Foreign body oesophagus: The case of a missing second coin.

Sir,

A 21-year-old female (weight 45 kg, height 156 cm) presented with a history of accidental swallowing of a coin/s (unsure of the number) 5 h earlier and odynophagia. She was reading and preparing for her exams at the time of incident. There was no history of psychiatric illness. Severe abrasions were noted on the posterior pharyngeal wall where the patient had scratched while trying to induce vomiting to expel the coin/s. Cardiovascular and respiratory system examinations were normal.

Radiographs on admission [Figure 1a and b] revealed a circular opacity (size correlated to that of a rupees-two coin) in the cervical oesophagus; it had migrated to the mid-oesophagus just before endoscopy [Figure 1c]. Thickness of the object on lateral view [Figure 1b] led to the suspicion that there may be two coins. She was put in supine, 30° head-low position to prevent the foreign body from migrating down further.

Figure 1

Preoperative radiographs showing foreign body (FB) a and b: FB at the cervicothoracic junction, c: FB in the lower thoracic region, d: FB after removal

In the operating room, after attaching routine monitors and preoxygenation, anaesthesia was induced with fentanyl 100 μg and propofol 100 mg. Neuromuscular blockade was achieved with succinylcholine 75 mg and endotracheal intubation was performed with a 6 mm cuffed oro-tracheal tube to facilitate insertion of the oesophagoscope. Positive pressure ventilation (PPV) was not administered before intubation. Relaxation was maintained further with atracurium, with (PPV). No foreign body was visualized in the upper airway during laryngoscopy and intubation. Anaesthesia was maintained with oxygen, N2O and isoflurane. The otorhinolaryngologist performed oesophagoscopy using a rigid oesophagoscope. There appeared to be two coins, one over the other with the upper coin proximal, at a distance of 30 cm from the incisors. They were grasped using long forceps and duly extracted along with the oesophagoscope. However, only one coin came out and it was found to be a rupees-two coin [Figure 1d]. The oesophagoscope was reintroduced in search of the second coin. No coin could be visualized even on advancing the scope to 35 cm. At this juncture, a fluoroscopic sweep was performed from neck to upper abdomen after covering the rest of the abdomen with a lead jacket. No foreign body could be detected. Possibility of there being only one coin was reconsidered and accepted. Head-low tilt was maintained throughout the procedure.

In view of the posterior pharyngeal wall abrasions and possibility of oesophageal mucosal oedema due to intraoperative manipulation, a 16 F nasogastric tube was passed under direct laryngoscopic guidance. To our surprise, the other rupees-two coin slipped into the pharynx and it was removed [Figure 1d]. The head and neck was screened with the C-arm. After a thorough oropharyngeal inspection, neuromuscular blockade was reversed and trachea extubated.

Foreign body ingestion in adults occurs more commonly among those with psychiatric disorders or mental retardation, prisoners and alcoholics.[1] Most of them pass through the gastrointestinal tract harmlessly.[23] About 10-20% may require non-operative intervention and only 1% or less surgery.[1234] The site of entrapment of oesophageal foreign bodies differs with age group, with about 75% of children and 70% of adults having entrapment at the upper oesophageal sphincter and at the lower oesophageal sphincter, respectively.[56] Most retained coins have a diameter between 23.45 and 26.00 mm in children.[3] Complications of coin ingestion, although rare, include oesophageal perforation, tracheo-oesophageal fistula, oesophago-aortic fistula, and death.[7]

Suspicion arose over existence of a second coin. Radiographs provided inconclusive evidence of a second coin. Only one coin was retrieved on oesophagoscopy. Repeated oesophagoscopy and fluoroscopic searches could not locate the second coin. The head-low tilt of the table and hyperextension of the neck during the procedure probably aided slipping of the coin into the nasopharynx. The chances of foreign bodies accidentally slipping into the nasopahrynx during retrieval are real[4] (especially in head-low position). Had we not inserted the nasogastric tube under direct laryngoscopy and retrieved the second coin prior to tracheal extubation, there could have been an airway mishap. Knowledge of the shape and size of the coins currently in use in our country also helped in suspecting that there may be a second coin. Fair knowledge about the common foreign bodies is useful in managing such patients.

In the event of multiple foreign bodies in the oesophagus, we suggest (1) An on-table radiograph before and after oesophagoscopy can help locate residual objects if they are radio-opaque, (2) a post-procedural nasogastric tube/suction catheter insertion may help to dislodge a latent object in the nasopharynx and (3) radiological screening of the entire craniothoracic region in case of missing radio-opaque foreign bodies.[1]

Managing oesophageal foreign bodies can be tricky because of the close proximity to the airway. A thorough search for the missing foreign body/s is a must to avoid airway mishaps when the clinician is unsure about the number of foreign bodies. Apart from the clinical skills, resourcefulness, and quick and rational thinking play an important role in managing such patients.