919

Esophageal Children:
Complications

Foreign
Diagnosis,

Bodies
Treatment,

in
and

.,-.

:
:

#{149}

Rodemick

I. Macphemsoni Jeanne G. Hill H. Biemann Othersen2 Edward P. Tagge2 Charles D. Smith2

OBJECTIVE. We performed this study to identify the role of radiology in the diagnosis, treatment, and complications of esophageal foreign bodies in children. MATERIALS AND METHODS. We retrospectively reviewed the charts and radiographs of 123 esophageal foreign bodies seen In 118 children at the Medical University of South Carolina from May 1980 through May I 995. RESULTS. Most foreign bodies were coins in the upper esophagus (69%) In Infants less than 2 years old (65%) for fewer than 24 hr (60%). The presenting symptoms varied, with 20% of patients asymptomatic. Respiratory symptoms that mimicked upper respiratory tract infections or croup proved misleading with long-standing foreign body retention. Preexisting esophageal disease was present in 17% of patients. The Foley catheter method of foreign body extraction was attempted in 53 cases (43%) and was successful without complications In 46 (87%). Esophagoscopy was attempted in 72 cases (58%) and was successful without complications in 66 (92%). Three patients had major complications: a fatal aortlcoesophageal fistula, an extraluminal migration of a coin, and a large esophageal diverticulum. Significant mucosal erosions were shown in six patients on radiologic studies after extraction. CONCLUSION. Early recognition and treatment of esophageal foreign bodies is
imperative because the complications are serious and can be life-threatening. Radiol-

ogy plays an important role in the initial diagnosis, in recognItion of complications, and in treatment. The Foley catheter method of foreign body extraction can be used on some patients, but esophagoscopy remains the safest method of esophageal foreign body extraction.
AJR

1996;166:91

9-924

Received September 28, 1995: revision November 13, 1995.

accepted

after

1 Section of Pediatric Radiology, The Medical University of South Carolina, 171 Ashley Ave., Charleston. SC 29425. Address correspondence to

Esophageal foreign bodies are a common and potentially serious cause of mombidity and mortality in children. The recognition and management of foreign body ingestions that are witnessed are generally not a problem. The clinical diagnosis of occult esophageal foreign bodies, however, can be difficult and the complications serious [1-3]. Traditionally, the diagnosis of a retained esophageal foreign body is established radiologically, and most are removed by esophagoscopy. In the late 19605, the Foley catheter technique of foreign body extraction was introduced [4, 5], and pediatric radiologists became involved in the treatment as well as the diagnosis of esophageal foreign bodies [6, 7]. Although this technique offers a fast, effective, and inexpensive alternative to esophagoscopy, some controvemsy exists about its safety [8].
In this paper, we discuss the clinical, madiologic, and surgical features ofthe 123

R. I. Macpherson.
2Section of Pediatric Surgery, The Medical University of South Carolina, Charleston, SC 29425.

0361 -803X196/1 664-919

American

Roentgen

Ray Society

episodes of retained esophageal foreign bodies that occurred in 118 children at the Medical University of South Carolina from May 1 980 through May i 995. This 15-year experience identifies many of the diagnostic difficulties, complications, and therapeutic pitfalls in treating esophageal foreign bodies. The mole of the Foley catheter technique in managing esophageal foreign bodies will also be discussed.

920

MACPHERSON

ET AL.

AJR:166,

April 1996

Materials

and

Methods the patient records and radiographs of ii8 children i 23 episodes of retained esophageal foreign bod1980 and May i 995. We tabulated and analyzed

36

We reviewed who experienced

ies between May

- Gastrointestinal
u::::Respiratory
#{149}Pain

the ages and sexes of the patients, the presenting symptoms and predisposing factors, the nature of the foreign bodies, sites in the esophagus, durations of retention, treatments, and complications. Seven cases were selected to illustrate certain diagnostic and therapeutic dilemmas we encountered in the series. Results

ElAsymptomatic

At the time offomeign body retention, the children ranged from 6 months to 17 years old. Eighty (65%) were infants between 6 months and 2 years old, 24 (20%) were between 2 and 5 years old, and 19 (15%) were more than 5 years old. Sixty-seven (54%) patients were male. At presentation, the foreign bodies had been in the esophagus fewer than 24 hr in 74 patients (60%), between 1 day and 1 week in 25 patients (20%), and from 1 week to 4 months in iO patients (8%). In 14 patients (11%), the duration was unknown. Twenty-one (17%) episodes had pmedisposing esophageal disease: postoperative esophageal atmesia (15 episodes in 12 patients), caustic stricture (four episodes in three patients), and postoperative fundoplication
(two episodes to the in two level patients). Eighty-five (69%) vertebra, of the foreign 26 (21%) in

I_I1oo
<24hrs I day to I wk

I wk to 4 mos compared

unknown

Fig. i .-Incidence
foreign body

of four major symptoms

with duration of

retention.

toms tions,

bodies
ryngeus

were lodged

in the upper
of the third

esophagus
thomacic

from the cricopha-

the mid esophagus, and 12 (10%) in the distal esophagus. Of the foreign bodies, 103 (84%) were not food: 85 (69%) were coins, 14 (11%) were other metallic foreign bodies, and 4 (3%) were nonopaque foreign bodies. Twenty (16%) of the foreign bodies were food, 15 (12%) nonopaque and 5 (4%) opaque. Table 1 summarizes the presenting symptoms and their incidences for all patients. When the major symptoms are compared with the interval between ingestion and clinical presentation (Fig. 1 ), we noted that gastrointestinal sympTABLE Foreign 1 . Presenting Bodies Symptom Asymptomatic Gastrointestinal Dysphagia Drooling
Vomiting

predominate in foreign body retentions for short durabut respiratory symptoms are more prevalent in longer retentions. For most asymptomatic patients, the foreign body ingestions had been witnessed and were short. Esophagoscopy was performed in 72 cases: as the primary treatment in 65 cases and the secondary treatment, following unsuccessful Foley extraction, in another seven. Esophagoscopy retrieved the foreign body without complication in 66 of the 72 procedures. In the remaining six, the foreign body passed spontaneously in three patients, two patients required surgery, and one who underwent unsuc cessful esophagoscopy at a referring hospital had a coin removed by Foley catheter in our institution. Foley catheter extraction, attempted in 53 episodes, was the primary treatment in 52 and secondary treatment in the case just mentioned. Foreign bodies were retrieved without clinical
complication in 46 of the 53 procedures, with the seven failures

Symptoms

in 123 Cases

of Esophageal

No. of Patients 25 57 31 i9
i7

Percentage 20 46 26 i6
i4

of Patients

undergoing esophagoscopy for successful extraction. Six esophagoscopies reported mucosal injuries, but only two were failed Foley extractions. An esophagograrn after the procedure was part of the protocol in the Foley catheter retrievals but not in the esophagoscopies. For three patients who had Foley catheter extractions and for one who had esophagoscopy after failed Foley retrieval, persistent esophageal defects were identified at the sites of the foreign bodes. Retention in these cases were 3 days, 5 days, and
unknown in the remaining two cases.

Gagging Anorexia
Respiratory

4 i
40

3 i
33

Cough Stridor Fever Congestion Wheezing Apnea Pneumonia Chest or neck pain Lethargy
Irritability Weight loss patients

25 i2 8 4 4 2 2 i3 2
2 1 had more than one presenting

2i iO 7 3 3 2 2 i i 2
2 i symptom.

Eight (7%) of the foreign bodies passed spontaneously. In five patients with documented coin retentions who were transferred from referring hospitals, two showed the coin in the stomach on chest madiogmaphs made after arrival at our
institution; in three, the esophagus was empty at esopha-

Note-Several

goscopy; and in the remaining three patients, the passage of a distal esophageal foreign body into the stomach after ingestion of peanut butter was witnessed at fluomoscopy. Three patients who ingested foreign bodies in the series had major complications. One child died from a safety pin that induced an aorticoesophageal fistula; a second had true and false esophageal diverticula caused by a retained tiddlywink; and the third had a retained coin that migrated through the esophageal wall to lodge between the trachea and esophagus.

AJR:166,

April 1996

ESOPHAGEAL

FOREIGN

BODIES

IN CHILDREN

92i

Discussion

Although retained esophageal foreign bodies are found throughout childhood, they are more common in infants (>2 years old). In our series, lateral views of the chest confirmed that the upper esophagus, particularly at the thomacic inlet, was
the most common site of retention. This differs from other

series of esophageal foreign bodies in which the cervical esophagus at the level of the cricopharyngeus was the most common location [9, iO]. Our series also confirmed that the most commonly retained esophageal foreign body in these infants and children were coins [9, 10] and that esophageal strictures, particularly those related to esophageal atmesia after surgery, were a common predisposing factor to recurrent esophageal foreign body retention in infants and children [ii]. Most of the foreign bodies were in the esophagus less than 24 hr before clinical presentation (Fig. 1). Virtually all of these episodes were witnessed by others. Many of these patients were asymptomatic at presentation. Most had gastrointestinal symptoms; respiratory symptoms and chest pain were frequent but less common.
In asymptomatic patients, diagnosis and treatment are usu-

and stridom mimics cmoup. An esophageal foreign body can cause these respiratory symptoms by three mechanisms. Cough or stmidom occurring soon after ingestion of an esophageal foreign body probably results from direct pressure on the trachea by the foreign body itself or by secondary esophageal dilatation (Fig. 2). With prolonged retention of the foreign body, associated pamaesophageal soft tissue can compromise the adjacent trachea and produce symptoms. An occult esophageal foreign body may not be suspected as the cause of these symptoms until it is shown on chest madiogmaphy or esophagogmaphy [1 3]. Complications of retained esophageal foreign bodies that are primarily related to perforation of the esophagus by the foreign body include mediastinitis with or without abscess [2, 9], esophagus-to-airway fistulas [1 13], esophagus-to-vascular fistulas [2, 9], extmalurninal migration of the foreign body [13-17], and false esophageal diverticula [18]. Prolonged retention with obstruction is the cause oftrue esophageal diverticula [19, 20]. The only fatality in our series occurred in an infant who exsanguinated through an aorticoesophageal fistula (Fig. 3) that was caused by an open safety pin failing to pass through the
, ,

esophagus.

Aorticoesophageal

fistulas

are uncommon

yet well-

ally straightforward. Because foreign bodies impacted in the upper or mid esophagus have little prospect of passing spontaneously, instrumentation should be pursued immediately [12].
Therefore, all patients with suspected foreign child body ingestions

documented complications that usually result from ingestion of sharp objects but that can also occur from erosion of the esophageal wall by blunt foreign bodies after prolonged retention [2].
Migration of a foreign body outside the esophagus into the

should

undergo

immediate
retention,

chest
even ifthe

radiography

or esophagogma-

phy to exclude

is asymptomatic.

As the time of retention relationship to symptoms diagnosis more difficult.

body ingestion is documented

of the foreign body increases, its can become obscure, making Frequently, the history of foreign
only in retrospect. The longer

the foreign body remains in the esophagus, incidence of respiratory symptoms. Cough,
gestion are often interpreted as upper

the greater the fever, and coninfections,

respiratory

mediastinum or the soft tissues of the neck is also an uncornmon but well-documented complication [1 3-i 7]. In this scenario, which could be called the buried treasure syndrome, a coin has a prolonged impaction in the esophagus, then penetrates the esophageal wall and migrates extraluminally, often between the esophagus and trachea. Although one of our patients who experienced this syndrome had dysphagia and weight loss, the usual presentation is one of unrelenting mespimatory symptoms that mimic an upper respiratory tract infection

Fig. 2.-Nonopaque, esophageal foreign body In 9month-old girl with esophageal atresla repair at birth who presented with acute stridor. Lateral esophagogram shows retained, nonopaque foreign body (prune pit) in stricture at site of esophageal atresla repair and tracheal compression (arrowhead) by dilated proxlmal esophagus. (Reprinted with permission from [23])

Fig. 3.-Aorticoesophageal

fistula

In i-year-old

boy with hematemesis. Radiograph of chest and abdomen shows massive left pleural fluid collection and open safety pin In lower abdomen (arrowhead).

Autopsy
massive

revealed

aorticoesophageal
from perforation

fistula
of aorta

and
by

left hemothorax

safety pin.

922

MACPHERSON

ET AL.

AJR:166, April 1996

or croup.

The

buried

coin

is identified

by chest

radiography

ciated

with

true

esophageal

diverticula

proximal

to the obstruc-

(Fig. 4A) but cannot be found at esophagoscopy. Esophagogmaphy (Fig. 4B) confirms the extraluminal location of a foreign body, and surgical extraction is curative. Esophageal diverticula are less common complications of prolonged retention of esophageal foreign bodies [18-20]. Another of our patients retained a tiddlywink in the esophagus, possibly for years, and developed a large true diverticulum
proximal (Fig. 5A) to the obstruction and that was seen on esophagogmaphy

tion. In a fourth patient, a retained tiddlywink was associated with marked symmetric esophageal dilatation, no true diverticulum, and a probable false diverticulum [20]. In this situation, true diverticula have been attributed to asymmetric dilatation of the
esophagus proximal to a long-standing obstruction [1 8, i 9].

been reported

CT (Fig. SB). Two strikingly similar [18, 19] in which impacted tiddlywinks

cases have were asso-

Conversely, false diverticula occur after a foreign body pemfomates the esophagus and a persistent communication develops between the esophagus and an associated encapsulated paraesophageal inflammatory process (Fig. 5). Because tiddlywinks are thin, coin-size, plastic disks with relatively sharp

Fig. 4.-Extraluminal migration of coin in 2year-old girl with 7-month history of dysphagla and weight loss. A, Lateral chest radiograph shows coin poetenor to trachea, but soft-tissue

rating

coin

from

trachea

contraindication to Foley Coin could not be seen with esophagoscopy. B, Lateral esophagogram shows coin

swelling sepa(arrowhead) was catheter extraction.

between esophagus and trachea with extravasation of contrast (arrowhead) around coin. At surgery, coin was found between trachea and esophagus.

Fig. 5.-Esophageal diverticula secondary to retained foreign body in 4-year-old girl with 4-month history of dysphagia and recurrent respiratory tract Infections. A, Lateral esophagogram shows large true diverticulum projecting posteriorly from proximal esophagus. Contrast media leaks from esophagus into soft-tissue mass between trachea (white arrowhead) and esophagus. Tiddlywink (black arrowhead) Is seen within false diverticulum. B, Axial CT scan of upper medlastinum shows true diverticulum (whiteanowhead) projecting posterior and to right. Tlddlywlnk(biackarrowhead) Is seen in false diverticulum, which extends anteriorand to left.

Fig. 6.-Foley

catheter

technique

for coin cx-

traction. Using sedation and guldewire, Foley catheter Is passed beyond Impacted coin. Balloon is inflated with water-soluble contrast and catheter is withdrawn. As coin is withdrawn into oropharynx, patient is placed face down In Trendelenbergs position to protect airway, and coin Is rapidly extracted from mouth.

AJR:166,

April 1996

ESOPHAGEAL

FOREIGN

BODIES

IN CHILDREN

923

Fig. 7.-Shallow esophageal erosion year-old boy with cough and congestion had coin in esophagus for uncertain Esophagogram following successful

In iwho time. Foley

catheter extraction fects (arrowheads) esophageal wall.

shows Irregular mucosal dowhere retained coin eroded

Fig. 8.-Deep esophageal erosion in 9-monthold boy with 3-day history of Irritability following wftnessed coin ingestion. Esophagogram, tel-

lowing successful Foley catheter extractIon, shows deep, rounded defect in proximal esophagus conforming to impacted coin.

edges,

they can cut through

the esophageal

wall faster than an

by haz-

actual coin plain chest

can and, being nonopaque, radiography. Parents should catheter in the to treat surgical coins

remain undetected be advised of the

Connems et al. [i2] noted that retained foreign bodies the upper and mid esophagus usually require some form
instrumentation, whereas those in the distal esophagus

in of
can

ard of these toys. Use of a Foley (Fig. 6) appeared tially, these catheters

esophageal foreign bodies literature in the i960s. Iniinto the stomach without [4]. Later,

pushed blind

pass spontaneously. In distal esophageal retentions, we have used a Foley catheter to push the foreign body into the stomach or have fed the patient peanut butter and watched it carry the foreign body into the stomach with fluoroscopy.
During our study, a child was ryngeal abscess that complicated referred to us with an esophagoscopy a metmophafor coin

the catheter
7]. One guidance showed author

was used to extract

suggested a technique [21],

them
extraction

from the esophagus

fluoroscopic in emergency

[5rooms

still practiced

[22]. A recent
that

survey
since

of North
the early with

American
1 970s,

pediatric
they have

radiologists
collectively

retrieval. However, in our medical center, none of the esophagoscopies to remove foreign bodies had any complications related to the procedure. Although the advocates of the Foley
catheter technique claim that it is faster and less expensive

extracted
fluomoscopic

over

2500

blunt

esophageal
a 95% success

foreign

bodies
only

under
one

guidance

mate and

serious complication [22]. Conversely, in a survey to which 1 52 pediatric otolaryngologists responded, 45 complications were ascribed to the procedure using Foley catheters and fluomoscopy [8]. The most of the foreign body into in the pediatric radiology in the otolaryngology serious complication is displacement the airway. Although not encountered survey [22] and mentioned only once [8], it remains a potential

[22], supporters of esophagoscopy techniques for outpatient surgery,

body removal can be performed

argue that esophagoscopy

safely under

with modern for foreign

general anes-

questionnaire

hazard that radiologists must avoid when using this method of treatment. In our medical center, we employ this procedure
only coins, in patients in the with retained blunt foreign period bodies, of time. that We the such as esophagus interface (Fig. for a short rely on foreign

thesia, and the patient can be discharged the same day [8], suggesting that a speed and economy gap no longer exists between the two procedures. In our medical center, however, the average cost of an esophagoscopy for foreign body removal is almost four times that of Foley catheter extraction. Despite anxiety over cost containment in medicine, certain
principles in the management of a patient ingestions with a possible that are wit-

retained
Infants

esophageal
or children

foreign
with

body should
body

not be compromised.

foreign

the lateral
sophageal

chest

radiographic
4A)

finding

of a thickened

tmacheoe-

as a predictor

body has been retained a relatively long time and Foley cathetem retrieval will be unsuccessful [10]. None of our patients had significant clinical complications from the procedure.
However, probably eign body, In a case we represent rather observed asymptomatic mural defects wall on

esophagogmams

made
than

after the procedure

of the esophageal a complication coin (Fig.

(Figs.

7 and 8) that
by the foritself. pro-

erosion

of the

procedure selection

of an extmaluminal

4), the

cess eliminated the potential disaster that could panied attempted Foley catheter extraction.

have accom-

nessed or are only suspected, even asyrnptomatic patients, should have the appropriate radiologic investigations to exclude impaction in the esophagus. When a foreign body is retained in the upper or mid esophagus, it should be removed immediately. Infants and children with chronic or recurrent upper respiratory tract infections, persistent croup, or even vague symptoms, such as lethargy and weight loss, should be investigated to exclude an esophageal foreign body. Although Foley catheter extraction represents a fast and inexpensive alternative to esophagoscopy, it should be employed only in carefully selected patients. Esophagoscopy remains the safest method of esophageal foreign body removal in infants and children.

924

MACPHERSON

ET AL.

AJR:166, April 1996

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2. Remsen K, Lawson W, Biller HF, et al. Unusual ing foreign bodies of the upper aerodigestive Laryngol 1983;92:32-44 3. Smith CP, Swischuk LE, Fagan CJ. An elusive, presentations system. Ann of penetratOtol Rhinol cause of

12.

Conners

GP, Chamberlain

JM, Ochsenschlager
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and
Med

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often unsuspected

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case of

hazards
:97-98

of esophageal

foreign

body extraction.

Pedi20.

9. Nandi P, Ong GB. Foreign body in the esophagus:

review of 2394 cases.

21.

10. Towbin R, Lederman HM, Dunbar JS, et al. Esophageal edema as a predictor of unsuccessful balloon extraction of esophageal foreign bodies.
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22.

Campbell JB, Condon yR. Catheter removal of blunt esophageal

foreign

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23.

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