Esophageal tear after removal of pin ended earrings from hypopharynx of a child: Case report and review of the literature.

This report describes an interesting case of pin-ended earring, a foreign body, in a child, which could not be manipulated by rigid esophagoscope. The surgeon was able to extract it, on the suggestion of the anesthesiologist, by Magill forceps. Examination of the site of impaction of FB showed a small tear attributed to penetration of pin end of the earring. The pediatric surgeon, on post-procedure consultation, advised to follow-up the patient in pediatric intensive care unit with antibiotic prophylaxis. Chest radiograph on the following days showed opacity in the upper right chest region, which was cleared on the fourth post-operative day. This paper describes the anesthetic and operative procedural manipulations that led to safe outcome.

INTRODUCTION

Recently great interest is being taken in the additional uses of Magill forceps under laryngoscopy.[1-5] It was described as Magill forceps technique (MFT),[6] and it was used to extract coins, marbles and other smooth FBs impacted in hypolarynx. Perforation due to FB removal in adults accounts for 16.7% of all cases.[7] There is no such recorded observation in children.

In this case, the initial endoscopic manipulation failed to visualize and remove the pin-ended earring. MFT is based on the insertion of a McIntosh laryngoscope into the pharynx to elevate the lower jaw of the patient to visualize the larynx and to expose the esophageal entrance, after which Magill forceps would be advanced into the oral cavity and then open it when the FB is seen so as to facilitate extraction of the FB. A small mucosal tear was observed after final checkup, which most probably was due to pin penetration and its effect on removal. This was treated conservatively in the PICU under antibiotic cover. This case study gives details of the case and a review of the literature.

CASE REPORT

A 14-month-old female patient was scheduled for removal of foreign body (FB) located in hypopharynx or the upper esophagus under general anesthesia. The foreign body appeared as radiopaque complex small metallic earring on chest radiographs [Figure 1].

Figure 1

Initial neck and chest radiograph AP and LL view

The child did not elicit respiratory distress or respiratory clinical signs, the lungs were clear and normal breathing sounds could be heard in the lungs. Radiograph of the chest did not demonstrate any lung abnormalities.

Anesthesia was started after the surgeon prepared the patient for rigid esophagoscopy, by pre-oxygenation and rapid sequenced induction using fentanyl, propofol and suxamethonium in appropriate dosages, followed by easy tracheal intubation using size 4.5 polyvenyl clear endotracheal tube. The surgeon expected the procedure to be lengthy, so rocuronium was added intravenously for longer muscle paralysis duration.

Rigid esophagoscopy was started, searching for FB in order to remove it. For around 45 minutes, the surgeon faced difficulties in locating and removing the FB. It seemed that the esophagoscope would bypass the FB, and the surgeon continued the exploration deep in the esophagus, without identifying the object. While the radiograph showed FB settled in the lower oropharynx or the upper esophageal area, it could be visualized easily using a laryngoscope. We advised the surgeon that Magill forceps could be suitable to pick up the FB.

By using these forceps, the surgeon under direct laryngoscopy was able to extract the FB [Figure 2].

Figure 2

Follow up post operative neck and chest radiograph AP supine view left image, taken day 1 right image was taken day 2

A check chest radiograph was done since the pin side of the earring was penetrating the mucous membrane layer, which was examined and showed a small cut in it. Pediatric surgeon was consulted, and he advised conservative management and prescribed suitable antibiotics.

The postoperative follow-up showed the expected obacity in the upper right chest field in the radiograph, which disappeared within 3 days. The patient was discharged from the PICU and shifted to the floor after that and then to the society to be reviewed if pulmonary symptoms appeared; or in ENT clinic within 1 month.

DISCUSSION

The endoscopic procedures are nowadays being used as an appropriate diagnostic technique. Perforation due to FB removal in adults accounts for 16.7% of all cases.[7] There is no such recorded observation in children.

The incidence of esophageal perforation from rigid esophagoscopy in adult is 0.11%, while that associated with fiber-optic examination ranges from 0.018% to 0.03%.[7]

Therapeutic endoscopy for removal of FB is associated with a much higher incidence, viz., 1% to 10%. Support of an anesthesiologist is most helpful to keep the patient paralyzed during anesthesia, so as to prevent traumatic endoscopy. Anesthesia and muscle paralysis is optimum in children to reduce the risk from instrumentation, like esophageal rupture, and to give the operator optimum field for examination and picking up the FB. In this case, all necessary precautions were taken, but rigid esophagoscopy did not allow the operator to see the FB, and the anesthesiologist indicated to the surgeon that he could see the earring in the hypolarynx. So making a change in the plan and implementing the use of MFT resulted in the successful removal of FB. The risk of penetration was evident in the initial chest radiograph [Figure 3].

Figure 3

Enlargement of neck radiograph showing the pin-end of the earring

Controlled endoscopic manipulation, post-procedure observation of the patient at the hospital and antibiotic prophylaxis coverage contributed to good outcome. In a recently published article on tackling the issue of esophageal foreign body (EFB),[78] a complicated case of foreign body in an adult was reported, which was treated with thoracotomy and postoperative ICU clong curce.[7] Also a retrospective study of patients with EFB, from 1962 to1998, was carried out, in which 400 patients of all ages with EFB were treated on an emergency basis. There were 202 (50%) men and 198 (49.6%) women, ranging in age from 1.5 to 95 years. The main symptoms patients complained of were difficulty in swallowing and pain. Detailed anamnesis, oropharynx and hypopharynx examination and finally radiological examination were the diagnostic tools. The location of the FB was in the cervical esophagus in 57% of the cases; in the thoracic FB, in 26%; and at the cardioesophageal junction, in 17%. The most common objects found were bones, morsels, coins and needles. Rigid esophagoscopy under general anesthesia was the main procedure in 343 (85.7%) cases. In 57 (14.3%) cases, other means such as flexible esophagoscopy, Fogarty or Foley catheters and boogieing were found to be very useful. Only 12 (3%) patients required surgery because either extraction was impossible or perforation was present. No major complications occurred in the surgical group; whereas in the group of rigid esophagoscopy, there was one case of iatrogenous esophageal perforation that presented with empyema thoraces, which was successfully treated. Finally, there was a case of an aortoesophageal fistula, with mortal outcome perioperatively. It is concluded that esophagoscopy is a reliable method in the treatment of EFB impaction. Alternative methods such as boogieing can be used only in selected cases with smooth foreign bodies. Surgical treatment is unavoidable in cases of irretrievable EFB or esophageal perforation. In the current case, which was the youngest child reported, and Magill forceps was used after esophagoscopy failed to remove a sharp-ended FB.[8] Children with FB may be victims of child abuse. Attention should be paid to extraordinary presentation of FB or perforation and migration as in a recently reported case of migration of the FB and perforation of the esophagus.[9]

In conclusion, the authors stress the seriousness of endoscopic extraction of FB as it is associated with danger. The anesthesiologist's role is to provide a safe operating condition of muscle relaxation and proper depth of anesthesia and analgesia. Also, anticipating troubles and supporting the operator in an apparently short procedure are vital.