This POTD is inspired by a common occurrence in the pediatric ED and a question that routinely shows up on board questions.
History: Mom and Dad are spring cleaning the apartment when 1 year old Freddy Boy starts having sporadic episodes of gagging or choking, and has vomited once. Parents report an episode where he looked like he was breathing faster and almost looked like he was struggling to catch his breath, which has since resolved. Mom and Dad panic and bring F.B. to your ED. Physical exam reveals a happy looking kid, vitals WNL, and a benign exam. Nothing in the back of the throat. Normal breath sounds BL.
As their provider, high on your differential is foreign body ingestion, and you begin your workup.
Background: Children frequently swallow foreign bodies, with coins being the most common. Other objects, such as fish or chicken bones, buttons, marbles, and the dreaded button battery are common (for adults, food boluses are most common, followed by fish bones, coins, fruit pits, pins, and dentures). A patient who has ingested a FB raises the concern- where is the coin? Is it in the esophagus, or the trachea? Has it already been swallowed and now in the stomach? What was the FB? Oftentimes the history can be suspicious for FB ingestion but the point (or object) of ingestion is often not witnessed.
Whether the coin/FB be in the esophagus or the airway can produce similar symptoms. Patients can be vomiting, have episodes of gagging and choking, stridor, complaining of chest pain, pain in the neck, throat, or upper back, drooling, and an inability to eat.
A lot of those symptoms are fighting words- they're usually how you describe a patient in danger of respiratory distress, and thus the patient with FB ingestion must be assessed with ABCs in mind on initial and repeat assessments.
Imaging:
The most important next step on evaluation for ingestion of moderate to high risk ingestion is to obtain imaging. Obtain a CXR AP and lateral; additionally, a babygram xray can include the chest and abdomen, which can pick up a coin that may have already passed through the esophageal sphincter and is likely on it's way out.
Back to our case. The child has an xray depicting:
https://prod-images-static.radiopaedia.org/images/219249/4b44984b51f84022153d6f2572b60f_jumbo.jpg
This is an example of the coin being in the esophagus. On AP imaging, coins in the esophagus show their face, while objects stuck in the trachea will usually be visible only by its edge. Obtaining a lateral view can often times help you visualize the trachea; a coin stuck in the trachea on lateral view will show you its face.
https://img.grepmed.com/uploads/5385/peds-trachea-coins-esophagus-chestxray-original.jpeg
In the esophagus, objects are most likely to get stuck at the cricopharyngeus muscle (about 75% of the time), at the level of the aortic arch, and the lower esophageal sphincter.
What to do depends on the object swallowed and where it is located. For esophageal FB, if the object is sharp, a single high powered magnet or several magnets, a disk battery stuck in the esophagus, if airway compromise is present or imminent due to mass effect on the trachea, evidence of perforation, unable to manage secretions, or if the point of ingestion is possible to be >24 hours, emergent/urgent endoscopy is needed.
For esophageal objects that don't have these characteristics, definitive intervention such as endoscopy can be delayed up tot 24 hours to allow a chance for the object to pass spontaneously. If past the lower esophageal junction, objects are very likely to pass through the GI tract on their own. If warranted, objects can be be monitored with serial xrays to follow the object on its way out. These benign objects can be expectantly managed, and the asymptomatic patient can be sent with follow up with PMD/GI.
For tracheal objects, such as this coin, in a patient without complete airway obstruction/on the verge of airway compromise, you can provide supplemental O2 if needed, have the parents calm the child if possible, and allow the patient to assume a position of comfort. These patients are likely to need bronchoscopy to remove, and it is important to get your ENT and possibly anesthesia friends involved in the case.
Best,
SD
Sources:
https://www.grepmed.com/images/5385/peds-trachea-coins-esophagus-chestxray
https://radiopaedia.org/cases/ingested-foreign-body-coin-in-oesophagus-3
https://learningradiology.com/archives2008/COW%20313-Coin%20in%20esophagus/coinesophcorrect.htm
https://www.ncbi.nlm.nih.gov/books/NBK430915/
https://www.uptodate.com/contents/foreign-bodies-of-the-esophagus-and-gastrointestinal-tract-in-children
