Approach to foreign body ingestion, method determines outcome.

Abstract

Dear Editor, Foreign body ingestion is a frequent presentation in pediatric population. However lack of a standardized protocol and varying approaches often lead to divergent outcomes in emergent cases. Presenting acutely, it is a source of significant patient and family distress as well as a variety of serious complications. With various management protocols advocating diverse strategies, formulation of a sound individual approach is imperative towards adequate patient handling. The dilemma is demonstrated by the course of two children we recently managed. One twenty one month old boy presented with severe respiratory distress and massive subcutaneous emphysema after a failed forceps removal following a coin ingestion the previous day (Figure 1). Contrast enhanced computed tomography showed a tear on the right side of the oropharynx leading to emphysema. The child was intubated and transferred to the intensive care unit where he was mechanically ventilated. On stabilization, a rigid esophagoscopy was performed which revealed a uvular tear and cricopharyngeal perforation that was discharging pus. Despite the successful removal of the coin with the esophagoscopy, the child developed mediastinitis and required two further weeks of broad-spectrum antibiotic therapy in intensive care before stabilization. Legend for Figure 1 Frontal chest roentgenogram showing round metallic density arrow) at the level of gastroesophageal junction. This child's fate was contrasted by that of a three day old patient who presented with respiratory distress with no history of foreign object ingestion. Routine plain radiography revealed a circular opacity in the cricopharnyx. Straight blade laryngoscopy and forceps removal was successful in evacuation of the foreign object, a marble in this case. Evidence of significant vocal cord edema and pressure effect was observed during the procedure. He was started on prophylactic antibiotics and followed an uneventful course thereafter with recovery and discharge within three days. These reports are just a preamble to highlight the somewhat disastrous sequelae often encountered owing to deficiencies in formulation of a sound approach in pediatric cases of foreign body ingestion. Inappropriate handling may lead to serious complications. This is manifest by the distinct fate of the two patients. Whereas an inadequate advance resulted in life-threatening sequelae in one case, appropriate handling led to prompt recovery in other. The need for a timely and adequate approach in all cases of ingested foreign bodies is highligted.