no bones about it…

The case.

A 15 year old male is bought to ED by his mother with a complaint of throat pain after eating a meal of chicken skewers that were cooked on the family barbecue. He is alert and in no apparent distress, breathing comfortably without stridor or drooling. His observations are within normal limits and his chest is clear to auscultation.

The skewers were prepared at home from chicken breast and they “are pretty sure there were no bones around” ….

[DDET What would you do next ??]

I ordered a CXR.

[/DDET]

[DDET What can you see ??]

 

• Metallic-appearing foreign body in the superior mediastinum. 

[/DDET]

[DDET What’s your next move ?]

• Where is this ?!
  • Most likely oesophageal given the history.
• It needs to come out ?!
  • Gastroenterology agree & will review the patient, however they ask for a CT with the question “Has it caused any damage ?!”

[/DDET]

[DDET Oesophageal Foreign Bodies…]

Approximately 80% of swallowed FBs are in children (aged 1-4 years). This will involve toys & coins for example and will lodge in the anatomically narrowed parts of the oesophagus. Adult patients generally provide an unequivocal history but can occasionally present with unintentional ingestion (eg. dentures). Adult impactions tend to be more distal.

Signs & Symptoms.

• Throat or retrosternal pain.
  • Localization of the object based on symptoms is rarely accurate.
• Dysphagia, vomiting, gagging.
• Children; refusal to eat/drink, vomiting, drooling, stridor, gagging.

Diagnosis.

• Plain X-ray can screen for radiopaque objects.
  • Eg. Coins will face forward on AP films (generally face-on in lateral films for tracheal placement).

• Bones are only seen on X-ray < 50% of the time.
• CT is a high-yield test.
  • Provides information on location as well as associated perforation or subsequent infection.

Management.

• Resuscitation [including airway protection with ventilatory & haemodynamic support].
  • Aspiration risk with secretion buildup from complete obstruction.
• Emergent endoscopy is required
  • Instances requiring urgent endoscopy;
    • Airway compromise
    • Sharp or elongated objects
    • Multiple FBs
    • Button batteries
      • Potential for mucosal injury or necrosis & perforation.
    • Two or more magnets.
    • Evidence of perforation
    • Coin at cricopharyngeus muscle
    • FB for > 24 hours.
  • Endoscopy allows removal of the majority of objects.
• Indirect laryngoscopy or fibreoptic visualization may be helpful for proximal objects.
• Other techniques;
  • Foley-catheter pulling object backs to oropharynx.
  • Bougie to advance objects further into the stomach.
  • Should only be used if object is blunt & lodged for < 24 hours.
• Glucagon:
  • Controversial. No better than ‘watchful waiting’. Promotes unwanted vomiting.
• Objects beyond the pylorus…
  • If shape or make is not of concern then treatment is expectant.
  • If this is deemed inappropriate surgical referral must be made.

 

Sharp Object Ingestion.

• Need immediate removal (if proximal to duodenum)
  • Intestinal perforation is common (~35%) when sharp objects pass distal to stomach.
• If object is distal to duodenum, then daily X-rays are required to document passage.
  • Failure to pass object > 3 days requires surgical opinion.

[/DDET]

[DDET The Outcome]

• Concerning proximity of the FB to mediastinal structures.
• Appropriate surgical teams notified at time of endoscopy in case of vascular catastrophe.
• An uneventful scope takes place a few hours later with successful retrieval of a small metallic wire frond.
• It turns out the barbecue was rather dirty prior to cooking and the father had scaled off the old material with a wire brush (a dislodged frond had then made its way into/onto a chicken skewer).

[/DDET]