip and thereafter oral feeding had reduced with occasional regurgitation and vomiting. Parents waited for about 36 hours at home with the hope that it might pass out through naturalis before they reported to us. On examination, no pathology was seen in Ears, Nose, throat or larynx. X-ray soft tissue Neck (A.E and Lateral view) revealed a flat radio-opaque shadow in the midline, at the level of C6and 7 with broad end superiorly and anchor like chain with two hooks lying inferiorly (Fig. 1 and 2). Diagnosis ofmetaUic sharp foreign body in the lower hypopharynx and adjoining upper end of the oesophagus was made and under general Anaesthesia, rigid fibroptic endoscopy was done. Foreign body was subsphincteric contrary to radiological diagnosis (probably because of extension of neck during X-rays). The visible upper part offorei~ body was
Fig. 1. Showing the EB. (AP view) 78
grasped with the F.B. forceps and gentle manipulation by rotation, pull or downward push could not dislodge the foreign body. It was established to be fixed with the possiblility that the sharp prongs at its lower end might be penetrating the oesophagus and forceful retrieval may result in perforation. Following day, again under general anaesthesia, Transcervical oesophagotomy through a right lower transverse cervical skin crease incision was performed. After making the opening in the oesophagus, the foreign body was grasped at its broad end but still it was not possible to retrieve it as the distal hooks were obstructing its removal (Fig. 3). Incision in the oesophagus was extended by another 7-8 mm and only then it could be freed all around and removed (Fig. 4). Nasogastric tube inserted, the opening in the oesophagus repaired with 4-0 Vicryl single layer sutures and the wound was closed in layers after putting a drain. Post operative period was closely monitored for any salivary leaks etc. and was uneventful. The drain
Fig. 2 Showing the EB. (Lateral view)
IJO & HNS, August 1999 (Special Number, EB.)
An Anusual Impacted Foretgn Body Oesophagus in an Infant-Karan Sharma et al
was removed after 72 hours had patient was discharged from the hospital after five days. No complaints were observed during follow up. Discussion
Although patients of all ages are susceptible to ingestion of foreign bodies but majority of them are in the paediatric age group (Webb 1988). The youngest patient of fish bone foreign body was 2 months old infant (Tung et al 1990). Fortunately, most common foreign bodies seen in young children are smooth like coins but presence of penetrating,
foreign body are high and includes pharyngeal or oesophageal perforation, localized or retropharyngeal abscess, mediastinitis and fatal oesophagoaortic fistula. The sharp foreign bodies especially large ones are probably best removed surgically and not endoscopically. Furthermore a foreign body more than 2.5 cm in diameter and 5 cms in length will probably not pass through gastrointestinal tract and should be removed endoscopically, of course, it should not be extremely sharp (Paparella et al 1991). Peroforation as a result of elusive foreign bodies are reported to occur in approximately 1 out 100 cases whereas its incidence is t per 3000 after instrumentation
Fig 3.Showing the distal hook obstructing its retrteval.
Fig. 4 Showing the EB. ariel"removal
sharp foreign body especially in an infant is really a challengeable task and requires a very meticulous and cautious approach. In the present case, it was really astonishing that how such an asymmetrical and quite a big foreign body with hooks was ingested by an infant of 5 months age.
(Remsen et al 1983). The incidence of perforation with flexible fibrescope is less than that of rigid oesophagoscope (01sen, 1982).
It is apparent that incidence of a penetrating foreign body in upper aerodigestive tract places a patient at significant risk of life threatening complications. The longer the foreign body is left, more likely the perforation is going to occur and more difficult is it to remove. Risks of unattended sharp, impacted
The inference is that the management of large, sharp or penetrating foreign bodies need a very careful evaluation for its management. Such foreign bodies are not a good first case and best be left to an experienced endoscopist. Furthermore, even most experienced endoscopist had also to be very cautious in dealing them and should not hesitate for their removal surgically i.e. transcervical or transthoracic oesophagotomy.
References 1. 2. 3. 4. 5.
Olsen, A.M. (1982) : Esophagoseopy : An update. Ann. OtoL RhinoL Laryngol. 91 : 551 - 557, Paparella, M. M.; Shumrick, D. A.; Gluckman, A.I. and Meyerhoff, H.L. (1991) : Otolaryngology 9pg. 2412, VoL 3, Edition 3rd, W.B. Saunders Company, Philadelphia. Remsen, K., Biller. H.E; Lawson,W. and Som, M.L. (1983) : Unusual presentation of penetrating foreign bodies of upper aerodigestive tract. Ann. OtoL RhinoL LaryngoL 105 : 32 - 44 Tung,M. C. E; Sham, C.L. and Hasselt, C.A. U (1995) : Ingestecd Foreign bodies - a contemporary management approach. J.L.O., 109 : 965 - 970, Webb, W.A. (1988) : Management of foreign bodies of the upper gastro-intestinal tract. Gastroenterology, 94 : 204 - 216. IJO & HNS, August 1999 (Special Number, EB.)
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