Pediatr Radiol (1992) 22:33%341
Pediatric Radiology 9 Springer-Verlag 1992
Esophageal perforation by a tooth in child abuse D. S. Ablin ~ and M. A. Reinhart 2 1Department of Radiology, 2Department of Pediatrics, University of California, Sacramento, USA Received: 10 March 1992; accepted: 8 May 1992
Abstract. A u n i q u e case of child a b u s e in a six-year-old H i s p a n i c girl is reported. I n this case, a t o o t h avulsed a n d swallowed d u r i n g a n episode of physical a b u s e a n d / o r sexual abuse, caused a n e s o p h a g e a l p e r f o r a t i o n resulting in a r e t r o p h a r y n g e a l abscess a n d m e d i a s t i n a l abscess c o n t a i n ing the tooth. A l t h o u g h t r a u m a t i c e s o p h a g e a l injuries in child a b u s e h a v e occurred, the p r e s e n c e of a t o o t h within the m e d i a s t i n a l abscess is a n u n i q u e m a n i f e s t a t i o n of child abuse.
Injuries to the t r a c h e a a n d e s o p h a g u s due to child a b u s e are rare [1]. A resulting m e d i a s t i n a l abscess or m e d i a s t i n a l p s e u d o c y s t d u e to e s o p h a g e a l p e r f o r a t i o n is e v e n r a r e r [2-5]. We p r e s e n t a n a d d i t i o n a l u n u s u a l case of esophageal p e r f o r a t i o n d u e to child abuse; in this case a tooth, avulsed a n d swallowed d u r i n g a n episode of physical a n d / o r sexual abuse, resulted in a n e s o p h a g e a l p e r f o r a t i o n with associated r e t r o p h a r y n g e a l a n d m e d i a s t i n a l abscess which c o n t a i n e d the tooth.
Case report A 6-year-old Hispanic female presented with a sore throat, fever, and dysphagia. After treatment with a course of Bicillin and Ampiciltin, she became afebrile and the sore throat resolved. 10 days later she had recurrent fever, sore throat, dysphagia, and deteriorating respiratory status. Laboratory evaluation showed an white blood count of 36,500 with 54 % polymorphonuclear leukocytes and 37 % band cells. A chest radiograph demonstrated a right pleural fluid collection and pneumothorax. A right chest tube was placed which drained purulent fluid, that cultured streptococcus viridans, staphylococcus aureus, and anaerobes. Her throat culture grew moderate hemophilus influenza. Increased drainage from the chest tube was noted when she drank fluids. The patient was transferred to our institution for further care of a suspected esophageal-pleural fistula. Past medical history was pertinent for ascariasis which resulted in intestinal obstruction and bowel perforation requiring a temporary
Present address: 765 Covell Boulevard, Davis, California 95616,
USA
colostomy. Social history revealed the parents to be impoverished illegal aliens from Mexico. The father was an unemployed farm worker. Physical examination revealed an alert active child in no apparent distress. Temperature was 38.3 ~ heart rate 140,respirations 26, and weight at the 25th percentile. There were a 5 • 3 cm and a 2 x 0.5 cm oval hypopigmented excoriated spot on the skin in the right infraclavicular region and right chin, respectively. A macular hypopigmented area was present on the right inner thigh. The child had poor dentition and shoddy cervical adenopathy in the neck. A right sided chest tube was in place bubbling. Breath sounds were heard bilaterally with no adventitious sounds. A scar was present on the abdomen which was soft and non-tender with normal bowel sounds. The remainder of the physical exam was normal. Chest and neck radiographs were obtained and findings are described in (Fig. la, b). A barium esophogram was performed and findings are described in (Fig. 2). Culture of pleural fluid grew the same organisms as outside hospital. Skin lesions revealed herpes simplex virus Type I. Following antibiotic treatment and surgery consultation, the patient was taken to the operating room where bronchoscopy, esophagoscopy, right neck exploration and right thoracotomy with decortication were performed for drainage of empyema, retropharyngeal and mediastinal abscess, and placement of gastrostomy. During the exploration, a hypopharyngeal and upper esophageal perforation at the level of the cricopharyngeus was found. This perforation communicated with a retropharyngeal and retroesophageal abscess cavity which extended into the right upper mediastinum where a tooth was found and removed. Following surgery, the patient remained febrile and the right hemithorax remained partially opacified on chest radiograph. A C T scan of the chest with and without intravenous contrast was obtained, see (Fig. 3). Neck exploration and right thoracotomy were performed for further drainage of the neck and mediastinal abscess and right empyema. The patient improved without recurrence. She was discharged with an esophageal-cutaneous fistula and gastrostomy tube. 5 months later, physical examination for follow-up of her esophageal-cutaneous fistula revealed a palpable lump over the right clavicle and weakness and muscle atrophy in her right upper extremity due to a right clavicular fracture with exuberant callus and a brachial plexus neuropathy. The scalp demonstrated several pustules, scarring and partial alopecia. There was a pigmented maculopathy of the left fovea. Multiple bruises were present on forehead, cheek, eyelids and all extremities. A human adult bite mark was noted on the left upper extremity. Extensive bruising and scarring was present in the pubic, perineal, buttock, and upper thigh areas. Genital examination
340
Fig.1. a Chest, radiograph, anteroposterior view. There is a right pleural fluid collection and right lung infiltrate representing pneumonia and empyema. A right chest tube is present. The mediastinum is wide and subcutaneous emphysema is present in the right neck. A radiopaque foreign body in the shape of a tooth is seen over the right upper mediastinum overlying the medial end of the 3rd posterior rib (black arrow). An old healed right clavicle fracture is present. b Neck, Lateral view. The prevertebral soft tissues are wide and contain a large amount of air causing marked anterior bowing of the hypopharynx and trachea Fig.2. A barium esophagram demonstrates extravasation of barium into a large abscess cavity (asterisks) in the right upper mediastinum with subsequent obscuration of the radiopaque foreign body seen on
clearly demonstrated findings indicating past physical abuse and penetrating genital injuries due to sexual abuse. At this time it became apparent that the original esophageal perforation most likely resulted from physical and/or sexual abuse which traumatically avulsed the tooth which the child swallowed. Physical trauma also most likely resulted in tooth impaction in and/or through the esophageal wall. No explanation of the injuries were given by the family.
the chest radiograph in Fig. la. The level of the perforation demonstrated surgically was at the level of the cricopharyngeus (black arrowhead). The normal esophagus is seen medial to the abnormal barium collection (black arrows) Fig.3. A C T of the chest with intravenous contrast, axial view, demonstrates marked rim enhancement (black arrows) of a complex right pyopneumothorax containing air fluid levels. The right lung is displaced anteriorly and compressed medially. The enhancingposterior mediastinum is wide and contains air (black arrowheads) due to mediastinal abscess and mediastinitis. The right chest wall is swollen due to edema, inflammation, and subcutaneous emphysema. The non-contrasted CT demonstrated small amounts of barium in the right hemithorax due to previous esophageal-pleural fistula
Discussion Most injuries to the o r o p h a r y n x , h y p o p h a r y n x , a n d esophagus are i a t r o g e n i c or f r o m foreign b o d y or caustic ingestion or accidental p e n e t r a t i n g t r a u m a [2-5]. I n j u r y to the o r o p h a r y n x in child abuse is n o t u n c o m m o n a n d m a y
341 be due to forced insertion of a eating utensil, bottle, or other foreign body, direct trauma, attempted suffocation, or sexual abuse. These types of injuries are usually of minor significance. However, injury to the hypopharynx or esophagus with resulting mediastinal abscess or mediastinal pseudocyst due to child abuse, although rare are serious, and should be considered when an infant or young child presents with unexplained erythematous neck swelling, subcutaneous emphysema, pneumomediastinum, wide mediastinum, stridor, and/or unexplained foreign body in the esophagus or in the mediastinum [1-5]. Presenting symptoms of esophageal foreign bodies may include fever; dysphagia or drooling; respiratory symptoms, such as cough, stridor, or pneumonia; or neck swelling [2, 3, 6, 7]. Vocal cord paralysis may occur [7]. The danger of aspirating a loose tooth or foreign body is well known, and is a cause of accidental death in children [7, 8]. However, swallowing a tooth is often benign as the foreign body usually readily passes through the gastrointestinal tract because of its small size [7]. Larger, irregular, or sharp esophageal foreign bodies tend to become lodged at five natural levels of compression: 1. the cricopharyngeus, 2. the thoracic inlet, 3. the aortic arch, 4. the tracheal bifurcation where the left main stem bronchus crosses the esophagus and, 5. the esophageal hiatus, with the majority lodged at the level of the thoracic inlet or esophageal hiatus. Impacted swallowed esophageal foreign bodies, whether accidental or nonaccidental in origin, can result in serious and fatal complications which include: esophageal perforation, esophageal stenosis, tracheoesophageal fistula, bronchoesophageal fistula, bronchopulmonary fistula, esophageal intramural abscess, mediastinitis or mediastinal abscess, and erosion into subclavian artery or aorta [2, 6, 7, 9, 10]. Esophageal perforation, mediastinal abscess, and foreign bodies may be difficult to diagnose by chest radiographs alone. Foreign bodies, especially non-radiopaque, may be unrecognized on an esophagram unless they produce a mass effect, filling defect, extravasation of contrast, or other abnormality. Bronchoscopy and/or esophagoscopy may be necessary. CT is helpful in diagnosing empyema, esophageal-pleural fistula, mediastinitis, mediastinal abscess, or in identifying an intramediastinal foreign body [11-13]. In this case the associated subsequent findings of bruising, bite mark, repeated clavicular fracture, and obvious signs of sexual abuse were the indications that the original
esophageal injuries were the result of repeated physical and/or sexual abuse. Child abuse must be considered in the differential diagnosis of mediastinal abscess, esophageal perforation, and impacted esophageal foreign bodies.
Acknowledgement. We gratefully thank Charlene Leasure for the careful preparation of this manuscript.
References 1. Kleinman PK (1987) Diagnostic imaging of child abuse. Visceral trauma, Chap 7. Williams and Wilkins, Baltimore, p 115 2. Ablin DS, Reinhart MA (1990) Esophageal perforation with mediastinal abscess in child abuse. Pediatr Radio120:524-525 3. Kleinman PK, Spevak MR, Hansen M (1992) Mediastinat pseudocyst caused by pharyngeal perforation during child abuse. AJR 158:1111-1113 4. Grace A, Grace S (1987) Child abuse within the ear, nose, and throat. J Otolaryngo116:108-111 5. Manning SC, Casselbrant M, Lammers D (1990) Otolaryngologic manifestations of child abuse. 20:7-16 6. Fernandes ET, Hollabaugh RS, Boulden T (1989) Mediastinal mass and radiolucent esophageal foreign body. J Pediatr Surg 24: 1135-1136 7. Banks W, Potsic WP (1978) Unsuspected foreign bodies of the aerodigestive tract. Ann Otol Rhinol Laryngo187: 515-518 8. Allison MJ, Pezzia A, Gerszten E, Giffler RF (1974) Aspiration pneumonia due to teeth-950 A.D. and 1973 A.D. South Med J 67:479-483 9. Kleinfeldt D, Busch-Peterson D, Hein J, Gtilzow HH, Herzog KH (1974) Mediastinal abscess following esophageal perforation by a swallowed glass splinter. HNO 22:324-325 10. Montinari M, Giangregorio F, Mangieri C (1975) Mediastinal abscess secondary to laceration of the esophagus secondary to extraction of a coin in a young girl. Minerva Chir 30:827-831 11. Carrol CL, Jeffrey RB, Federle MR Vernacchia FS (1987) CT evaluation of mediastinal infections. J Comput Assist Tomogr 11:449-454 12. Breatnach E, Nath PH, Delany DJ (1986) The role of computed tomography in acute and subacute m ediastinitis. Clin Radio1137: 139-145 13. Wechsler RJ (1986) CT of esophageal-pleural fistulae. AJR 147: 907-909 Deborah S. Ablin, MD University of California Davis Medical Center Department of Radiology 2516 Stockton Boulevard, TICON II Sacramento, CA 95 817 USA
Pediatric Radiology 9 Springer-Verlag 1992
Esophageal perforation by a tooth in child abuse D. S. Ablin ~ and M. A. Reinhart 2 1Department of Radiology, 2Department of Pediatrics, University of California, Sacramento, USA Received: 10 March 1992; accepted: 8 May 1992
Abstract. A u n i q u e case of child a b u s e in a six-year-old H i s p a n i c girl is reported. I n this case, a t o o t h avulsed a n d swallowed d u r i n g a n episode of physical a b u s e a n d / o r sexual abuse, caused a n e s o p h a g e a l p e r f o r a t i o n resulting in a r e t r o p h a r y n g e a l abscess a n d m e d i a s t i n a l abscess c o n t a i n ing the tooth. A l t h o u g h t r a u m a t i c e s o p h a g e a l injuries in child a b u s e h a v e occurred, the p r e s e n c e of a t o o t h within the m e d i a s t i n a l abscess is a n u n i q u e m a n i f e s t a t i o n of child abuse.
Injuries to the t r a c h e a a n d e s o p h a g u s due to child a b u s e are rare [1]. A resulting m e d i a s t i n a l abscess or m e d i a s t i n a l p s e u d o c y s t d u e to e s o p h a g e a l p e r f o r a t i o n is e v e n r a r e r [2-5]. We p r e s e n t a n a d d i t i o n a l u n u s u a l case of esophageal p e r f o r a t i o n d u e to child abuse; in this case a tooth, avulsed a n d swallowed d u r i n g a n episode of physical a n d / o r sexual abuse, resulted in a n e s o p h a g e a l p e r f o r a t i o n with associated r e t r o p h a r y n g e a l a n d m e d i a s t i n a l abscess which c o n t a i n e d the tooth.
Case report A 6-year-old Hispanic female presented with a sore throat, fever, and dysphagia. After treatment with a course of Bicillin and Ampiciltin, she became afebrile and the sore throat resolved. 10 days later she had recurrent fever, sore throat, dysphagia, and deteriorating respiratory status. Laboratory evaluation showed an white blood count of 36,500 with 54 % polymorphonuclear leukocytes and 37 % band cells. A chest radiograph demonstrated a right pleural fluid collection and pneumothorax. A right chest tube was placed which drained purulent fluid, that cultured streptococcus viridans, staphylococcus aureus, and anaerobes. Her throat culture grew moderate hemophilus influenza. Increased drainage from the chest tube was noted when she drank fluids. The patient was transferred to our institution for further care of a suspected esophageal-pleural fistula. Past medical history was pertinent for ascariasis which resulted in intestinal obstruction and bowel perforation requiring a temporary
Present address: 765 Covell Boulevard, Davis, California 95616,
USA
colostomy. Social history revealed the parents to be impoverished illegal aliens from Mexico. The father was an unemployed farm worker. Physical examination revealed an alert active child in no apparent distress. Temperature was 38.3 ~ heart rate 140,respirations 26, and weight at the 25th percentile. There were a 5 • 3 cm and a 2 x 0.5 cm oval hypopigmented excoriated spot on the skin in the right infraclavicular region and right chin, respectively. A macular hypopigmented area was present on the right inner thigh. The child had poor dentition and shoddy cervical adenopathy in the neck. A right sided chest tube was in place bubbling. Breath sounds were heard bilaterally with no adventitious sounds. A scar was present on the abdomen which was soft and non-tender with normal bowel sounds. The remainder of the physical exam was normal. Chest and neck radiographs were obtained and findings are described in (Fig. la, b). A barium esophogram was performed and findings are described in (Fig. 2). Culture of pleural fluid grew the same organisms as outside hospital. Skin lesions revealed herpes simplex virus Type I. Following antibiotic treatment and surgery consultation, the patient was taken to the operating room where bronchoscopy, esophagoscopy, right neck exploration and right thoracotomy with decortication were performed for drainage of empyema, retropharyngeal and mediastinal abscess, and placement of gastrostomy. During the exploration, a hypopharyngeal and upper esophageal perforation at the level of the cricopharyngeus was found. This perforation communicated with a retropharyngeal and retroesophageal abscess cavity which extended into the right upper mediastinum where a tooth was found and removed. Following surgery, the patient remained febrile and the right hemithorax remained partially opacified on chest radiograph. A C T scan of the chest with and without intravenous contrast was obtained, see (Fig. 3). Neck exploration and right thoracotomy were performed for further drainage of the neck and mediastinal abscess and right empyema. The patient improved without recurrence. She was discharged with an esophageal-cutaneous fistula and gastrostomy tube. 5 months later, physical examination for follow-up of her esophageal-cutaneous fistula revealed a palpable lump over the right clavicle and weakness and muscle atrophy in her right upper extremity due to a right clavicular fracture with exuberant callus and a brachial plexus neuropathy. The scalp demonstrated several pustules, scarring and partial alopecia. There was a pigmented maculopathy of the left fovea. Multiple bruises were present on forehead, cheek, eyelids and all extremities. A human adult bite mark was noted on the left upper extremity. Extensive bruising and scarring was present in the pubic, perineal, buttock, and upper thigh areas. Genital examination
340
Fig.1. a Chest, radiograph, anteroposterior view. There is a right pleural fluid collection and right lung infiltrate representing pneumonia and empyema. A right chest tube is present. The mediastinum is wide and subcutaneous emphysema is present in the right neck. A radiopaque foreign body in the shape of a tooth is seen over the right upper mediastinum overlying the medial end of the 3rd posterior rib (black arrow). An old healed right clavicle fracture is present. b Neck, Lateral view. The prevertebral soft tissues are wide and contain a large amount of air causing marked anterior bowing of the hypopharynx and trachea Fig.2. A barium esophagram demonstrates extravasation of barium into a large abscess cavity (asterisks) in the right upper mediastinum with subsequent obscuration of the radiopaque foreign body seen on
clearly demonstrated findings indicating past physical abuse and penetrating genital injuries due to sexual abuse. At this time it became apparent that the original esophageal perforation most likely resulted from physical and/or sexual abuse which traumatically avulsed the tooth which the child swallowed. Physical trauma also most likely resulted in tooth impaction in and/or through the esophageal wall. No explanation of the injuries were given by the family.
the chest radiograph in Fig. la. The level of the perforation demonstrated surgically was at the level of the cricopharyngeus (black arrowhead). The normal esophagus is seen medial to the abnormal barium collection (black arrows) Fig.3. A C T of the chest with intravenous contrast, axial view, demonstrates marked rim enhancement (black arrows) of a complex right pyopneumothorax containing air fluid levels. The right lung is displaced anteriorly and compressed medially. The enhancingposterior mediastinum is wide and contains air (black arrowheads) due to mediastinal abscess and mediastinitis. The right chest wall is swollen due to edema, inflammation, and subcutaneous emphysema. The non-contrasted CT demonstrated small amounts of barium in the right hemithorax due to previous esophageal-pleural fistula
Discussion Most injuries to the o r o p h a r y n x , h y p o p h a r y n x , a n d esophagus are i a t r o g e n i c or f r o m foreign b o d y or caustic ingestion or accidental p e n e t r a t i n g t r a u m a [2-5]. I n j u r y to the o r o p h a r y n x in child abuse is n o t u n c o m m o n a n d m a y
341 be due to forced insertion of a eating utensil, bottle, or other foreign body, direct trauma, attempted suffocation, or sexual abuse. These types of injuries are usually of minor significance. However, injury to the hypopharynx or esophagus with resulting mediastinal abscess or mediastinal pseudocyst due to child abuse, although rare are serious, and should be considered when an infant or young child presents with unexplained erythematous neck swelling, subcutaneous emphysema, pneumomediastinum, wide mediastinum, stridor, and/or unexplained foreign body in the esophagus or in the mediastinum [1-5]. Presenting symptoms of esophageal foreign bodies may include fever; dysphagia or drooling; respiratory symptoms, such as cough, stridor, or pneumonia; or neck swelling [2, 3, 6, 7]. Vocal cord paralysis may occur [7]. The danger of aspirating a loose tooth or foreign body is well known, and is a cause of accidental death in children [7, 8]. However, swallowing a tooth is often benign as the foreign body usually readily passes through the gastrointestinal tract because of its small size [7]. Larger, irregular, or sharp esophageal foreign bodies tend to become lodged at five natural levels of compression: 1. the cricopharyngeus, 2. the thoracic inlet, 3. the aortic arch, 4. the tracheal bifurcation where the left main stem bronchus crosses the esophagus and, 5. the esophageal hiatus, with the majority lodged at the level of the thoracic inlet or esophageal hiatus. Impacted swallowed esophageal foreign bodies, whether accidental or nonaccidental in origin, can result in serious and fatal complications which include: esophageal perforation, esophageal stenosis, tracheoesophageal fistula, bronchoesophageal fistula, bronchopulmonary fistula, esophageal intramural abscess, mediastinitis or mediastinal abscess, and erosion into subclavian artery or aorta [2, 6, 7, 9, 10]. Esophageal perforation, mediastinal abscess, and foreign bodies may be difficult to diagnose by chest radiographs alone. Foreign bodies, especially non-radiopaque, may be unrecognized on an esophagram unless they produce a mass effect, filling defect, extravasation of contrast, or other abnormality. Bronchoscopy and/or esophagoscopy may be necessary. CT is helpful in diagnosing empyema, esophageal-pleural fistula, mediastinitis, mediastinal abscess, or in identifying an intramediastinal foreign body [11-13]. In this case the associated subsequent findings of bruising, bite mark, repeated clavicular fracture, and obvious signs of sexual abuse were the indications that the original
esophageal injuries were the result of repeated physical and/or sexual abuse. Child abuse must be considered in the differential diagnosis of mediastinal abscess, esophageal perforation, and impacted esophageal foreign bodies.
Acknowledgement. We gratefully thank Charlene Leasure for the careful preparation of this manuscript.
References 1. Kleinman PK (1987) Diagnostic imaging of child abuse. Visceral trauma, Chap 7. Williams and Wilkins, Baltimore, p 115 2. Ablin DS, Reinhart MA (1990) Esophageal perforation with mediastinal abscess in child abuse. Pediatr Radio120:524-525 3. Kleinman PK, Spevak MR, Hansen M (1992) Mediastinat pseudocyst caused by pharyngeal perforation during child abuse. AJR 158:1111-1113 4. Grace A, Grace S (1987) Child abuse within the ear, nose, and throat. J Otolaryngo116:108-111 5. Manning SC, Casselbrant M, Lammers D (1990) Otolaryngologic manifestations of child abuse. 20:7-16 6. Fernandes ET, Hollabaugh RS, Boulden T (1989) Mediastinal mass and radiolucent esophageal foreign body. J Pediatr Surg 24: 1135-1136 7. Banks W, Potsic WP (1978) Unsuspected foreign bodies of the aerodigestive tract. Ann Otol Rhinol Laryngo187: 515-518 8. Allison MJ, Pezzia A, Gerszten E, Giffler RF (1974) Aspiration pneumonia due to teeth-950 A.D. and 1973 A.D. South Med J 67:479-483 9. Kleinfeldt D, Busch-Peterson D, Hein J, Gtilzow HH, Herzog KH (1974) Mediastinal abscess following esophageal perforation by a swallowed glass splinter. HNO 22:324-325 10. Montinari M, Giangregorio F, Mangieri C (1975) Mediastinal abscess secondary to laceration of the esophagus secondary to extraction of a coin in a young girl. Minerva Chir 30:827-831 11. Carrol CL, Jeffrey RB, Federle MR Vernacchia FS (1987) CT evaluation of mediastinal infections. J Comput Assist Tomogr 11:449-454 12. Breatnach E, Nath PH, Delany DJ (1986) The role of computed tomography in acute and subacute m ediastinitis. Clin Radio1137: 139-145 13. Wechsler RJ (1986) CT of esophageal-pleural fistulae. AJR 147: 907-909 Deborah S. Ablin, MD University of California Davis Medical Center Department of Radiology 2516 Stockton Boulevard, TICON II Sacramento, CA 95 817 USA
