The Laryngoscope C 2014 The American Laryngological, V
Rhinological and Otological Society, Inc.
Upper Aerodigestive Magnetic Foreign Bodies in Children Julie C. Brown, MDCM, MPH; Fred M. Baik, MD; Henry C. Ou, MD; Jeffrey P. Otjen, MD; Hannah G. Parish; Dylan K. Chan, MD, PhD Objectives/Hypothesis: Small, powerful magnets are increasingly available in toys and other products, and are responsible for increasing numbers of foreign body injuries in children. Small, spherical, neodymium magnets available since 2008 are of particular concern. We aimed to identify all cases of upper aerodigestive foreign bodies at our institution over 15.5 years of study. Study Design: Case series including all patients treated at an urban, tertiary care children’s hospital who had upper aerodigestive magnetic foreign bodies, from January 1, 1998 through April 30, 2013. Methods: We manually reviewed 7,049 patient records abstracted from billing data to identify all patients 0 to 20 years of age who had upper aerodigestive magnetic foreign bodies. Results: We identified four cases of upper aerodigestive magnetic foreign bodies, one involving the hypopharynx, and three involving the upper esophagus. Three occurred in 2010 or later. Two cases involve the ingestion of multiple, spherical, neodymium magnets recently marketed as desktop toys. In both of these cases, there was a rapid development of mucosal injury at the site of attraction between two magnets. Conclusions: As small, powerful magnets become more ubiquitous, pediatric magnet foreign body injuries are increasing. Although most are gastrointestinal, we identified four recent cases involving the upper aerodigestive tract. Multiple magnets lodged in the hypopharynx or esophagus can rapidly cause pressure necrosis of mucosal tissues, and merit prompt management. Education regarding magnet safety and improved magnet safety standards are needed to reduce the risk of these injuries. Key Words: Esophageal, aerodigestive, airway, magnet(s), children, foreign body/foreign bodies, vallecula. Level of Evidence: 4 Laryngoscope, 124:1481–1485, 2014
INTRODUCTION
MATERIALS AND METHODS
Magnetic foreign body injuries appear to be on the rise.1–3 The majority of these injuries are ingestions involving the gastrointestinal tract, which are primarily managed by gastroenterologists and general surgeons.2 However, magnetic foreign bodies are also seen in the ear, nose, and upper airway, which can necessitate care from otolaryngologists. When two or more magnets are involved, the attractive forces of the magnets can trap mucosa, causing the magnets to lodge in the hypopharynx or esophagus. We report four cases of magnets that lodged in the upper aerodigestive tract. Two cases involve small, spherical magnets recently sold in sets as desktop or executive toys.
We used billing data as well as personal communication with all otolaryngologists at an urban, tertiary care children’s hospital to identify patients 0 to 20 years of age who had upper aerodigestive magnetic foreign bodies, from January 1, 1998 through April 30, 2013. Billing data were reviewed for: 1) all patient visits for a surgical procedure involving a foreign body from January 1, 1998 through August 31, 2013 (2173 records), 2) all radiology visits for foreign body encounters from October 1, 2008 through August 31, 2013 (matching to hospital records, 1808 records), and 3) all patient visits with International Classification of Diseases-9th Revision (ICD-9) diagnostic codes indicative of a foreign body January 1, 2008 through August 31, 2013 (codes 931–939.9, E912 and E915; 3068 records). All magnetic foreign bodies involving the hypopharynx, airways, or esophagus were eligible for inclusion. This study was approved by our local institutional review board.
From the Seattle Children’s Hospital (J.C.B., H.C.O., J.P.O., H.G.P., Seattle, Washington; the Department of Pediatrics, Division of Emergency Medicine (J.C.B.), Department of Otolaryngology–Head and Neck Surgery (F.M.B., H.C.O., D.K.C.), and the Department of Radiology (J.P.O.), University of Washington, Seattle, Washington, U.S.A. Editor’s Note: This Manuscript was accepted for publication October 29, 2013. This work was performed at the Seattle Children’s Hospital, Seattle, Washington, U.S.A. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Julie C. Brown, MD, MPH, Division of Pediatric Emergency Medicine, MB.7.520, Seattle Children’s Hospital, PO Box 5271, Seattle, WA 98105. E-mail: [email protected] D.K.C.),
RESULTS We identified four cases of upper aerodigestive magnetic foreign bodies. Three cases after 2008 were identified by both ICD-9 diagnosis code and surgical procedure code search strategies. One additional case from 2000 was found using the surgical procedures data only. Only one case was identified using the radiology data search strategy.
Case 1
DOI: 10.1002/lary.24489
In 2013, a 5-year-old developmentally typical male found a collection of 0.5 mm spherical magnets on the street and swallowed four of them. He immediately
Laryngoscope 124: June 2014
Brown et al.: Upper Aerodigestive Magnetic Foreign Bodies
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Fig. 1. Case 1: radiographs of four small, spherical magnets in the upper esophagus.
experienced neck pain and vomited once. On arrival to the emergency department soon afterward, he continued to complain of neck pain. A chest radiograph identified the magnets lodged in a square formation in his upper esophagus (Fig. 1). The patient was taken to the operating room and suspension laryngoscopy was performed 6.5 hours after the ingestion. The foreign bodies were visualized at the esophageal inlet (Fig. 2). The closest magnet was grasped with a straight forceps. All four magnets quickly reshaped into a line, which was then readily extracted. There was a small degree of mucosal erosion adjacent to where the magnets were found, suggesting that the mucosa was pinched by the magnets. This may explain why the magnets did not progress further along the alimentary tract, as well as the patient’s discomfort. The patient recovered well.
Case 2 In 2012, a 4-year-old developmentally typical female put two magnetic balls in her mouth at the same time. She attempted to swallow these, with subsequent odynophagia. She notified her mother, who offered her a banana and some water, without resolution of her pain. She was taken to a local emergency department, where she appeared uncomfortable, but without drooling, stridor, wheezing, respiratory distress, or cyanosis. Anteroposterior and lateral neck radiographs revealed two spherical, radiopaque foreign bodies in the region of the vallecula (Fig. 3). She was transferred to our institution, where direct laryngoscopy was performed 13 hours after the ingestion. She was found to have two magnets attracting across lingual and glottic surfaces of the base of the epiglottis on the right side. After removal using McGill forceps, there was some mild mucosal injury of the epiglottis and aryepiglottic fold at the site of each magnet (Fig. 4). The patient recovered well.
(Fig. 5). She presented to the emergency department soon afterward with complaints of difficulty feeding and drooling. On rigid esophagoscopy, the foreign body was identified in the upper esophagus, and a foreign body forceps was used to remove it. There was no evident esophageal injury and the patient recovered well.
Case 4 In 2000, a 10-month old swallowed a square magnet which lodged in the upper esophagus. He initially gagged and coughed, but was subsequently asymptomatic and able to drink. It was visible on radiographs at the level of the cricopharyngeus (Fig 6). When the magnet didn’t move after a night of observation, he was taken for endoscopy, where it was removed with peanut grasping forceps. Following removal, there was a small amount of bleeding at the site of the magnet, but no evident perforation. The patient recovered well.
Case 3 In 2010, an 11-month-old previously healthy female swallowed a single, large, U-shaped magnetic lapel pin
Fig. 2. Case 1: four magnets visualized just distal to the esophageal inlet.
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Fig. 3. Case 2: radiographs of two small, spherical magnets in the hypopharynx.
DISCUSSION We believe these are the first reported cases of magnets lodging in the upper aerodigestive tract. We are aware of three previously reported esophageal cases, two of which involved the lower esophagus, and the third is unspecified.4–6 Otolaryngologists are increasingly likely to be involved in cases of magnetic foreign bodies, as small, high-powered magnets are increasingly available in toys, jewelry, and household products, and magnet-related foreign body injuries are increasing.1–3,7 An analysis of National Electronic Injury Surveillance System data indicates that there have been over 22,000 pediatric cases of ingested magnetic foreign bodies in the United States from 2002 to 2011, with a 5-fold increase in magnet ingestions, comparing the first two and the final two years of study.1 The two cases that involve spherical magnetic balls were both recent. These magnets are frequently swallowed in groups and thus have increased potential to adhere to each other across mucosa.2 In addition, when three or more of these balls are ingested, they can form chains that can subsequently snap closed into loops, sometimes trapping mucosa in the process.8 Magnets attracting across mucosal tissue within one segment of bowel, or across loops of bowels, can rapidly cause erosion and perforation.9–11 Sets of 0.5-cm-diameter spherical neodymium magnets first entered the market in 2008 and were more widely available by 2009. Millions of these sets, mostly containing 216 magnets per set, have been sold in the past few years. In 2012, the Consumer Product Safety Commission requested that American companies selling these magnets recall their products,12 and ultimately took legal action against those who did not comply.13,14 Although the largest company selling these magnets has recently liquidated, magnet sets currently remain for sale by other companies in the United States, pending the outcome of these lawsuits, and can also be purchased from other countries via internet sites and shipped to the United States. Although still much more rare than coin ingestions, otolaryngologists need to be aware of the increasing risk Laryngoscope 124: June 2014
of magnet ingestions in children. Multiple magnets ingestions should be treated emergently, as the pressure from two magnets across mucosa can rapidly cause mucosal erosion and perforation. With reported single magnet ingestions, providers must consider carefully whether or not a second magnet might be present and difficult to distinguish from the first, as this can be easily missed.15 Additional magnets might also be present further along in the alimentary tract. If multiple magnets end up in the intestines, they can attract across intestinal walls, potentially resulting in bowel perforation and peritonitis. Prior to removal, patients with the potential for multiple magnet ingestions should have imaging of the entire digestive tract. During endoscopic removal, the proceduralist should attempt to maintain stable visualization of all of the magnets, to ensure that one or more does not become detached and pass further down the esophagus. They should also be aware that magnets may attract to endoscopes and other metallic equipment, and thus escape visualization during the procedure.
Fig. 4. Case 2: injury at the base of the epiglottis, where one of two attracting magnets was located.
Brown et al.: Upper Aerodigestive Magnetic Foreign Bodies
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Fig. 5. Case 3: radiographs of a magnetic lapel pin in the upper esophagus.
Fig. 6. Case 4: Radiographs of a thin, square magnet in the mid-esophagus.
They may be found adhering to the equipment on removal from the patient. Endoscopically or surgically retrieved magnets should generally not be returned to the patient, to prevent reingestion.2 The increase in magnet ingestions has prompted the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition to develop an algorithm assisting the clinician in decision-making for these children.16 Children with multiple magnetic foreign bodies, or any magnets not progressing as far as the stomach, should be referred promptly for further management. Families and caregivers of young children, as well as older children with a history of developmental disability, pica, Laryngoscope 124: June 2014
1484
or autism, should be advised to keep magnets away from the child’s environment. Teenagers should be educated regarding the hazards of imitating piercings or otherwise putting small magnets in or near their nose or mouth.
CONCLUSION Earlier recognition of magnet ingestions may facilitate successful removal and decrease the risk of complications. Otolaryngologists need to be aware of the increasing incidence and risks associated with preventable and potentially lethal magnet ingestions in Brown et al.: Upper Aerodigestive Magnetic Foreign Bodies
children, and the special considerations surrounding their removal.
BIBLIOGRAPHY 1. Silverman JA, Brown JC, Willis MM, Ebel BE. Increase in pediatric magnet-related foreign bodies requiring emergency care. Ann Emerg Med 2013;62(6):604–608.e1. 2. Agbo C, Lee L, Chiang V, et al. Magnet-related injury rates in children: a single hospital experience. J Pediatr Gastroenterol Nutr 2013;57:14–17. 3. Brown JC, Otjen JP, Drugas GT. Too attractive: the growing problem of magnet ingestions in children. Pediatr Emerg Care 2013;29:1170–1174. 4. Durko A, Czkwianianc E, Bak-Romaniszyn L, Malecka-Panas E. Accidental ingestion of two magnets—aggressive or prolonged approach? Pol Merkur Lekarski 2007;22:416–418. 5. Lin MT, Yeung CY, Lee HC, Sheu JC, Wang NL, Lee KS. Management of foreign body ingestion in children: experience with 42 cases. Acta Paediatr Taiwan 2003;44:269–273. 6. Seo TJ, Park CH, Jeong HK, et al. Endoscopic removal of impacted magnetic foreign bodies in the gastroesophageal junction. Surg Laparosc Endosc Percutan Tech 2011;21:e313–e315. 7. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Warning labels ineffective at preventing high-powered magnet ingestions: NASPGHAN releases new survey findings. 2012. Available at: http://www.naspghan.org/user-assets/Documents/pdf/Advocacy/ Magnets/NASPGHAN%20Media%20Advisory%20on%20Magnet%20Ingestions. pdf. Accessed October 8, 2013. 8. Otjen JP, Rohrmann CA Jr, Iyer RS. Imaging pediatric magnet ingestion with surgical-pathological correlation. Pediatr Radiol 2012;43:851–859.
Laryngoscope 124: June 2014
9. Anselmi EH, San Roman CG, Fontoba JEB, et al. Intestinal perforation caused by magnetic toys. J Pediatr Surg 2007;42:e13–e16. 10. Naji H, Isacson D, Svensson JF, Wester T. Bowel injuries caused by ingestion of multiple magnets in children: a growing hazard. Pediatr Surg Int 2012;28:367–374. 11. Nishi Y, Sasajima K, Matsutani T, et al. Intestinal fistulas caused by ingestion of magnets in an adult [in Japanese]. Jpn J Gastroenterol Surg 2008;41:2069–2074. 12. U.S. Consumer Product Safety Commission. Safety standard for magnet sets; notice of proposed rulemaking [billing code 6355-01-P, 16 CFR part 1240]. CPSC brief. 2012. Available at: https://www.federalregister.gov/ articles/2012/09/04/2012-21608/safety-standard-for-magnet-sets. Accessed October 8, 2013. 13. U.S. Consumer Product Safety Commission. CPSC sues Star Networks USA over hazardous, high-powered magnet balls and cubes [release #13-077, December 19, 2012]. News from CPSC. 2012. Available at: http://www.cpsc.gov/en/Newsroom/News-Releases/2013/CPSC-Sues-StarNetworks-USA-Over-Hazardous-High-Powered-Magnetic-Balls-and-Cubes. Accessed October 8, 2013. 14. U.S. Consumer Products Safety Commission. CPSC sues Zen Magnets over hazardous, high-powered magnetic balls action prompted by ongoing harm to children from ingested magnets [release #12-243, August 7, 2012]. 2012. Available at: http://www.cpsc.gov/Newsroom/ News-Releases/2012/CPSC-Sues-Zen-Magnets-Over-Hazardous-HighPowered-Magnetic-Balls-Action-prompted-by-ongoing-harm-to-childrenfrom-ingested-magnets. Accessed October 8, 2013. 15. Butterworth J, Feltis B. Toy magnet ingestion in children: revising the algorithm. J Pediatr Surg 2007;42:e3–e5. 16. Hussain SZ, Bousvaros A, Gilger M, et al. Management of ingested magnets in children. J Pediatr Gastroenterol Nutr 2012;55:239–242.
Brown et al.: Upper Aerodigestive Magnetic Foreign Bodies
1485
Rhinological and Otological Society, Inc.
Upper Aerodigestive Magnetic Foreign Bodies in Children Julie C. Brown, MDCM, MPH; Fred M. Baik, MD; Henry C. Ou, MD; Jeffrey P. Otjen, MD; Hannah G. Parish; Dylan K. Chan, MD, PhD Objectives/Hypothesis: Small, powerful magnets are increasingly available in toys and other products, and are responsible for increasing numbers of foreign body injuries in children. Small, spherical, neodymium magnets available since 2008 are of particular concern. We aimed to identify all cases of upper aerodigestive foreign bodies at our institution over 15.5 years of study. Study Design: Case series including all patients treated at an urban, tertiary care children’s hospital who had upper aerodigestive magnetic foreign bodies, from January 1, 1998 through April 30, 2013. Methods: We manually reviewed 7,049 patient records abstracted from billing data to identify all patients 0 to 20 years of age who had upper aerodigestive magnetic foreign bodies. Results: We identified four cases of upper aerodigestive magnetic foreign bodies, one involving the hypopharynx, and three involving the upper esophagus. Three occurred in 2010 or later. Two cases involve the ingestion of multiple, spherical, neodymium magnets recently marketed as desktop toys. In both of these cases, there was a rapid development of mucosal injury at the site of attraction between two magnets. Conclusions: As small, powerful magnets become more ubiquitous, pediatric magnet foreign body injuries are increasing. Although most are gastrointestinal, we identified four recent cases involving the upper aerodigestive tract. Multiple magnets lodged in the hypopharynx or esophagus can rapidly cause pressure necrosis of mucosal tissues, and merit prompt management. Education regarding magnet safety and improved magnet safety standards are needed to reduce the risk of these injuries. Key Words: Esophageal, aerodigestive, airway, magnet(s), children, foreign body/foreign bodies, vallecula. Level of Evidence: 4 Laryngoscope, 124:1481–1485, 2014
INTRODUCTION
MATERIALS AND METHODS
Magnetic foreign body injuries appear to be on the rise.1–3 The majority of these injuries are ingestions involving the gastrointestinal tract, which are primarily managed by gastroenterologists and general surgeons.2 However, magnetic foreign bodies are also seen in the ear, nose, and upper airway, which can necessitate care from otolaryngologists. When two or more magnets are involved, the attractive forces of the magnets can trap mucosa, causing the magnets to lodge in the hypopharynx or esophagus. We report four cases of magnets that lodged in the upper aerodigestive tract. Two cases involve small, spherical magnets recently sold in sets as desktop or executive toys.
We used billing data as well as personal communication with all otolaryngologists at an urban, tertiary care children’s hospital to identify patients 0 to 20 years of age who had upper aerodigestive magnetic foreign bodies, from January 1, 1998 through April 30, 2013. Billing data were reviewed for: 1) all patient visits for a surgical procedure involving a foreign body from January 1, 1998 through August 31, 2013 (2173 records), 2) all radiology visits for foreign body encounters from October 1, 2008 through August 31, 2013 (matching to hospital records, 1808 records), and 3) all patient visits with International Classification of Diseases-9th Revision (ICD-9) diagnostic codes indicative of a foreign body January 1, 2008 through August 31, 2013 (codes 931–939.9, E912 and E915; 3068 records). All magnetic foreign bodies involving the hypopharynx, airways, or esophagus were eligible for inclusion. This study was approved by our local institutional review board.
From the Seattle Children’s Hospital (J.C.B., H.C.O., J.P.O., H.G.P., Seattle, Washington; the Department of Pediatrics, Division of Emergency Medicine (J.C.B.), Department of Otolaryngology–Head and Neck Surgery (F.M.B., H.C.O., D.K.C.), and the Department of Radiology (J.P.O.), University of Washington, Seattle, Washington, U.S.A. Editor’s Note: This Manuscript was accepted for publication October 29, 2013. This work was performed at the Seattle Children’s Hospital, Seattle, Washington, U.S.A. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Julie C. Brown, MD, MPH, Division of Pediatric Emergency Medicine, MB.7.520, Seattle Children’s Hospital, PO Box 5271, Seattle, WA 98105. E-mail: [email protected] D.K.C.),
RESULTS We identified four cases of upper aerodigestive magnetic foreign bodies. Three cases after 2008 were identified by both ICD-9 diagnosis code and surgical procedure code search strategies. One additional case from 2000 was found using the surgical procedures data only. Only one case was identified using the radiology data search strategy.
Case 1
DOI: 10.1002/lary.24489
In 2013, a 5-year-old developmentally typical male found a collection of 0.5 mm spherical magnets on the street and swallowed four of them. He immediately
Laryngoscope 124: June 2014
Brown et al.: Upper Aerodigestive Magnetic Foreign Bodies
1481
Fig. 1. Case 1: radiographs of four small, spherical magnets in the upper esophagus.
experienced neck pain and vomited once. On arrival to the emergency department soon afterward, he continued to complain of neck pain. A chest radiograph identified the magnets lodged in a square formation in his upper esophagus (Fig. 1). The patient was taken to the operating room and suspension laryngoscopy was performed 6.5 hours after the ingestion. The foreign bodies were visualized at the esophageal inlet (Fig. 2). The closest magnet was grasped with a straight forceps. All four magnets quickly reshaped into a line, which was then readily extracted. There was a small degree of mucosal erosion adjacent to where the magnets were found, suggesting that the mucosa was pinched by the magnets. This may explain why the magnets did not progress further along the alimentary tract, as well as the patient’s discomfort. The patient recovered well.
Case 2 In 2012, a 4-year-old developmentally typical female put two magnetic balls in her mouth at the same time. She attempted to swallow these, with subsequent odynophagia. She notified her mother, who offered her a banana and some water, without resolution of her pain. She was taken to a local emergency department, where she appeared uncomfortable, but without drooling, stridor, wheezing, respiratory distress, or cyanosis. Anteroposterior and lateral neck radiographs revealed two spherical, radiopaque foreign bodies in the region of the vallecula (Fig. 3). She was transferred to our institution, where direct laryngoscopy was performed 13 hours after the ingestion. She was found to have two magnets attracting across lingual and glottic surfaces of the base of the epiglottis on the right side. After removal using McGill forceps, there was some mild mucosal injury of the epiglottis and aryepiglottic fold at the site of each magnet (Fig. 4). The patient recovered well.
(Fig. 5). She presented to the emergency department soon afterward with complaints of difficulty feeding and drooling. On rigid esophagoscopy, the foreign body was identified in the upper esophagus, and a foreign body forceps was used to remove it. There was no evident esophageal injury and the patient recovered well.
Case 4 In 2000, a 10-month old swallowed a square magnet which lodged in the upper esophagus. He initially gagged and coughed, but was subsequently asymptomatic and able to drink. It was visible on radiographs at the level of the cricopharyngeus (Fig 6). When the magnet didn’t move after a night of observation, he was taken for endoscopy, where it was removed with peanut grasping forceps. Following removal, there was a small amount of bleeding at the site of the magnet, but no evident perforation. The patient recovered well.
Case 3 In 2010, an 11-month-old previously healthy female swallowed a single, large, U-shaped magnetic lapel pin
Fig. 2. Case 1: four magnets visualized just distal to the esophageal inlet.
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Fig. 3. Case 2: radiographs of two small, spherical magnets in the hypopharynx.
DISCUSSION We believe these are the first reported cases of magnets lodging in the upper aerodigestive tract. We are aware of three previously reported esophageal cases, two of which involved the lower esophagus, and the third is unspecified.4–6 Otolaryngologists are increasingly likely to be involved in cases of magnetic foreign bodies, as small, high-powered magnets are increasingly available in toys, jewelry, and household products, and magnet-related foreign body injuries are increasing.1–3,7 An analysis of National Electronic Injury Surveillance System data indicates that there have been over 22,000 pediatric cases of ingested magnetic foreign bodies in the United States from 2002 to 2011, with a 5-fold increase in magnet ingestions, comparing the first two and the final two years of study.1 The two cases that involve spherical magnetic balls were both recent. These magnets are frequently swallowed in groups and thus have increased potential to adhere to each other across mucosa.2 In addition, when three or more of these balls are ingested, they can form chains that can subsequently snap closed into loops, sometimes trapping mucosa in the process.8 Magnets attracting across mucosal tissue within one segment of bowel, or across loops of bowels, can rapidly cause erosion and perforation.9–11 Sets of 0.5-cm-diameter spherical neodymium magnets first entered the market in 2008 and were more widely available by 2009. Millions of these sets, mostly containing 216 magnets per set, have been sold in the past few years. In 2012, the Consumer Product Safety Commission requested that American companies selling these magnets recall their products,12 and ultimately took legal action against those who did not comply.13,14 Although the largest company selling these magnets has recently liquidated, magnet sets currently remain for sale by other companies in the United States, pending the outcome of these lawsuits, and can also be purchased from other countries via internet sites and shipped to the United States. Although still much more rare than coin ingestions, otolaryngologists need to be aware of the increasing risk Laryngoscope 124: June 2014
of magnet ingestions in children. Multiple magnets ingestions should be treated emergently, as the pressure from two magnets across mucosa can rapidly cause mucosal erosion and perforation. With reported single magnet ingestions, providers must consider carefully whether or not a second magnet might be present and difficult to distinguish from the first, as this can be easily missed.15 Additional magnets might also be present further along in the alimentary tract. If multiple magnets end up in the intestines, they can attract across intestinal walls, potentially resulting in bowel perforation and peritonitis. Prior to removal, patients with the potential for multiple magnet ingestions should have imaging of the entire digestive tract. During endoscopic removal, the proceduralist should attempt to maintain stable visualization of all of the magnets, to ensure that one or more does not become detached and pass further down the esophagus. They should also be aware that magnets may attract to endoscopes and other metallic equipment, and thus escape visualization during the procedure.
Fig. 4. Case 2: injury at the base of the epiglottis, where one of two attracting magnets was located.
Brown et al.: Upper Aerodigestive Magnetic Foreign Bodies
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Fig. 5. Case 3: radiographs of a magnetic lapel pin in the upper esophagus.
Fig. 6. Case 4: Radiographs of a thin, square magnet in the mid-esophagus.
They may be found adhering to the equipment on removal from the patient. Endoscopically or surgically retrieved magnets should generally not be returned to the patient, to prevent reingestion.2 The increase in magnet ingestions has prompted the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition to develop an algorithm assisting the clinician in decision-making for these children.16 Children with multiple magnetic foreign bodies, or any magnets not progressing as far as the stomach, should be referred promptly for further management. Families and caregivers of young children, as well as older children with a history of developmental disability, pica, Laryngoscope 124: June 2014
1484
or autism, should be advised to keep magnets away from the child’s environment. Teenagers should be educated regarding the hazards of imitating piercings or otherwise putting small magnets in or near their nose or mouth.
CONCLUSION Earlier recognition of magnet ingestions may facilitate successful removal and decrease the risk of complications. Otolaryngologists need to be aware of the increasing incidence and risks associated with preventable and potentially lethal magnet ingestions in Brown et al.: Upper Aerodigestive Magnetic Foreign Bodies
children, and the special considerations surrounding their removal.
BIBLIOGRAPHY 1. Silverman JA, Brown JC, Willis MM, Ebel BE. Increase in pediatric magnet-related foreign bodies requiring emergency care. Ann Emerg Med 2013;62(6):604–608.e1. 2. Agbo C, Lee L, Chiang V, et al. Magnet-related injury rates in children: a single hospital experience. J Pediatr Gastroenterol Nutr 2013;57:14–17. 3. Brown JC, Otjen JP, Drugas GT. Too attractive: the growing problem of magnet ingestions in children. Pediatr Emerg Care 2013;29:1170–1174. 4. Durko A, Czkwianianc E, Bak-Romaniszyn L, Malecka-Panas E. Accidental ingestion of two magnets—aggressive or prolonged approach? Pol Merkur Lekarski 2007;22:416–418. 5. Lin MT, Yeung CY, Lee HC, Sheu JC, Wang NL, Lee KS. Management of foreign body ingestion in children: experience with 42 cases. Acta Paediatr Taiwan 2003;44:269–273. 6. Seo TJ, Park CH, Jeong HK, et al. Endoscopic removal of impacted magnetic foreign bodies in the gastroesophageal junction. Surg Laparosc Endosc Percutan Tech 2011;21:e313–e315. 7. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Warning labels ineffective at preventing high-powered magnet ingestions: NASPGHAN releases new survey findings. 2012. Available at: http://www.naspghan.org/user-assets/Documents/pdf/Advocacy/ Magnets/NASPGHAN%20Media%20Advisory%20on%20Magnet%20Ingestions. pdf. Accessed October 8, 2013. 8. Otjen JP, Rohrmann CA Jr, Iyer RS. Imaging pediatric magnet ingestion with surgical-pathological correlation. Pediatr Radiol 2012;43:851–859.
Laryngoscope 124: June 2014
9. Anselmi EH, San Roman CG, Fontoba JEB, et al. Intestinal perforation caused by magnetic toys. J Pediatr Surg 2007;42:e13–e16. 10. Naji H, Isacson D, Svensson JF, Wester T. Bowel injuries caused by ingestion of multiple magnets in children: a growing hazard. Pediatr Surg Int 2012;28:367–374. 11. Nishi Y, Sasajima K, Matsutani T, et al. Intestinal fistulas caused by ingestion of magnets in an adult [in Japanese]. Jpn J Gastroenterol Surg 2008;41:2069–2074. 12. U.S. Consumer Product Safety Commission. Safety standard for magnet sets; notice of proposed rulemaking [billing code 6355-01-P, 16 CFR part 1240]. CPSC brief. 2012. Available at: https://www.federalregister.gov/ articles/2012/09/04/2012-21608/safety-standard-for-magnet-sets. Accessed October 8, 2013. 13. U.S. Consumer Product Safety Commission. CPSC sues Star Networks USA over hazardous, high-powered magnet balls and cubes [release #13-077, December 19, 2012]. News from CPSC. 2012. Available at: http://www.cpsc.gov/en/Newsroom/News-Releases/2013/CPSC-Sues-StarNetworks-USA-Over-Hazardous-High-Powered-Magnetic-Balls-and-Cubes. Accessed October 8, 2013. 14. U.S. Consumer Products Safety Commission. CPSC sues Zen Magnets over hazardous, high-powered magnetic balls action prompted by ongoing harm to children from ingested magnets [release #12-243, August 7, 2012]. 2012. Available at: http://www.cpsc.gov/Newsroom/ News-Releases/2012/CPSC-Sues-Zen-Magnets-Over-Hazardous-HighPowered-Magnetic-Balls-Action-prompted-by-ongoing-harm-to-childrenfrom-ingested-magnets. Accessed October 8, 2013. 15. Butterworth J, Feltis B. Toy magnet ingestion in children: revising the algorithm. J Pediatr Surg 2007;42:e3–e5. 16. Hussain SZ, Bousvaros A, Gilger M, et al. Management of ingested magnets in children. J Pediatr Gastroenterol Nutr 2012;55:239–242.
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