Ingested foreign bodies (FBs) account for many emergency department visits, and most pass through the gastrointestinal (GI) tract spontaneously. However, in children with prior GI tract surgeries (ie, tracheoesophageal fistula or esophageal strictures), FBs may be dislodged and may require surgical intervention. Small children tend to ingest shiny objects, mainly coins (pennies are the most frequently ingested, followed by quarters, dimes, and nickels), beads, button batteries, toys, or small parts of toys. Most FBs are usually blunt or smooth objects. Adolescents usually ingest FBs other than coins, may eat too fast and have food bolus impaction or suffer from esophageal abnormality, neurologic or psychological disorder, and have intentional ingestion of FBs (ie, pencils, nails, or razors). Patients typically present with drooling, excessive salivation, voice changes, vomiting, or respiratory symptoms.
Figure 15.1 ▪ Drooling as a Presenting Sign of an Esophageal Foreign Body (FB).
An afebrile child presented with a sudden onset of drooling and inability to eat solid foods. There was no witnessed episode of choking, gagging or any FB ingestion. An esophageal FB was suspected based on the history and subsequently confirmed (see Figure 15.2C). Drooling is a very common and consistent sign seen with a high-grade esophageal obstruction. (Photo contributor: Binita R. Shah, MD.)
Emergency Department Treatment and Disposition
Hand-held metal detectors can be used to identify the location of metallic FBs, single radiograph of neck, chest, and abdomen can help locate radio-opaque FBs. Obtain anteroposterior and lateral chest radiographs if the FB is above the diaphragm to determine if it is in the trachea or esophagus and whether there is more than one FB (eg, 2 or more coins stacked together). If the FB is suspected to be radiolucent and perforation is NOT a concern, contrast esophagram may be useful. Consider CT scan with coronal and sagittal reconstructions if FB is thought to have migrated to the extraluminal space, or perforation or fistulas are suspected (see Fig. 15.18). Objects lodged in the proximal esophagus may threaten the airway and should be removed promptly. Use endoscopy to emergently remove FB if it poses a risk of corrosive injury (ie, button battery) or risk of perforation (ie, sharp objects such as open safety pin or razor blades). Prompt endoscopic evaluation is also necessary (even if the radiographs are unrevealing) in symptomatic patients (eg, respiratory distress or difficulty managing secretions). Rigid endoscopy with forceps extraction under general anesthesia is the standard method for removal of objects that may be sharp or are embedded in the mucosa as well as objects that may have been in place for a prolonged period or for patients with previous esophageal disease or GI surgeries. This method provides a controlled setting with airway management and direct visualization of the esophagus (ie, mucosal injury or esophageal pathology). Flexible fiberoptic endoscopy, extraction by Foley ...