Radio-opaque Foreign Body Research Articles

Intra-orbital Foreign Body

Abstract Background: This case report describes a young man with an intra-orbital foreign body (FB) in both eyes. Case Report: Intra-orbital FBs are rare, with few cases reported in the literature. This is because the orbit protects the globe from external forces, and the orbit is a closed cavity with one opening. This report details the case of a 28-year-old man who presented to the emergency unit with an 11-hour history of an intra-orbital FB. The patient was lying on a bench when a stationary motorcycle fell on him. He noticed that he was unable to open both eyes and was rushed to a peripheral hospital, then subsequently referred to this tertiary center. On examination, he was ill-looking and anxious but not febrile or pale. Systemic examination did not reveal any abnormality. Unaided visual acuity in the right eye (OD) was nil perception of light, while left eye visual acuity (OS) was counting fingers. The right eyelid was ptotic due to edema. He underwent basic laboratory investigations that were all normal. A plain X-ray revealed a radio-opaque FB penetrating the left orbit, fracturing the medial walls into the right orbit, with the round end positioned behind the right globe. The FB was identified as a broken part of a brake/clutch lever from the motorcycle. A computerized tomography scan showed a metallic object in both orbits, accompanied by pneumocephalus, and suggested transection of the right optic nerve. The patient was prepared for FB removal and repair of the lid penetration under general anesthesia, following review by the ENT surgeon and neurosurgeon. The brake lever was successfully removed, and the patient was administered antibiotics. Post-operatively, visual acuity in the right eye remained at nil perception of light, while that in the left eye improved to 6/9 upon discharge. Conclusion: There is no established protocol for managing intra-orbital FBs, as removal depends on factors such as the size, composition, and potential compression damage to structures around the globe, which could further compromise vision or function. Small inert objects may be left in place if removal would cause damage. However, in this case, removal was deemed necessary for several reasons.

Unusual Airway Foreign Bodies in Children: Demographics and Management.

The aim is to study the demographics and management of unusual airway foreign bodies (UAFBs) in children. A retrospective observational study (2000-2020) of children with UAFBs, who underwent bronchoscopic removal. The demographics, types of foreign bodies, clinical and radiological features, management, and outcomes were collated and analyzed. Common foreign bodies, such as nuts, seeds, and vegetable aspirations, were excluded. Among 531 children who had bronchoscopic retrieval of airway foreign bodies, 74 (59 males/15 females) had unusual foreign bodies. These included pen caps, whistles, plastic objects, pins, coal piece, stones, clay, pencil, gold ornament, and glass bangle. Thirty-one children presented within 1 day of aspiration, 37 within 1 month and 6 till 6 months. Thirty-nine were below 5 years, and the rest were between 5 and 15 years. Cough, respiratory distress, fever, choking, and noisy breathing were common presentations. Others are stridor, whistling, cyanosis, loss, and change of voice. Chest X-ray showed ipsilateral hyperinflation (23), haziness (21), radio-opaque foreign body (17) and was normal in 14. The left main bronchus, followed by the right main bronchus and trachea, were the sites of impaction. Four children required additional procedures (tracheotomy and thoracotomy). There was one mortality in the study cohort. Aspiration of unusual foreign bodies is not uncommon in children. Most aspirations are witnessed and predominant in boys. The left bronchus is the common site of impaction, and X-ray clinches the diagnosis. Presentation is delayed, and bronchoscopic retrieval, though challenging, has favorable outcome.

Endoscopic retrieval of oesophageal foreign body in a dachshund

Four-year-old male Dachshund dog was presented to Madras Veterinary College and Teaching Hospital with the history of gradual weight loss and chronic vomiting for more than twenty days. Previously the dog was treated in several places with anti-emetics, proton pump inhibitors, H2 blockers, fluid therapy and antibiotics but there was no improvement. On clinical examination the dog was severely dehydrated, increased skin tenting time and increased capillary refill time. Hematobiochemical assessment revealed mild hypoproteinemia and hypoalbuminemia. Radiographic examination of thorax and abdomen revealed no radio-opaque foreign body in the gastrointestinal tract and ultrasound examination also confirmed the same. Contrast radiographic examination revealed absence of megaesophagus and foreign body in gastrointestinal tract. Hence upper gastrointestinal endoscopy was performed and which revealed presence of plastic thread twine along the esophagus from the level of pharynx to cardia and the foreign body was retrieved using endoscopic forceps. Further the animal was treated with fluid therapy along with other supportive therapy. The dog was shown the clinical improvement after third day.

Transmigration of Surgical Gauze: A Rare Case of Intraluminal Gossypiboma

Gossypiboma, a rare but significant complication of retained surgical gauze, can lead to considerable morbidity and presents diagnostic challenges. We describe the case of a 40-year-old female who presented with a three-day history of generalized abdominal pain, accompanied by bilious vomiting and bowel obstruction. Her medical history included an open cholecystectomy seven months earlier. An abdominal X-ray suggested a linear radio-opaque foreign body, which was confirmed as gossypiboma by contrast-enhanced CT. During an exploratory laparotomy, a 30 x 30 cm surgical gauze was found within the ileum and successfully removed. This case highlights the ongoing risk of retained surgical items, even with modern advancements in surgical practice and technology. It underscores the importance of meticulous surgical technique, including accurate surgical counts, adherence to standardized protocols. This case serves as a critical reminder for all surgical teams to maintain heightened vigilance throughout all phases of surgery.

Esophageal discoid foreign body detection and classification using artificial intelligence.

Early and accurate radiographic diagnosis is required for the management of children with radio-opaque esophageal foreign bodies. Button batteries are some of the most dangerous esophageal foreign bodies and coins are among the most common. We hypothesized that artificial intelligence could be used to triage radiographs with esophageal button batteries and coins. Our primary objective was to train an object detector to detect esophageal foreign bodies, whether button battery or coin. Our secondary objective was to train an image classifier to classify the detected foreign body as either a button battery or a coin. We trained an object detector to detect button batteries and coins. The training data set for the object detector was 57 radiographs, consisting of 3 groups of 19 images each with either an esophageal button battery, esophageal coin or no foreign body. The foreign bodies were endoscopically confirmed, and the groups were age and gender matched. We then trained an image classifier to classify the detected foreign body as either a button battery or a coin. The training data set for the image classifier consisted of 19 radiographs of button batteries and 19 of coins, cropped from the object detector training data set. The object detector and image classifier were then tested on 103 radiographs with an esophageal foreign body, and 103 radiographs without a foreign body. The object detector was 100% sensitive and specific for detecting an esophageal foreign body. The image classifier accurately classified all 6/6 (100%) button batteries in the testing data set and 93/95 (97.9%) of the coins. The remaining two coins were incorrectly classified as button batteries. In addition to these images with a single button battery or coin, there were two unique cases in the testing data set: a stacked button battery and coin, and two stacked coins, both of which were classified as coins. Artificial intelligence models show promise in detecting and classifying esophageal discoid foreign bodies and could potentially be used to triage radiographs for radiologist interpretation.

Migratory foreign body in the chest

A 12 years old male child presented to our institution 3 days after he sustained a penetrating injury to his left antero-lateral chest by a sewing needle. At presentation, he was stable except having a localized chest pain at the site of the needle. The pertinent finding was on the chest examination in which there was a pinpointed entry wound at the left 4th intercostal space antero-laterally with a localized tenderness. Chest x-ray revealed a radio opaque foreign body. After obtaining chest ultrasound which localized and marked the needle in the anterior chest wall, local exploration of the chest wall was done over the marked area but foreign body was not found. Hence, thoracic cavity was entered through antero-medial thoracotomy with a finding of a sewing needle in the anterior mediastinum with its tip embedded in the pericardium. Needle was removed without any sequel and patient was discharged improved on the second post-operative day.

Fatal attraction: A case of multiple magnet ingestion in an infant

Background: Foreign body ingestion is common amongst young children, and they tend to pass spontaneously in most. Multiple magnet ingestion, though not very common, requires early intervention to avoid serious complications. Case presentation: A 1 year old infant was brought to us with symptoms of bilious vomiting and abdominal pain. A plain abdominal x ray revealed presence of multiple radio opaque foreign bodies adherent to each other, lying in the small bowel. This raised the suspicion of accidental ingestion of multiple magnets, which was confirmed on detailed interrogation of the parents. An exploratory laparotomy revealed volvulus with pressure necrosis causing multiple perforations of the small bowel, for which a bowel resection with anastomosis and a loop ileostomy was performed, also all the magnetic beads were removed intact. The stoma was reversed after 4 weeks. At follow up the child has grown well with no residual complaints. Conclusion: The importance of early detection and intervention in a case of multiple magnet ingestion in children should be emphasised amongst the parents of young children. Spread of awareness by the primary paediatricians would help in reducing the morbidity and mortality. Keywords: multiple magnets; intestinal obstruction; perforation.

Retrospective Study of the Round Radiopaque Foreign Bodies in the Oesophagus

Introduction Ingested foreign bodies (FBs) of the digestive tract can be divided into radiolucent and radiopaque, based on their appearance in Roentgenogram. Coins and button-batteries (BBs) constitute majority of the radiopaque FBs that are round in shape. Materials and Methods Medical records of children admitted with foreign bodies in the GI tract during the last 5 years have been reviewed. We have taken into our study, round radio-opaque FBs and analyzed the results. Results Out of 120 radiopaque FBs, in 112 cases they are lodged in cricopharyngeal sphincter (CPS), which were removed. Of these, 103 were coins and 9 were BBs. Five coins, which had crossed the CPS, ultimately passed out naturally with faeces. Three BBs, impacted in the oesophagus, distal to the CPS, were removed via esophagoscopy, on emergency basis. One child with impacted BB developed mediastinitis and died. Conclusion A round opaque disc shaped FB which is impacted or seen below CPS should not be treated as coin every time. High index of suspicion is needed to rule out BB ingestion as it is associated with high morbidity and mortality. Aim of this study is to stress on the need for educating primary care physicians and rural medical practitioners to avoid wait and watch policy, thus reducing misdiagnosis of coins for BBs.

Surgical Instrument’s Tip Fracture During Cataract Surgery

Purpose: To describe a case of a surgical instrument’s tip fracture during cataract surgery. Method: Case report. Results: We report a case of a 60-year-old gentleman who underwent phacoemulsification of the left eye. It was noted that the tip of the second instrument (lens chopper) was fractured during the last quadrant removal of the opacified lens, which disappeared posteriorly. The surgery was successfully completed, and the intraocular lens appeared stable without posterior capsular rent. An urgent computed tomography scan (CT scan) of orbit was arranged. It showed a round radio opaque foreign body near the lens at the lateral aspect of the left intraocular lens (IOL), measuring approximately 0.3cm. The patient underwent foreign body removal using an intraocular magnet by a vitreoretinal surgeon two days after the phacoemulsification surgery. The patient had an uneventful recovery with a vision of 6/60 pinhole 6/6 at six weeks post operatively. Conclusion: Surgical instrument’s tip fracture is a known complication during phacoemulsification; however, it was under-reported among surgeons. Careful inspection of all instruments before introducing them to the eye is mandatory, and early identification of this condition during surgery may avoid major complications.

Capsular dissection technique for reducing recurrent laryngeal neuropraxia and temporary hypoparathyroidism after thyroidectomy: a single center experience

<p class="abstract"><strong>Background:</strong> Foreign bodies in aerodigestive tract is common, frequent, and sometime life threatening emergency for otorhinolaryngologists mainly in the paediatric group. The aims of the present study was to find the incidence of foreign bodies, in relation to demographic factors, type and sites of foreign bodies its clinical presentations and its management.</p><p class="abstract"><strong>Methods:</strong> A prospective study was conducted on 100 cases coming to the ear, nose and throat (ENT) emergency and outpatient department (OPD). After thorough history, clinical examination, routine blood and urine investigations and urine done. Radiological examination was done to visualize the radio-opaque foreign body, and if the foreign body was not radio-opaque then computed tomography (CT) scan was done. </p><p class="abstract"><strong>Results:</strong> Incidence of foreign was 67% in male than 33% in female. Mostly foreign bodies were in nose (49%), followed by oesophageal (31%), abdominal (14%), and bronchus (6%) respectively. 33% were totally asymptomatic, 25% with mucupurulent discharge from nose, dysphagia (16%), nasal obstruction (15%), and odynophagia (11%) respectively. Most of the foreign bodies were inorganic in nature, coin (42%), pearls (8.16%), and battery (6.45%). Among organic foreign bodies peanut was most common (33.33%), grains (10%). All foreign bodies were removed successfully with minimal morbidity and zero mortality.</p><p class="abstract"><strong>Conclusions:</strong> Present study suggested incidence was very common among male children, in rural background, with common asymptomatic presentation. With high index of suspicion, and proper and timely intervention all 100 cases were managed successfully. But still educating the parents about keeping such things away from kids prevent these incident.</p>

Infected laryngeal foreign body: A case report

Foreign body aspiration is a major cause of accidental death in children. Laryngeal foreign bodies in some cases, especially when it is narrow cause little airway obstruction and may even present like upper airway infection. This can delay the diagnosis and even may be mis-treated as laryngitis. A child presented to the department of ENT with throat pain and hoarseness of voice but gave a history of foreign body ingestion 1 week before. Though the child presented with laryngitis like symptoms, considering the foreign body ingestion history, diagnostic work-up was done to rule out foreign body in larynx. On X-ray, a radio-opaque foreign body was seen in the larynx above the glottis. He was taken to the operation theatre and under general anaesthesia, foreign body was seen and was piercing the posterior pharyngeal wall. It was carefully removed and pus was seen leaking from the removal site. After a course of antibiotics, the child was apparently normal then.A Laryngeal foreign body shows a wide variety of presentations depending on its size and shape. Hence, the children with laryngitis like symptoms should be investigated for foreign body aspiration irrespective of the symptoms if a history of foreign body ingestion was given.

Common Radiological Findings in Children with Suspected Foreign Body Inhalation

BACKGROUND: Foreign body inhalation is an emergency situation, affecting children mostly in first decade of life. An aspirated solid or semisolid object may lodge in the larynx or trachea may cause complete obstruction. Lesser degrees of obstruction or passage of the obstructive object beyond the carina can result in less severe signs and symptoms. Chronic debilitating symptoms with recurrent infections might occur with delayed extraction, or the patient may remain asymptomatic. Many aspirated foreign bodies are unexpectedly discovered, go undetected, or are misdiagnosed. In many cases with suspected foreign body radiological findings may reveal other findings e.g. emphysema, atelectasis, air trapping.
 OBJECTIVE: To determine the frequency of common radiological findings among children with suspected foreign body inhalation.
 MATERIAL AND METHODS: This cross-sectional descriptive study was conducted at Department of ENT, Khyber Teaching Hospital, Peshawar, from April 2017 to October 2017. In this study a total of 141 patients were observed. All patients were subjected to detailed history and clinical examination. X ray chest (AP and lateral views) of all the patients was performed to detect common radiological findings (Radio-opaque Foreign Body (FB), Pneumonia, Emphysema, atelectasis and Air Trapping). The demographic details like name, age, gender, address and contacts were recorded on a pre-designed proforma.
 RESULTS: In this study mean age was 8 years with SD ± 3.563. Sixty percent children were male while 40% children were female. Sixteen percent children had Radio opaque FB, 13% children had pneumonia, 28% had emphysema, 18% children had atelectasis while 25% had Air trapping.
 CONCLUSION: Our study concludes that the frequency of Radio opaque was 16%, pneumonia 13%, emphysema 28%, atelectasis 18%, Air trapping 25% among children with suspected foreign body inhalation.
 KEY WORDS: radiological findings, suspected foreign body inhalation, Pneumonia, Emphysema, atelectasis and Air Trapping

ROLE OF RIGID BRONCHOSCOPY IN MANAGEMENT OF TRACHEOBRONCHIAL FOREIGN BODY ASPIRATION

Objective: To determine the role of Rigid Bronchoscopy in Management of Tracheobronchial Foreign Body Aspiration.
 Material and Methods: This study was conducted in otolaryngology department, Khyber teaching hospital, Peshawar of one year duration from January 2018 to December 2019. Total 90 Patients of age 4 months to 14 years on clinical suspicion of foreign body bronchus were included, while patients with history of bronchial asthma, pulmonary tuberculosis and radio opaque foreign body bronchus were excluded.
 Results: Total number of patients was 90 in which male patients were 60 (66.67 %) and female patients were 30 (33.33 %), patients with foreign body bronchus were 80 (88.89%). Male patients with foreign body bronchus was 53 (58.89%) and female 27 (30.00%). In age range from 4 months to 3 years, 35(39%) Patients underwent bronchoscopy in which foreign body bronchus retrieved in 30(37.5%) patients. Conclusion: Patients with history of repeated chest infection, relieved by medicines for some time should not be over look, as vegetative foreign body bronchus are radiolucent and patients usually present late in respiratory compromised state, the clinician must urge, for prompt treatment as rigid bronchoscopy.

S2662 An Unexpected Cause of Refractory Liver Abscesses

INTRODUCTION: We report a case of multifocal liver abscesses with recurrent fevers refractory to prolonged antibiotic therapy and catheter drainage due to penetration of a toothpick into the portal vein. CASE DESCRIPTION/METHODS: A 72-year-old male with type II diabetes presented with fever, confusion, and right upper quadrant pain associated with malaise and unintentional weight loss. Objective findings were consistent with septic shock and acute liver injury. Computed tomography (CT) and Magnetic Resonance Imaging (MRI) showed a 6.9 × 8.0 × 5. hepatic abscess and several scattered fluid collections (Figure 1). Immediate broad-spectrum antibiotics and percutaneous catheter drainage resulted in clinical improvement. Abscess fluid and blood cultures grew actinomyces odontolyticus and streptococcus viridans, respectively. Amebic serology was negative. Transition to appropriate outpatient antibiotics resulted in two readmissions for recurrent fevers with persistent drainage output for weeks. A repeat CT showed a shrunken abscess and a 4.6 cm radio-opaque linear foreign body penetrating through the gastric antrum into a branch of the left portal vein (Figure 2). Review of previous imaging confirmed the foreign body was present since first admission. Upper endoscopy showed a patch of erythematous mucosa in the antrum encircling a pinpoint opening to a fistulous tract and exuding purulent fluid (Figure 3). Exploratory laparotomy revealed a 4.5 cm wooden toothpick in the portal vein surrounded by a dense fibrotic scar. Foreign body removal and porto-enteric fistula repair were performed. Follow up CT showed complete resolution of the abscess. DISCUSSION: Penetrating foreign body is a rare cause of liver abscess. To our knowledge, penetration of a foreign body into the portal vein resulting in liver abscesses has never been reported. Discovery of foreign body requires a high index of suspicion as patients rarely remember ingesting the object, and it can be easily missed on CT. When suspected, a non-contrast CT is recommended with attention to coronal/sagittal views with signs such as thickened antral wall and fistulous tract. Non-specific clinical features such as hematemesis, subacute/chronic abdominal pain, and failure of antibiotic therapy can be suggestive. In the setting of any of these findings, foreign body should be considered in patients with unexplained liver abscess.Figure 1.: A large dominant hepatic abscess measuring 6.9 × 8.0 × 5.3cm, involving segments 4A and 4B of the liver, extending to and involving the anterior wall of the gallbladder, as well as several scattered small fluid collections (MRI of liver without contrast).Figure 2.: A 4.6cm radio-opaque linear foreign body penetrating through the gastric antrum into a branch of the left portal vein (CT of abdomen and pelvis without contrast).Figure 3.: A patch of erythematous mucosa in the pre-pyloric antrum encircling a pinpoint opening to a fistulous tract and scant purulent liquid; the foreign body was not visible (upper endoscopy).

S3443 Recurrent Acuphagia: Endoscopy or Not?

INTRODUCTION: Acuphagia is uncontrollable ingestion of metal or sharp objects. It is a psychiatric disorder. Few cases of recurrent acuphagia are reported in literature. We describe the case of a 27-year-old lady with recurrent episodes and the dilemma faced in management. CASE DESCRIPTION/METHODS: 26-year-old lady with a past medical history multiple psychiatric disorders and an 8 year history of recurrent radio-opaque foreign body ingestion. She ingested a screw driver shaft and had previously ingested razor blades, 60 paper clips, spoons, bobby pins, pens, phone stylus. She required many esophagogastroduodenoscopies(EGDs) .Open laparotomy was done once for gastric perforation. Recurrent ingestion was related to craving anesthetic agents as a means of relieving anxiety. At review, her vital signs were stable. The foreign body was visualized on x ray and successfully removed from the stomach using a snare at EGD.Her medications were adjusted by psychiatry. She represented a month later after swallowing an unfolded paper clip confirmed on imaging. Due to lack of symptoms and adjudged low risk, EGD was not done, leaving her dissatisfied. DISCUSSION: Foreign body ingestion is more common in children compared to adults. Adult foreign body ingestion is increasing.(1) Recurrent intentional ingestion is more common in the elderly, prisoners and people with underlying psychiatric disorders.(2) Acuphagia is a form of pica, the consumption of non-nutritious substances. This patient had many psychiatric diagnoses. Most foreign bodies pass through the gastrointestinal tract spontaneously. Some require intervention. European guidelines recommend conservative management for asymptomatic patients with ingestion of small, blunt objects (except batteries and magnets)(3). Indications for endoscopy include symptomatic patients, ingestion of sharp or pointed materials, batteries, magnets and large substances. Those with complications, for example perforation, intestinal obstruction require surgery. Our patient required multiple upper gastrointestinal endoscopies. Although largely asymptomatic, she mainly ingested sharp metal objects that put her at a risk for perforation.Managing this patient was challenging due to multiple presentations. Medication readjustments to manage anxiety thereby preventing recurrences were not fully successful. The threshold for endoscopy was raised. Propofol is being avoided for endoscopy as much as possible as this was the specific agent she craved.Figure 1Figure 2

Gastrointestinal perforation caused by ingested fish bone. Computed tomography findings in 58 patients

Context and objectiveFish bones (FB) are the most commonly ingested objects and the most common cause of foreign body perforation of the GI tract. Patients present with varied and nonspecific clinical presentations. The inability to obtain a history of FB ingestion and its wide spectrum of nonspecific clinical presentations makes dietary FB perforation extremely difficult to diagnose, being a laparoscopic or surgical diagnosis.The aim of our study is to describe radiological features in CT that will alert you to look for the FB and then make an accurate presurgical diagnosis. Materials and methodsAll patients (n=58) with radiological diagnosis of gastrointestinal perforation caused by fish bone detected by CT between 2007 to 2017 were retrospectively reviewed. Inclusion criteria were: fish bone located beyond the oesophagus, radiological diagnosis by CT and confirmation by surgery, endoscopy or radiological control.Descriptive analysis was made. Radiological features were studied including radio-opaque foreign body, mural thickness, fatty infiltration or extraluminal air bubbles. Also potential complications were assessed. ResultsThere were 58 patients, 39 men and 19 women, with an average age of 70. Ileon was the most frequent site of perforation (20 patients). 100% showed regional fatty infiltration, 98% included foreign body, 45% had mural thickening and 20% localised extraluminal air bubbles. 15 Abscess were found (3 in the liver) and just 5 showed pneumoperitoneum. ConclusionFatty infiltration is the feature more common. Therefore, if fatty infiltration is seen in isolation radiologist should look for foreign body.

Perforación gastrointestinal por espina de pescado. Hallazgos radiológicos en tomografía computarizada en 58 pacientes

Context and objetiveFish bones (FB) are the most commonly ingested objects and the most common cause of foreign body perforation of the GI tract. Patients present with varied and nonspecific clinical presentations. The inability to obtain a history of FB ingestion and its wide spectrum of nonspecific clinical presentations makes dietary FB perforation extremely difficult to diagnose, being a laparoscopic or surgical diagnosis.The aim of our study is to describe radiological features in CT that will alert you to look for the FB and then make an accurate presurgical diagnosis. Materials and methodsAll patients (n=58) with radiological diagnosis of gastrointestinal perforation caused by fish bone detected by CT between 2007 to 2017 were retrospectively reviewed. Inclusion criteria were: fish bone located beyond the esophagus, radiological diagnosis by CT and confirmation by surgery, endoscopy or radiological control.Descriptive analysis was made. Radiological features were studied including radioopaque foreign body, mural thickness, fatty infiltration or extraluminal air bubbles. Also potential complications were assessed. ResultsThere were 58 patients, 39 men and 19 women, with an average age of 70. Ileon was the most frequent site of perforation (20 patients). 100% showed regional fatty infiltration, 98% included foreign body, 45% had mural thickening and 20% localized extraluminal air bubbles. 15 abscess were found (3 in the liver) and just 5 showed pneumoperitoneum. ConclusionFatty infiltration is the feature more common. Therefore, if fatty infiltration is seen in isolation radiologist should look for foreign body.

It was inhaled not swallowed-Neglected 5 month foreign body airway

A delayed detection of foreign body airway implicated high morbidity. The longer duration of the foreign body in the lung can lead to a more sinister complication. A radiolucent foreign body, non organic foreign body and unwitnessed foreign body ingestion contribute significantly to the delay in the diagnosis of foreign body aspiration. We report a case of an undiagnosed radio opaque foreign body in the right bronchus for five months in a 8-year-old child, which the onset of foreign body ingestion was witnessed by parents. Eventually he presented with pneumonia and atelectasis.
 Bangladesh Journal of Medical Science Vol.18(4) 2019 p.820-822

Spontaneous Passage of Ingested Coin in Children

Objective: To determine the factors related to spontaneous passage of ingested coins in children.
 Methods:
 Study Design: Retrospective Study
 Setting: Tertiary Government Hospital
 Subjects: The records of 136 pediatric patients with a history of coin ingestion seen at the emergency room department of our institution between December 2012 and May 2014 were retrospectively reviewed. Demographic data such as age and gender of the patient were recorded, including the type of coin, location of coin in the esophagus, time of ingestion and time of spontaneous passage into the stomach (for those that passed spontaneously).
 Results: Spontaneous passage in 27 out of 136 pediatric patients with radiographic evidence of a round radio-opaque foreign body initially located in the esophagus eventually passed into the stomach or intestines, accounting for 20% of the total number of cases. Coin ingestion was more common in patients aged 5 to 6 years (33% of cases), with slight male predominance (58%). One peso coins were the most common type of coin ingested, however only 24% of these spontaneously passed. The rate of spontaneous passage was highest in smaller sized coins (5 and 25 centavo coin) compared to larger sized coins (5 peso). Proximally located coins, albeit more common than middle and distally located coins, were the least likely to spontaneously pass (12%). Average time interval from ingestion to passage of the coin was 12 hours.
 Conclusion: Many factors are related to spontaneous passage of foreign bodies in the esophagus. The age of the patient, type of coin ingested, and initial location of the coin in the esophagus should be considered. Older patients, smaller sized coins, and distally located coins have the highest probability of spontaneous passage beyond the esophagus. A 12-hour observation period may be considered in patients with single esophageal coin ingestion.
 Keywords: foreign body, esophagus, esophagoscopy

TREE NUT ALLERGY MASQUERADING AS FOREIGN BODY ASPIRATION: PISTACHIO ALLERGY PRESENTING WITH ISOLATED SUPRAGLOTTIC EDEMA

Introduction Foreign body aspiration and food allergy are common causes of respiratory distress in pediatric patients. We present a case of respiratory distress in a 19 month old male who reportedly choked on a pistachio. However, during evaluation for foreign body aspiration, he was found to have isolated supraglottic edema due to pistachio IgE mediated hypersensitivity. Case Description A previously healthy 19 month old male presented with coughing and difficulty breathing immediately after reportedly choking on a pistachio. His respiratory rate was 50, heart rate was 180 bpm, and pulse oximetry was 30% which improved to 100% with supplemental oxygen. Exam was notable for grunting, accessory respiratory muscle use, and the absence of rash, angioedema, or wheezing. He was given intramuscular epinephrine 0.15mg without improvement. Chest X-ray revealed no radio-opaque foreign body or pneumothorax. Otolaryngology performed immediate laryngoscopy/bronchoscopy that revealed significant supraglottic edema of epiglottis, aryepiglottic folds, and bilateral arytenoids (Figure 1). There was no evidence of foreign body, and he was intubated for airway protection. Intravenous epinephrine 9mcg, dexamethasone 7mg, and diphenhydramine 12.5mg were administered with improvement of edema. He was successfully extubated and discharged. Six weeks later, IgE to pistachio was 4.91 KU/L and cashew was 3.25 KU/L. IgE testing to other tree nuts was negative. He has subsequently had no further episodes with strict avoidance of tree nuts. Discussion Food allergy must be considered in the differential diagnosis of foreign body aspiration, despite the lack of cutaneous findings and particularly following the ingestion of commonly allergic foods.