Ms. B, age 81 years, had hypertension, hyperlipidemia, bipolar disorder, chronic back pain, and arthritis. She presented to the emergency department with a two-day history of progressive dysphagia. She had recently taken all seven of her daily pills at once and felt the sensation of them being stuck in her throat. Her symptoms resolved after drinking ginger ale and daytime cough syrup. Over the next day, she noted increased difficulty swallowing her food, followed by shortness of breath and coughing.
1. History and physical examination
Ms. B was afebrile, BP 132/56 mm Hg, heart rate 99 beats per minute, and respiratory rate 22 breaths per minute. The patient was in mild respiratory distress and able to speak only a few words at a time. Upper-airway wheezes were noted in all lung fields. Pain was elicited in the submandibular region of the neck.
WBC was 15,600/ml. Ms. B could not localize the exact location of the pain. Possible explanations considered included globus hystericus (related to crico-pharyngeal spasm and anxiety), structural abnormality of the esophagus (e.g., a web, stricture, diverticula, or carcinoma), and motor abnormality (e.g., diffuse esophageal spasm, achalasia, or scleroderma).
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Further history revealed that Ms. B had an argument with her son the night prior to admission and may have swallowed something in the aftermath. Signs and symptoms of an ingested foreign body (FB) are largely dependent upon where the FB lodged. Most ingested FBs will pass safely thru the gut and be eliminated with stool. If a FB becomes lodged, signs and symptoms are largely dependent on where it lodges. The esophagus has three areas of narrowing: the upper esophageal sphincter, the crossover of the aorta, and the lower esophageal sphincter. Roughly 70% of adults have impaction at the level of the lower esophageal sphincter.
2. Diagnosis
Posteroanterior and lateral x-ray of the chest showed no evidence for pulmonary edema, pneumonia, or radio-opaque object. X-rays are generally unhelpful if the FB is not radio-opaque. Given the pain elicited in the submandibular region of the neck, a CT scan was ordered to rule out perforation or abscess formation. Perforation occurs in roughly 1% of cases of ingested FBs but can be difficult to diagnose.
A CT scan of the neck revealed a metallic FB of unknown etiology within the hypopharynx (Figure 1). Narrowing of the supraglottic airway by marked cervical prevertebral soft tissue swelling was noted.
Ms. B was admitted to intensive care for FB obstruction in the hypopharynx with associated narrowing of the supraglottic airway secondary to edema. She received IV dexamethasone (Decadron) 10 mg every eight hours and IV clindamycin 600 mg every eight hours. Under general anesthesia, a laryngoscope was introduced posterior to the arytenoids and elevated to reveal a small metallic piece of the FB (later identified as a small metal binder clip). An esophagram showed no evidence of extravasation of contrast to suggest perforation and no evidence of aspiration.
3. Discussion
Aspirated FBs kill an estimated 1,500 people annually. All patients who complain of an FB of the throat should be considered serious and undergo a thorough history and physical examination. The FBs most commonly aspirated by adults include food and portions of dental prostheses.
Patients with oropharyngeal FBs may present with a FB sensation particularly after eating chicken or fish and can usually localize the sensation of the FB. Patients with esophageal FBs typically present with an acute case of dysphagia with a history of ingestion. FBs in the stomach and intestine typically present with a history of a swallowed object that has passed through the esophagus.
Physical examination may be helpful in localizing the FB. An FB in the tracheobronchial tree usually stimulates coughing and wheezing. Esophageal obstruction typically results in drooling and inability to swallow secretions or fluids. The hypopharynx can be examined closely after being anesthetized with a spray to see if FBs may be lodged in the vallecula, base of the tongue, or tonsils.
Radiographs of the soft tissue (neck and plain posterioanterior) should be performed. Obstructive overinflation of the affected lobes during expiration may be seen. However, 25% of patients with FBs have radiographs that are within normal limits.Radiographs are helpful if the object is radio-opaque. Non-radio-opaque objects include such commonly ingested objects as fish and chicken bones and the aluminum pull-tops on beverage cans.
CT scan is considered superior to radiographs for localization and identification and is the procedure of choice if one suspects perforation or abscess formation. Not every patient with odynophagia/dysphagia requires a CT scan, as only 17% to 25% will actually have a trapped FB. The remainder are experiencing pain from the mucosal injury.
Laboratory tests generally are not helpful. If infection or complications are suspected, a complete blood count may be indicated.
Emergent endoscopy is indicated for patients whose airway is compromised or who show signs of complications. Flexible endoscopy has become the procedure of choice over rigid endoscopy because it is less expensive and does not require general anesthesia. Both procedures allow for visualization of the esophageal mucosa with a success rate for FB removal of 94.1%. A barium swallow and/or manometry studies may be needed for a complete workup for possible problems with motility but should be deferred, as they may impair or delay an endoscopic intervention.
An FB found in the stomach after endoscopy is generally not removed because the risk of removal outweighs the small risks of letting it pass. Obvious exceptions include razor blades or material too large to pass through the ileum. These items may require surgical intervention for proper and safe removal.
If at the time of endoscopy the FB is found to be perforating the mucosa and the CT did not reveal the area, the endoscopy is generally halted and cardiothoracic or otolaryngologic surgery consulted.
Patients who are stable and in whom the workup shows no evidence of esophageal entrapment or is negative for a FB can be discharged with analgesics and instructions to follow up in 24 hours. Many objects will be passed in the stool days to weeks after being swallowed.
Ms. B responded well to treatment after the binder clip was removed. She was able to tolerate clear liquids shortly after surgery. She was discharged to home the next day with psychiatric follow-up.
A good understanding of the signs and symptoms of FB aspiration is necessary. With appropriate investigation, management, and treatment, the prognosis for most patients is good. In many cases, the object will pass on its own or can be removed with minimal complications.
Ms. Ramirez is a physician assistant and Dr. Wong is attending physician, internal medicine at New York Presbyterian –The Allen Hospital, New York City. Dr. Rieber is attending physician, gastroenterology at New York Associates in Gastroenterology, Bronx.
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All electronic documents accessed October 15, 2010.
