Ann 0101 84: 1975
UNEXPECTED RADIOGRAPHIC FINDINGS RELATED TO FOREIGN BODIES WIU'RED T. MORIOKA, M.D.
ROBERT H. MAISEL, M.D.
THOMAS W. SMITH, M.D.
ROBERT W. CANTRELL, M.D.
SAN DIEGO, CALIFORNIA
SUMMARY - In two asymptomatic patients, routine preoperative radiographs revealed three pennies in the esophagus in one patient and a spring from a toy in another patient. In contrast, two symptomatic patients, one with a flip-top cap from a beer can in the esophagus and the other with a piece of photographic film in the larynx, had negative findings on their radiographs. Salient points of the cases are that diagnois can be delayed by inadequate history, misinterpretation of signs and symptoms, and unexpected radiographic findings. Special attention should be focused on the flip-top cap ingestion case. Sixty-five percent of 677 people polled have placed flip-top caps into full cans. Fifty-two people almost swallowed a flip-top cap. Otolaryngologists should be alerted about the radiolucency of this metallic foreign body, and the general population should be discouraged from this dangerous practice.
Radiographs taken of patients who have swallowed or aspirated foreign bodies may not reveal them.l" and routine x-rays may show unsuspected foreign bodies. Two patients with unsuspected foreign bodies, three coins in the esophagus of one and a spring in the right bronchus intermedius of the other, had these foreign bodies discovered on routine preoperative chest x-rays. Two symptomatic cases suspected of having foreign bodies had negative findings on x-ray. Endoscopy performed due to clinical symptoms located a flip-top cap of a can in the esophagus of one patient and a piece of photographic film in the larynx of another patient. These cases are presented to alert otolaryngologists to unexpected radiographic findings in cases involving foreign bodies.
CASE REPORTS Case 1. A three-year-old male was admitted to the ophthalmology service
with esotropia. Preoperative chest x-ray revealed a right middle lobe infiltrate and three coins in the midthoracic esophagus (Fig. 1). There was no history of pulmonary or gastrointestinal problems. After the x-rays, the parents stated that the child had been a poor eater for two years with occasional minor episodes of dysphagia, but no previous pulmonary problems were mentioned. He had been evaluated two years previously for gastrointestinal problems, which were attributed to emotional problems. Esophagoscopy was performed, and three pennies were found. The coins were removed without complications. Mild mucosal erythema was evident, but no other abnormalities were noted. Bronchoscopy revealed small amounts of purulent material in both main stem bronchi. No anatomical deformity in the airway was seen. Case 2. A six-year-old boy was ad-
From the Department of Otolaryngology, Naval Regional Medical Center, San Diego, California. The opinions or assertions contained herein are those of the authors and are not to be construed as official or as reflecting the view of the Department of the Navy. Presented at the meeting of the American Broncho-Esophagological Association Atlanta Georgia, April 7-8, 1975. ' , 627
Downloaded from aor.sagepub.com at East Carolina University on April 23, 2015
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mitted to the otolaryngology service for myringotomies and insertion of ventilating tubes. Preoperative chest x-ray showed a coiled spring in the right bronchus intermedius. The parents reported a bout of severe coughing which subsided after a few minutes two months previously. A mild, intermittent nonproductive cough persisted. During bronchoscopy a 1)2 em coiled spring was removed. The spring was imbedded in the mucosa. Removal was accomplished by inserting the grasping forceps into the lumen of the spring, opening the forceps, and withdrawing the spring into the bronchoscope (Fig. 2A).
Fig. 1. (Case 1) Preoperative chest x-ray revealing three coins in the esopha-
gus.
ABC
S :
Fig. 2. A) (Case 2) Coiled spring removed with grasping forceps during bronchoscopy. B) (Case 3) Piece of photographic film which was found wedged between the vocal cords. C) (Case 4) Flip-top cap removed by esophagoscopy.
Case 3. An eleven-month-old female was admitted to the pediatric service with a diagnosis of laryngotracheobronchitis. Three days prior to admission, she developed an expiratory wheeze. On the day of admission the patient had a fever of 39.5 C, a barking cough, tachypnea, and inspiratory and expiratory stridor. The epiglottis appeared normal. The diagnosis was laryngotraeheobronchitis with a differential including foreign body, subglottic stenosis, and laryngeal polyp. The child was treated initially with a mist tent with nebulized racemic epinephrine and epinephrine subcutaneous. After the first day the child was afebrile, and the cough was diminished. Stridor persisted during agitation, and the cry was weak. Soft tissue x-ray of the neck revealed no foreign body. Chest x-ray showed a suggestion of subglottic swelling. Four days after admission, diagnostic laryngoscopy was performed to determine the cause of the persistent stridor. A small piece of photographic film was found wedged between the vocal cords (Fig. 2B). After removal of the film the child became asymptomatic. Case 4. A 31-year-old male was admitted after accidentally swallowing the flip-top cap from a beer can. He placed the flip-top cap into the full can of beer to prevent littering. As he was drinking the beer, he felt the cap enter his mouth but was unable to avoid swallowing it.
Downloaded from aor.sagepub.com at East Carolina University on April 23, 2015
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remained for a long period with probable damage to the bronchus." Patient No.3 was admitted with a diagnosis of laryngotracheobronchitis. During hospitalization foreign body was repeatedly mentioned in the differential diagnosis. Due to negative x-ray findings and improvement of the patient, diagnosis was delayed. Four days after admission, laryngoscopy and removal of the segment of photographic film stopped the stridor. With the increase of radiolucent material'v':? that can be DISCUSSION ingested or aspirated, pediatricians, Most cases of foreign body ingestion radiologists, and otolaryngologists must or aspiration are readily diagnosed and be suspicious of negative radiographs treated. In some cases, there are factors and think of foreign bodies in children that can confuse and delay diagno- with esophageal or respiratory sympsis.2 ,4 ,5 toms. Patient No.4 ingested a flip-top cap In Cases 1 and 2, the unusual foreign bodies discovered on preoperative chest from a beer can. Cervical, chest, and x-rays were unexpected. The patients abdomen x-rays were negative for a were thought to be asymptomatic, and metallic foreign body. As shown in this there was a significant delay in the patient, thin metallic objects can be diagnosis. The delay related to: 1) the radiolucent. Eight hours after admission young age of the children; 2) the par- due to persistent symptoms, esophagosents not observing the ingestion or copy was performed with removal of aspiration; 3) parents observing the in- the flip-top cap. Repeat chest x-ray cident but assuming that coughing had with the flip-top cap taped to the chest expelled the foreign body; and 4) symp- wall did not show the foreign body. toms being disregarded or misdiagA survey was conducted to determine nosed. the incidence of placing flip-top caps In Case 1 the parents did not observe into a full can. Four hundred and fortythe child actually ingesting the coins. one (65%) of 677 people polled stated His subsequent symptoms of "poor that they have placed flip-top caps into feeding" and occasional dysphagia were a full can. Two hundred eighty people noticed, but they were attributed to still continue the practice. Of the 161 "emotional problems." This case points who have stopped, 130 stated that they out three factors that delay diagnosis: had read or heard about the danger in 1) young children cannot communicate magazines, newspapers, or on the radio. adequately their symptoms or difficul- Of the 441 people who did place caps ties; 2) parents do not always know into full cans, 52 or 12% said they almost what their children have ingested; and swallowed a flip-top cap. 3) the symptoms can be disregarded or SUMMARY attributed to other causes by parents Preoperative radiographs in asymptoand physicians. matic patients revealed three pennies in The second patient was observed the esophagus in one patient and a during his aspiration incident, but his spring from a toy in the bronchus of mother thought he had coughed up the another patient. Two symptomatic paforeign body. His subsequent symp- tients, one with a flip-top beer can cap toms of intermittent mild cough were in the esophagus and another with a disregarded. Without the radiographs, piece of photographic film in her larynx, the foreign body most likely would have had negative findings on their radio-
X-rays of the neck, chest, and abdomen were negative for this metallic foreign body. He complained of a mild ache in the retrosternal area. The patient was admitted for observation. The next morning the retrosternal ache increased. Esophagoscopy was performed and the flip-top cap (Fig. 2C) was located and removed from its location 34 em from the upper incisor teeth. A mucosal abrasion was noted at 30 em, but his postoperative course was uneventful.
Downloaded from aor.sagepub.com at East Carolina University on April 23, 2015
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graphs. Diagnosis and treatment may be delayed due to: 1) young children cannot give an adequate history; 2) parents may be unaware of the ingestion of aspiration; 3) parents may believe that the foreign body was expelled during coughing; 4) the signs and symp-
toms are misinterpreted; and 5) radiolucent foreign bodies. The ingestion of a flip-top cap from a can deserves special attention. The practice of placing flip-top caps into full cans is common and we feel this practice should be discouraged.
Request for reprints should be sent to Wilfred T. Morioka, M.D., Department of Otolaryngology, Naval Regional Medical Center, San Diego, California 92134. REFERENCES 1. Kim IG, Brummitt WM, Humphry A, et al: Foreign body in the airway: a review of 202 cases. Laryngoscope 83:347-354, 1973
or pneumonia (the esophageal foreign body). Am J Roentgenol Radium Ther Nucl Med 122:80-89, 1974
2. Brooks JW: Foreign bodies in the air and food passages. Ann Surg 175:720-732, 1972 3. Winship WS, Le Roux PD, Le Roux BT: Retention of radiotranslucent foreign bodies in the oesophagus as a cause of stridor. S Afr Med J 48:831-832, 1974
5. Steichen FM, Fellini A, Einhorn AH: Acute foreign body laryngo-tracheal obstruction: a cause for sudden and unexpected death in children. Pediatrics 48:281-285, 1971 6. Jackson C: Observations on the pathology of foreign bodies in the air and food passages. Otolaryngol Clin North Am 1:3-35, 1968
4. Smith PC, Swischuk LE, Fagan CJ: An elusive and often unsuspected cause of stridor
7. Pyman C: Radiolucent foreign bodies. Aust Paediatr J 8: 166, 1972
NOTICE The American Otological Society, Inc., notes with regret that its archives are not complete. The Council desires to remedy this insofar as possible and has directed the Editor-Librarian to seek replacement for volumes depleted from the library. Accordingly, anyone in possession of any of the following volumes is earnestly requested to notify the Editor-Librarian. If recompense is desired, any fair price will be honored. Vol. III, 1882-1887 Vol. XV, 1919-1921 (In some cases, these years may be in separate volumes) Vol. XVIII, 1928 Vol. XXXIV, 1944 Vol. XLVI, 1958 Brian F. McCabe, M.D., Editor-Librarian, American Otological Society, Inc., University Hospitals, Iowa City, Iowa, 52242.
Downloaded from aor.sagepub.com at East Carolina University on April 23, 2015
UNEXPECTED RADIOGRAPHIC FINDINGS RELATED TO FOREIGN BODIES WIU'RED T. MORIOKA, M.D.
ROBERT H. MAISEL, M.D.
THOMAS W. SMITH, M.D.
ROBERT W. CANTRELL, M.D.
SAN DIEGO, CALIFORNIA
SUMMARY - In two asymptomatic patients, routine preoperative radiographs revealed three pennies in the esophagus in one patient and a spring from a toy in another patient. In contrast, two symptomatic patients, one with a flip-top cap from a beer can in the esophagus and the other with a piece of photographic film in the larynx, had negative findings on their radiographs. Salient points of the cases are that diagnois can be delayed by inadequate history, misinterpretation of signs and symptoms, and unexpected radiographic findings. Special attention should be focused on the flip-top cap ingestion case. Sixty-five percent of 677 people polled have placed flip-top caps into full cans. Fifty-two people almost swallowed a flip-top cap. Otolaryngologists should be alerted about the radiolucency of this metallic foreign body, and the general population should be discouraged from this dangerous practice.
Radiographs taken of patients who have swallowed or aspirated foreign bodies may not reveal them.l" and routine x-rays may show unsuspected foreign bodies. Two patients with unsuspected foreign bodies, three coins in the esophagus of one and a spring in the right bronchus intermedius of the other, had these foreign bodies discovered on routine preoperative chest x-rays. Two symptomatic cases suspected of having foreign bodies had negative findings on x-ray. Endoscopy performed due to clinical symptoms located a flip-top cap of a can in the esophagus of one patient and a piece of photographic film in the larynx of another patient. These cases are presented to alert otolaryngologists to unexpected radiographic findings in cases involving foreign bodies.
CASE REPORTS Case 1. A three-year-old male was admitted to the ophthalmology service
with esotropia. Preoperative chest x-ray revealed a right middle lobe infiltrate and three coins in the midthoracic esophagus (Fig. 1). There was no history of pulmonary or gastrointestinal problems. After the x-rays, the parents stated that the child had been a poor eater for two years with occasional minor episodes of dysphagia, but no previous pulmonary problems were mentioned. He had been evaluated two years previously for gastrointestinal problems, which were attributed to emotional problems. Esophagoscopy was performed, and three pennies were found. The coins were removed without complications. Mild mucosal erythema was evident, but no other abnormalities were noted. Bronchoscopy revealed small amounts of purulent material in both main stem bronchi. No anatomical deformity in the airway was seen. Case 2. A six-year-old boy was ad-
From the Department of Otolaryngology, Naval Regional Medical Center, San Diego, California. The opinions or assertions contained herein are those of the authors and are not to be construed as official or as reflecting the view of the Department of the Navy. Presented at the meeting of the American Broncho-Esophagological Association Atlanta Georgia, April 7-8, 1975. ' , 627
Downloaded from aor.sagepub.com at East Carolina University on April 23, 2015
628
MORIOKA ET AL.
mitted to the otolaryngology service for myringotomies and insertion of ventilating tubes. Preoperative chest x-ray showed a coiled spring in the right bronchus intermedius. The parents reported a bout of severe coughing which subsided after a few minutes two months previously. A mild, intermittent nonproductive cough persisted. During bronchoscopy a 1)2 em coiled spring was removed. The spring was imbedded in the mucosa. Removal was accomplished by inserting the grasping forceps into the lumen of the spring, opening the forceps, and withdrawing the spring into the bronchoscope (Fig. 2A).
Fig. 1. (Case 1) Preoperative chest x-ray revealing three coins in the esopha-
gus.
ABC
S :
Fig. 2. A) (Case 2) Coiled spring removed with grasping forceps during bronchoscopy. B) (Case 3) Piece of photographic film which was found wedged between the vocal cords. C) (Case 4) Flip-top cap removed by esophagoscopy.
Case 3. An eleven-month-old female was admitted to the pediatric service with a diagnosis of laryngotracheobronchitis. Three days prior to admission, she developed an expiratory wheeze. On the day of admission the patient had a fever of 39.5 C, a barking cough, tachypnea, and inspiratory and expiratory stridor. The epiglottis appeared normal. The diagnosis was laryngotraeheobronchitis with a differential including foreign body, subglottic stenosis, and laryngeal polyp. The child was treated initially with a mist tent with nebulized racemic epinephrine and epinephrine subcutaneous. After the first day the child was afebrile, and the cough was diminished. Stridor persisted during agitation, and the cry was weak. Soft tissue x-ray of the neck revealed no foreign body. Chest x-ray showed a suggestion of subglottic swelling. Four days after admission, diagnostic laryngoscopy was performed to determine the cause of the persistent stridor. A small piece of photographic film was found wedged between the vocal cords (Fig. 2B). After removal of the film the child became asymptomatic. Case 4. A 31-year-old male was admitted after accidentally swallowing the flip-top cap from a beer can. He placed the flip-top cap into the full can of beer to prevent littering. As he was drinking the beer, he felt the cap enter his mouth but was unable to avoid swallowing it.
Downloaded from aor.sagepub.com at East Carolina University on April 23, 2015
FOREIGN BODIES
629
remained for a long period with probable damage to the bronchus." Patient No.3 was admitted with a diagnosis of laryngotracheobronchitis. During hospitalization foreign body was repeatedly mentioned in the differential diagnosis. Due to negative x-ray findings and improvement of the patient, diagnosis was delayed. Four days after admission, laryngoscopy and removal of the segment of photographic film stopped the stridor. With the increase of radiolucent material'v':? that can be DISCUSSION ingested or aspirated, pediatricians, Most cases of foreign body ingestion radiologists, and otolaryngologists must or aspiration are readily diagnosed and be suspicious of negative radiographs treated. In some cases, there are factors and think of foreign bodies in children that can confuse and delay diagno- with esophageal or respiratory sympsis.2 ,4 ,5 toms. Patient No.4 ingested a flip-top cap In Cases 1 and 2, the unusual foreign bodies discovered on preoperative chest from a beer can. Cervical, chest, and x-rays were unexpected. The patients abdomen x-rays were negative for a were thought to be asymptomatic, and metallic foreign body. As shown in this there was a significant delay in the patient, thin metallic objects can be diagnosis. The delay related to: 1) the radiolucent. Eight hours after admission young age of the children; 2) the par- due to persistent symptoms, esophagosents not observing the ingestion or copy was performed with removal of aspiration; 3) parents observing the in- the flip-top cap. Repeat chest x-ray cident but assuming that coughing had with the flip-top cap taped to the chest expelled the foreign body; and 4) symp- wall did not show the foreign body. toms being disregarded or misdiagA survey was conducted to determine nosed. the incidence of placing flip-top caps In Case 1 the parents did not observe into a full can. Four hundred and fortythe child actually ingesting the coins. one (65%) of 677 people polled stated His subsequent symptoms of "poor that they have placed flip-top caps into feeding" and occasional dysphagia were a full can. Two hundred eighty people noticed, but they were attributed to still continue the practice. Of the 161 "emotional problems." This case points who have stopped, 130 stated that they out three factors that delay diagnosis: had read or heard about the danger in 1) young children cannot communicate magazines, newspapers, or on the radio. adequately their symptoms or difficul- Of the 441 people who did place caps ties; 2) parents do not always know into full cans, 52 or 12% said they almost what their children have ingested; and swallowed a flip-top cap. 3) the symptoms can be disregarded or SUMMARY attributed to other causes by parents Preoperative radiographs in asymptoand physicians. matic patients revealed three pennies in The second patient was observed the esophagus in one patient and a during his aspiration incident, but his spring from a toy in the bronchus of mother thought he had coughed up the another patient. Two symptomatic paforeign body. His subsequent symp- tients, one with a flip-top beer can cap toms of intermittent mild cough were in the esophagus and another with a disregarded. Without the radiographs, piece of photographic film in her larynx, the foreign body most likely would have had negative findings on their radio-
X-rays of the neck, chest, and abdomen were negative for this metallic foreign body. He complained of a mild ache in the retrosternal area. The patient was admitted for observation. The next morning the retrosternal ache increased. Esophagoscopy was performed and the flip-top cap (Fig. 2C) was located and removed from its location 34 em from the upper incisor teeth. A mucosal abrasion was noted at 30 em, but his postoperative course was uneventful.
Downloaded from aor.sagepub.com at East Carolina University on April 23, 2015
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graphs. Diagnosis and treatment may be delayed due to: 1) young children cannot give an adequate history; 2) parents may be unaware of the ingestion of aspiration; 3) parents may believe that the foreign body was expelled during coughing; 4) the signs and symp-
toms are misinterpreted; and 5) radiolucent foreign bodies. The ingestion of a flip-top cap from a can deserves special attention. The practice of placing flip-top caps into full cans is common and we feel this practice should be discouraged.
Request for reprints should be sent to Wilfred T. Morioka, M.D., Department of Otolaryngology, Naval Regional Medical Center, San Diego, California 92134. REFERENCES 1. Kim IG, Brummitt WM, Humphry A, et al: Foreign body in the airway: a review of 202 cases. Laryngoscope 83:347-354, 1973
or pneumonia (the esophageal foreign body). Am J Roentgenol Radium Ther Nucl Med 122:80-89, 1974
2. Brooks JW: Foreign bodies in the air and food passages. Ann Surg 175:720-732, 1972 3. Winship WS, Le Roux PD, Le Roux BT: Retention of radiotranslucent foreign bodies in the oesophagus as a cause of stridor. S Afr Med J 48:831-832, 1974
5. Steichen FM, Fellini A, Einhorn AH: Acute foreign body laryngo-tracheal obstruction: a cause for sudden and unexpected death in children. Pediatrics 48:281-285, 1971 6. Jackson C: Observations on the pathology of foreign bodies in the air and food passages. Otolaryngol Clin North Am 1:3-35, 1968
4. Smith PC, Swischuk LE, Fagan CJ: An elusive and often unsuspected cause of stridor
7. Pyman C: Radiolucent foreign bodies. Aust Paediatr J 8: 166, 1972
NOTICE The American Otological Society, Inc., notes with regret that its archives are not complete. The Council desires to remedy this insofar as possible and has directed the Editor-Librarian to seek replacement for volumes depleted from the library. Accordingly, anyone in possession of any of the following volumes is earnestly requested to notify the Editor-Librarian. If recompense is desired, any fair price will be honored. Vol. III, 1882-1887 Vol. XV, 1919-1921 (In some cases, these years may be in separate volumes) Vol. XVIII, 1928 Vol. XXXIV, 1944 Vol. XLVI, 1958 Brian F. McCabe, M.D., Editor-Librarian, American Otological Society, Inc., University Hospitals, Iowa City, Iowa, 52242.
Downloaded from aor.sagepub.com at East Carolina University on April 23, 2015
