Letters to Editor
Foreign body oesophagus: The case of a missing second coin Sir, A 21‑year‑old female (weight 45 kg, height 156 cm) presented with a history of accidental swallowing of a coin/s (unsure of the number) 5 h earlier and odynophagia. She was reading and preparing for her exams at the time of incident. There was no history of psychiatric illness. Severe abrasions were noted on the posterior pharyngeal wall where the patient had scratched while trying to induce vomiting to expel the coin/s. Cardiovascular and respiratory system examinations were normal. Radiographs on admission [Figure 1a and b] revealed a circular opacity (size correlated to that of a rupees‑two coin) in the cervical oesophagus; it had migrated to the mid‑oesophagus just before endoscopy [Figure 1c]. Thickness of the object on lateral view [Figure 1b] led to the suspicion that there may be two coins. She was put in supine, 30˚ head‑low position to prevent the foreign body from migrating down further. In the operating room, after attaching routine monitors and preoxygenation, anaesthesia was induced with fentanyl 100 μg and propofol 100 mg. Neuromuscular blockade was achieved with succinylcholine 75 mg and endotracheal intubation was performed with a 6 mm cuffed oro‑tracheal tube to facilitate insertion of the oesophagoscope. Positive pressure ventilation (PPV) was not administered before intubation. Relaxation was maintained further with atracurium, with (PPV). No foreign body was visualized in the upper airway during laryngoscopy and intubation. Anaesthesia was maintained with oxygen, N2O and isoflurane. The otorhinolaryngologist performed oesophagoscopy using a rigid oesophagoscope. There appeared to be two coins, one over the other with the upper coin proximal, at a distance of 30 cm from the incisors. They were grasped using long forceps and duly extracted along with the oesophagoscope. However, only one coin came out and it was found to be a rupees‑two coin [Figure 1d]. The oesophagoscope was reintroduced in search of the second coin. No coin could be visualized even on advancing the scope to 35 cm. At this juncture, a fluoroscopic sweep was performed from neck to upper abdomen after covering the rest of the abdomen with a lead jacket. No foreign 364
a
c
b
d
Figure 1: Preoperative radiographs showing foreign body (FB) a and b: FB at the cervicothoracic junction, c: FB in the lower thoracic region, d: FB after removal
body could be detected. Possibility of there being only one coin was reconsidered and accepted. Head‑low tilt was maintained throughout the procedure. In view of the posterior pharyngeal wall abrasions and possibility of oesophageal mucosal oedema due to intraoperative manipulation, a 16 F nasogastric tube was passed under direct laryngoscopic guidance. To our surprise, the other rupees‑two coin slipped into the pharynx and it was removed [Figure 1d]. The head and neck was screened with the C‑arm. After a thorough oropharyngeal inspection, neuromuscular blockade was reversed and trachea extubated. Foreign body ingestion in adults occurs more commonly among those with psychiatric disorders or mental retardation, prisoners and alcoholics.[1] Most of them pass through the gastrointestinal tract harmlessly.[2,3] About 10-20% may require non‑operative intervention and only 1% or less surgery.[1‑4] The site of entrapment of oesophageal foreign bodies differs with age group, with about 75% of children and 70% of adults having entrapment at the upper oesophageal sphincter and at the lower oesophageal sphincter, respectively.[5,6] Most retained coins have a diameter between 23.45 and 26.00 mm in children.[3] Complications of coin ingestion, although rare, include oesophageal perforation, tracheo‑oesophageal fistula, oesophago‑aortic fistula, and death.[7] Suspicion arose over existence of a second coin. Radiographs provided inconclusive evidence of a second coin. Only one coin was retrieved on oesophagoscopy. Repeated oesophagoscopy and fluoroscopic searches could not locate the second coin. The head‑low tilt of Indian Journal of Anaesthesia | Vol. 58 | Issue 3 | May-Jun 2014
Letters to Editor
the table and hyperextension of the neck during the procedure probably aided slipping of the coin into the nasopharynx. The chances of foreign bodies accidentally slipping into the nasopahrynx during retrieval are real[4] (especially in head‑low position). Had we not inserted the nasogastric tube under direct laryngoscopy and retrieved the second coin prior to tracheal extubation, there could have been an airway mishap. Knowledge of the shape and size of the coins currently in use in our country also helped in suspecting that there may be a second coin. Fair knowledge about the common foreign bodies is useful in managing such patients. In the event of multiple foreign bodies in the oesophagus, we suggest (1) An on‑table radiograph before and after oesophagoscopy can help locate residual objects if they are radio‑opaque, (2) a post‑procedural nasogastric tube/suction catheter insertion may help to dislodge a latent object in the nasopharynx and (3) radiological screening of the entire craniothoracic region in case of missing radio‑opaque foreign bodies.[1]
6. 7.
Conway WC, Sugawa C, Ono H, Lucas CE. Upper GI foreign body: An adult urban emergency hospital experience. Surg Endosc 2007;21:455‑60. Raval MV, Campbell BT, Phillips JD. Case of the missing penny: Thoracoscopic removal of a mediastinal coin. J Pediatr Surg 2004;39:1758‑60. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.135098
Unusual cause for raised airway pressures related to anaesthesia workstation Sir,
Managing oesophageal foreign bodies can be tricky because of the close proximity to the airway. A thorough search for the missing foreign body/s is a must to avoid airway mishaps when the clinician is unsure about the number of foreign bodies. Apart from the clinical skills, resourcefulness, and quick and rational thinking play an important role in managing such patients.
Vijay G Yaliwal, Harihar V Hegde, JS Arunkumar1, Santosh S Garag1, P Raghavendra Rao Departments of Anaesthesiology, 1Otorhinolaryngology, SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India Address for correspondence: Dr. Harihar V Hegde, Department of Anaesthesiology, SDM College of Medical Sciences and Hospital, Dharwad - 580 009, Karnataka, India. E‑mail: [email protected]
REFERENCES 1. Webb WA. Management of foreign bodies of the upper gastrointestinal tract: Update. Gastrointest Endosc 1995;41:39‑51. 2. Singh B, Kantu M, Har‑El G, Lucente FE. Complications associated with 327 foreign bodies of the pharynx, larynx and esophagus. Ann Otol Rhinol Laryngol 1997;106:301‑4. 3. Tander B, Yazici M, Rizalar R, Ariturk E, Ayyildiz SH, Bernay F. Coin ingestion in children: Which size is more risky? J Laparoendosc Adv Surg Tech A 2009;19:241‑3. 4. Gitzelmann CA, Gysin C, Weiss M. Dorsal flexion of head and neck for rigid oesophagoscopy‑‑a caution for hidden foreign bodies dropped into the epipharynx. Acta Anaesthesiol Scand 2003;47:1178‑9. 5. Cheng W, Tam PK. Foreign‑body ingestion in children: Experience with 1,265 cases. J Pediatr Surg 1999;34:1472‑6. Indian Journal of Anaesthesia | Vol. 58 | Issue 3 | May-Jun 2014
We would like to report an incident of raised airway pressures in a patient due to the lack of timely maintenance of the Datex‑Ohmeda Aisys care station (GE Finland)®. A 28 year old, American Society of Anaesthesiologists 1, patient with a history of a road traffic accident 5 h ago was rushed to the operating room with a Glasgow coma scale of 8/15. He had an uneventful rapid sequence induction and intubation with an 8.5 mm internal diameter cuffed endotracheal tube (ETT). After connecting the closed circuit of the Aisys® to the (ETT) we noticed that the bag was tight and only 2‑3 ml/kg of tidal volume could be delivered with high airway pressures (35 cm H2O). Auscultation revealed equal bilateral air entry with no added sounds. The end‑tidal CO2 trace appeared as depicted below [Figure 1] without proper angles. Multiple differential diagnoses for raised airway pressure such as mucous plug, bronchospasm, endo‑bronchial intubation, pneumothorax etc., were ruled out/treated with bronchodilators, ETT suctioning.[1] The plane of anaesthesia was also deepened, but all the above interventions showed no improvement in airway pressures. It was during this time that we noticed that the fraction of inspired CO2 on the agent monitor was 4 mm of Hg, prompting us to replace the CO2 absorbent. When the 365
Copyright of Indian Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Foreign body oesophagus: The case of a missing second coin Sir, A 21‑year‑old female (weight 45 kg, height 156 cm) presented with a history of accidental swallowing of a coin/s (unsure of the number) 5 h earlier and odynophagia. She was reading and preparing for her exams at the time of incident. There was no history of psychiatric illness. Severe abrasions were noted on the posterior pharyngeal wall where the patient had scratched while trying to induce vomiting to expel the coin/s. Cardiovascular and respiratory system examinations were normal. Radiographs on admission [Figure 1a and b] revealed a circular opacity (size correlated to that of a rupees‑two coin) in the cervical oesophagus; it had migrated to the mid‑oesophagus just before endoscopy [Figure 1c]. Thickness of the object on lateral view [Figure 1b] led to the suspicion that there may be two coins. She was put in supine, 30˚ head‑low position to prevent the foreign body from migrating down further. In the operating room, after attaching routine monitors and preoxygenation, anaesthesia was induced with fentanyl 100 μg and propofol 100 mg. Neuromuscular blockade was achieved with succinylcholine 75 mg and endotracheal intubation was performed with a 6 mm cuffed oro‑tracheal tube to facilitate insertion of the oesophagoscope. Positive pressure ventilation (PPV) was not administered before intubation. Relaxation was maintained further with atracurium, with (PPV). No foreign body was visualized in the upper airway during laryngoscopy and intubation. Anaesthesia was maintained with oxygen, N2O and isoflurane. The otorhinolaryngologist performed oesophagoscopy using a rigid oesophagoscope. There appeared to be two coins, one over the other with the upper coin proximal, at a distance of 30 cm from the incisors. They were grasped using long forceps and duly extracted along with the oesophagoscope. However, only one coin came out and it was found to be a rupees‑two coin [Figure 1d]. The oesophagoscope was reintroduced in search of the second coin. No coin could be visualized even on advancing the scope to 35 cm. At this juncture, a fluoroscopic sweep was performed from neck to upper abdomen after covering the rest of the abdomen with a lead jacket. No foreign 364
a
c
b
d
Figure 1: Preoperative radiographs showing foreign body (FB) a and b: FB at the cervicothoracic junction, c: FB in the lower thoracic region, d: FB after removal
body could be detected. Possibility of there being only one coin was reconsidered and accepted. Head‑low tilt was maintained throughout the procedure. In view of the posterior pharyngeal wall abrasions and possibility of oesophageal mucosal oedema due to intraoperative manipulation, a 16 F nasogastric tube was passed under direct laryngoscopic guidance. To our surprise, the other rupees‑two coin slipped into the pharynx and it was removed [Figure 1d]. The head and neck was screened with the C‑arm. After a thorough oropharyngeal inspection, neuromuscular blockade was reversed and trachea extubated. Foreign body ingestion in adults occurs more commonly among those with psychiatric disorders or mental retardation, prisoners and alcoholics.[1] Most of them pass through the gastrointestinal tract harmlessly.[2,3] About 10-20% may require non‑operative intervention and only 1% or less surgery.[1‑4] The site of entrapment of oesophageal foreign bodies differs with age group, with about 75% of children and 70% of adults having entrapment at the upper oesophageal sphincter and at the lower oesophageal sphincter, respectively.[5,6] Most retained coins have a diameter between 23.45 and 26.00 mm in children.[3] Complications of coin ingestion, although rare, include oesophageal perforation, tracheo‑oesophageal fistula, oesophago‑aortic fistula, and death.[7] Suspicion arose over existence of a second coin. Radiographs provided inconclusive evidence of a second coin. Only one coin was retrieved on oesophagoscopy. Repeated oesophagoscopy and fluoroscopic searches could not locate the second coin. The head‑low tilt of Indian Journal of Anaesthesia | Vol. 58 | Issue 3 | May-Jun 2014
Letters to Editor
the table and hyperextension of the neck during the procedure probably aided slipping of the coin into the nasopharynx. The chances of foreign bodies accidentally slipping into the nasopahrynx during retrieval are real[4] (especially in head‑low position). Had we not inserted the nasogastric tube under direct laryngoscopy and retrieved the second coin prior to tracheal extubation, there could have been an airway mishap. Knowledge of the shape and size of the coins currently in use in our country also helped in suspecting that there may be a second coin. Fair knowledge about the common foreign bodies is useful in managing such patients. In the event of multiple foreign bodies in the oesophagus, we suggest (1) An on‑table radiograph before and after oesophagoscopy can help locate residual objects if they are radio‑opaque, (2) a post‑procedural nasogastric tube/suction catheter insertion may help to dislodge a latent object in the nasopharynx and (3) radiological screening of the entire craniothoracic region in case of missing radio‑opaque foreign bodies.[1]
6. 7.
Conway WC, Sugawa C, Ono H, Lucas CE. Upper GI foreign body: An adult urban emergency hospital experience. Surg Endosc 2007;21:455‑60. Raval MV, Campbell BT, Phillips JD. Case of the missing penny: Thoracoscopic removal of a mediastinal coin. J Pediatr Surg 2004;39:1758‑60. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.135098
Unusual cause for raised airway pressures related to anaesthesia workstation Sir,
Managing oesophageal foreign bodies can be tricky because of the close proximity to the airway. A thorough search for the missing foreign body/s is a must to avoid airway mishaps when the clinician is unsure about the number of foreign bodies. Apart from the clinical skills, resourcefulness, and quick and rational thinking play an important role in managing such patients.
Vijay G Yaliwal, Harihar V Hegde, JS Arunkumar1, Santosh S Garag1, P Raghavendra Rao Departments of Anaesthesiology, 1Otorhinolaryngology, SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India Address for correspondence: Dr. Harihar V Hegde, Department of Anaesthesiology, SDM College of Medical Sciences and Hospital, Dharwad - 580 009, Karnataka, India. E‑mail: [email protected]
REFERENCES 1. Webb WA. Management of foreign bodies of the upper gastrointestinal tract: Update. Gastrointest Endosc 1995;41:39‑51. 2. Singh B, Kantu M, Har‑El G, Lucente FE. Complications associated with 327 foreign bodies of the pharynx, larynx and esophagus. Ann Otol Rhinol Laryngol 1997;106:301‑4. 3. Tander B, Yazici M, Rizalar R, Ariturk E, Ayyildiz SH, Bernay F. Coin ingestion in children: Which size is more risky? J Laparoendosc Adv Surg Tech A 2009;19:241‑3. 4. Gitzelmann CA, Gysin C, Weiss M. Dorsal flexion of head and neck for rigid oesophagoscopy‑‑a caution for hidden foreign bodies dropped into the epipharynx. Acta Anaesthesiol Scand 2003;47:1178‑9. 5. Cheng W, Tam PK. Foreign‑body ingestion in children: Experience with 1,265 cases. J Pediatr Surg 1999;34:1472‑6. Indian Journal of Anaesthesia | Vol. 58 | Issue 3 | May-Jun 2014
We would like to report an incident of raised airway pressures in a patient due to the lack of timely maintenance of the Datex‑Ohmeda Aisys care station (GE Finland)®. A 28 year old, American Society of Anaesthesiologists 1, patient with a history of a road traffic accident 5 h ago was rushed to the operating room with a Glasgow coma scale of 8/15. He had an uneventful rapid sequence induction and intubation with an 8.5 mm internal diameter cuffed endotracheal tube (ETT). After connecting the closed circuit of the Aisys® to the (ETT) we noticed that the bag was tight and only 2‑3 ml/kg of tidal volume could be delivered with high airway pressures (35 cm H2O). Auscultation revealed equal bilateral air entry with no added sounds. The end‑tidal CO2 trace appeared as depicted below [Figure 1] without proper angles. Multiple differential diagnoses for raised airway pressure such as mucous plug, bronchospasm, endo‑bronchial intubation, pneumothorax etc., were ruled out/treated with bronchodilators, ETT suctioning.[1] The plane of anaesthesia was also deepened, but all the above interventions showed no improvement in airway pressures. It was during this time that we noticed that the fraction of inspired CO2 on the agent monitor was 4 mm of Hg, prompting us to replace the CO2 absorbent. When the 365
Copyright of Indian Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
