We present two interesting case reports of open safety pins, one with open sharp end pointed up and the other pointed down. The age of the patients is extremes.
Case Report
Open Safety pin in upper digestive tract - Report of two rare cases Dr. Saumik Saha*, Dr. Sandipan Naskar**, Dr. Neha Singh***, Dr. Agniva Basu****, Dr. Atish Haldar*****, Dr. Ranjan Paul******
Introduction : Sharp foreign bodies in the oesophagus especially open safety pins pose a real challenge to otolaryngologists because of its potential of perforation. There are different techniques described for removal of open safety pins with pointed edge facing up - rotating it in the stomach1, engaging the pointed edge into the scope and withdrawing it2, or closing it in the lumen of oesophagus3, but all these techniques require experience. Rigid scope is preferred for removal of sharp and penetrating foreign bodies4.The sharp ends of the foreign body or entire foreign body itself can be introduced into the lumen of rigid endoscope and removed without any risk of lacerating the mucosa during extraction. No such 5 protection is possible with flexible endoscope . Case Report : We present two interesting case reports of open safety pins, one with open sharp end pointed up and the other pointed down. The age of the patients is extremes of age-one year, the other 65 year old. We followed the second method in both the cases. Case report -1 : A 65 year old woman presented with accidental impaction of open safety pin in the oesophagus while trying to clear her teeth after lunch after five days. Radiological examination showed it to be impacted opposite T-1 vertebra. She was complaining of pain during deglutition. Vitals were stable, chest was clear. Emergency oesophagoscopy was planned under GA the safety pin was found to be impacted about 18 cm from the central incisors. The sharp end was grasped ,whole of the pin was
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taken inside the oesophagoscope and the safety pin removed no esophageal mucosa injury was noted Ryle’s tube introduced and kept for three days post -operative recovery was uneventful. Case report - 2 : A one and a half year male child ingested an open safety pin while playing and presented with pain in throat after ingestion of an unknown foreign body as his parents could not give any proper history regarding the type of foreign body however the baby had excessive salivation. On radiological examination it was found to be an open safety pin in oesophagus with the open sharp end facing upwards opposite to the T-6 vertebra. Chest was clear bilaterally with adequate air entry and vitals being stable. Emergency oesophagoscopy was planned under GA. The sharp end being impregnated inside the oesophageal mucosa could not be visualized. Ryles tube was introduced and kept for 2 days. The postoperative recovery was uneventful. Discussion : Foreign body ingestion is common in children, but frequently seen among adults also. Foreign body is ingested accidentally but occassionally homicidal or suicidal. Most common foreign bodies in children are coins9, but marbles, button, batteries, safety pins and bottle tops are also reported. In adults common foreign bodies are bones, dentures and metallic wires6. Foreign bodies which have gone beyond the oesophagus will pass uneventfully through intestinal tract in70-80% cases7. The level at which progress is impeded are cricopharynx, pylorus, duodenum, duodenojejunal flexure etc 8 , Radiological localization is mandatory for decision making regarding the removal. Smooth foreign bodies do not pose much threat but may cause airway obstruction11.
Senior Resident, 1st Year PGT 2nd Year PGT 3rdYear PGT Assistant Professor Professor & HOD Dept. of ENT, Calcutta National Medical College, Kolkata
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Sharp foreign bodies, if not retrieved at the earliest may penetrate oesophageal wall and cause complications. So, aggressive approach is required for sharp foreign bodies like, chicken bone, safety pin, fish bones. The best method of removing impacted foreign body remain 15 controversial . Rigid endoscopic removal of foreign body is safe and effective, but often requires GA10. Technological advances have allowed us to master the techniques of foreign body removal, but still complications do occur. Pulmonary complications are most common, followed by retropharyngeal abscess and local infectious complications16. Complications rate of 12.6% in adults and 4.6 %in children has been reported14, pulmonary complications being the most common in children and retropharyngeal abscess in adults12 . Retropharyngeal abscess in adults is commonly due to sharp foreign bodies like fish bone13. Conclusion : Sharp foreign bodies specially open safety pins in oesophagus are dangerous as oesophageal rupture may occur during it's removal. In our two cases the open sharp ends of the safety pins were in opposite direction and also the two cases were in extreme of ages. Yet could remove the safety pins safely by taking the sharp end of the safety pins inside the rigid oesophagoscope before removal. Thus this is an effective method of removing open safety pins in our set up where sophisticated instruments are unavailable. References 1. Sanowski RA. Foreign body extraction in the gastrointestinal tract. In: Gastroenterological endoscopy, ed. Sivak MV., W.B. Saunders Co: Philadelphia; 1987. p. 321-31. 2. Webb WA, McDaniel L, Jone L. Foreign bodies of the upper gastrointestinal tract: Current management. South Med J 1984;77:1083- 6. 3. Hawkins D. Removal of blunt foreign bodies from the esophagus. Ann OtolRhinolLaryngol 1990;99:935-40.
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4. Hamilton JK, Polter DE. Gastrointestinal foreign bodies. In: Gastrointestinal disease: Pathophysiology, Diagnosis and Management, editors. Sleisenger MH, Fordtran JS. W.B. Saunders Co: Philadelphia; 1993. p. 286-92. 5. Marcon NE. Overtubes and foreign bodies. Can J Gastroenterol 1990;4:599-602. 6. Giordano A, Adams G, Boies L, Meyerhoff W. Current management of esophageal foreign bodies. Arch Otolaryngol 1981;107:249-51. 7. Tibbling L, Stenquist M. Foreign bodies in the esophagus. A study of causative factors. Dysphagia 1991;6:224-7. 8. Campbell JB, Condon VR. Catheter removal of blunt esophageal foreign bodies in children: Survey of the Society for pediatric radiology. Pediatr Radiol 1989;19:361-5. 9. Bonadio WA, Jona JZ, Glicklich M, Cohen R. Esophageal bouginage technique for coin ingestion in children. J PediatrSurg 1988;23:917-8. Foreign bodies in upper digestive tract. 10. Nixon GW. Foley catheter method of esophageal foreign body removal: Extension of applications. Am J Radiol 1979;132:441-2. 11. Ferrucci JT, Long JA. Radiologic treatment of esophageal food impaction using intravenous glucagons. Radiology 1977;125:25-8. 12. Sawant P, Nanivadekar SA, Dave UR, Kanakia RR, Satarkar RP, Bhatia RS, et al. Endoscopic removal of impacted foreign bodies. Indian J Pediatr 1994;61:197-9. 13. Holinger LD. Management of sharp and penetrating foreign bodies of the upper aerodigestive tract. Ann OtolRhinolLaryngol 1990;99:684- 8. 14. Vyas K, Sawant P, Rathi P, Das HS, Borse N. Foreign bodies in gut. JAPI 2000;48:394-6. 15. Singh B, GadyHar EL, Kantu M, Lucente FE. Complications associated with 327 foreign bodies of the pharynx, larynx and esophagus. Ann OtolRhinolLaryngol 1997;106:301-4. 16. Nandi P, Ong GB. Foreign body in the esophagus: Review of 2,394 cases. Br J Surg 1978;65:5-9.
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