Journal of Medicine and Medical Science Vol. 2(3) pp. 714-717, March 2011
Available online @http://www.interesjournals.org/JMMS
Copyright © 2011 International Research Journals
Case Report
Foreign body (disk battery) in the oesophagus
mimicking respiratory problem in a 13 months old
baby-delayed diagnosis
A.N. Umanax, M. E. Offiong,X Atana Uket Ewa,Xx P. Francisx, Abiola Grace Adekanyex, R. B.
Mgbex, N. Akpanx, A. Basseyx
X
ORL Unit, Department of Surgery, University of Calabar Teaching Hospital, Calabar
Xx
Peadiatric Department, University of Calabar Teaching Hospital, Calabar
Accepted 25 March, 2011
Foreign Bodies (FB) in the Aerodigestive tract are a medical emergency often seen in the extremes of
age groups particularly in children. Occasionally, diagnosis is delayed because a history of the initial
phase in children is missed and the child presents in the asymptomatic phase known to last hours to
weeks. The aim of this paper is to present a case of delayed diagnosis of Disk battery in the esophagus
mimicking respiratory problem in a 13 month baby. A review of relevant literature is also done. The
diagnostic relevance of careful history taking, examination and simple plain radiograph of the neck and
chest in a previously well child with respiratory symptoms refractory to medical treatment but
consistent with airway obstruction is highlighted.
Keywords: Oesophageal Foreign Bodies, Disk Battery, Delayed Diagnosis
INTRODUCTION
The oesophagus is a fibromuscular tube without a serosa
coat in its entire length. It extends from the
cricopharyngeus to the cardia of the stomach measuring
about 25 cm in the adult. The oesophagus is a direct
posterior relation of the laryngotracheobronchial airway
for most of its length. It serves the function of involuntary
transportation of swallowed food into the stomach. It has
4 anatomical constrictions which in concert with the size,
shape and consistency of the foreign body predispose to
the lodgment of foreign bodies.
Aspirated foreign bodies can settle in the Larynx,
Trachea or Bronchus with 80-90 % lodging in the
bronchus. In adults, larger aspirated objects lodge in the
larynx or trachea and smaller objects in the right
bronchus. In children, the frequency of smaller objects is
equal in both bronchi (Murray, 2009).
The Extremes of age groups, most commonly the 1-3
pediatric age groups, are more susceptible to accidental
swallow or aspiration of FB. The pediatric group lack
molars for grinding food, run and play with food or objects
*Corresponding author Email: aniefonumana@yahoo.com
in the mouth, and lack coordination of swallowing and
glottis closure (Murray, 2009). Infants and very young
children tend to explore their world by taste. The elderly
are susceptible as they become edentulous and wear illfitting dentures.
Types of FB encountered vary considerably from
dentures, meat bolus and bones in adults to coins, fish
bone, metallic or plastic toy parts or any object small
enough to enter the mouth in children.
The majority of swallowed FB passes harmlessly and
spontaneously through the gastrointestinal tract (Lin et
al., 2007). About 70 % of oesophageal objects lodge in
the upper and mid oesophagus (LOUIE et al., 2009) the
cricopharyngeus being the commonest site (Cerri et al.,
2003; Macpherson et al.,1996). Risk of injury from
ingested FB depends upon its size, shape and
consistency (Kenna et al., 1988; Wolach, 1994).
Recovery after removal is slower with organic FB than
with plastic or metal object because organic objects
cause greater inflammatory reaction. Of all dangerous
oesophageal FB, disk battery is the most dangerous. The
mechanisms of disk battery injury include; direct
corrosive action due to leakage, low voltage burns, toxic
Umana et al. 715
absorption of substances, and pressure necrosis (Temple
et al., 1983; Samad et al., 1999; Bass et al., 1992).
Liquefaction necrosis and perforation has been reported
4-6 hours after ingestion and lodgment of disk battery in
the oesophagus (Litovitz et al., 1984; Shabino et al.,
1979; Maves et al., 1984). Therefore, delayed diagnosis
or removal predisposes the child to serious
complications. As at 1983, there were only 8 reported
cases of disk battery ingestion in the literature. The
frequency has risen to 10 per million per year with
serious injuries in 1 per 1000 ingestions (Cowan et al.,
2002). We present our first case of disk battery impartion
in the oesophagus in order to raise awareness of its
possibility and potential dangers of delay or misdiagnosis
to children in our region.
CASE REPORT
A 13 month old female baby presented to our ORL outpatient clinic, University of Calabar Teaching Hospital,
Calabar, Nigeria with a 7week history of barking cough,
wheezing and noisy breathing. There was no history of
witnessed or suspected foreign body ingestion or
aspiration from the mother who was the sole caregiver.
The cough was of sudden onset and usually precipitated
by feeding and worse in the lying position. The noisy
breathing which started 4 days after onset of coughing
was associated with wheezing and mild difficulty in
breathing which worsen during sleep. There was no
history of voice changes, fever or regurgitation of feeds
(breast milk and Semisolid cereals). The child rejected
attempts at introduction to solid bolus meals during this
period.
The baby was misdiagnosed by the Family physician,
and receiving medical treatment for bronchial asthma
without significant improvement of symptoms.
On physical examination, the baby was healthy looking,
but had mild biphasic Stridor and transmitted bronchial
breath sounds in all lung fields.
We made a clinical diagnosis of mild upper airway
obstruction secondary to foreign body aspiration probably
lodged in the trachea.
A plain radiograph of Neck and Chest (AP-View)
showed a highly radio opaque circular object of about
20mm in diameter in the upper chest.
The
tracheobronchial airway was of adequate patency but
deviated to the right. There was no mediastinal shift.
Figure1.
Patient was admitted into the hospital for emergency
endoscopic evaluation under general anesthesia.
Panendoscopy, a combined rigid and flexible
esophagoscopy, using a flexible nasendoscope
introduced via the lumen of the rigid oesophagoscope,
revealed a metallic disk battery impacted in the midoesophagus, 12cm from the upper incisor tooth. The
battery was partially embedded in Granulation tissue. The
FB was removed with minimal bleeding without additional
mucosal injury. There was no apparent tracheoeosophageal fistula on close flexible endoscopic
inspection of impaction site. Flexible bronchoscopy was
also done to exclude airway foreign body. A nasogastric
tube was passed and left insitu for 72 hours. Postoprerative management was uneventful. Patient was
discharged home on the 5th day post-FB removal to
continue follow up in the outpatient clinic.
DISCUSSION
Foreign Bodies in the aerodigestive tract are a medical
emergency and challenge to the otorhinolaryngologist.
They are potentially life threatening conditions causing
about 3000 deaths every year despite improved medical
care and public awareness (Ozguner et al., 2004).
Presentation depends on the type, size of foreign Body,
site of lodgment, degree of obstruction as well as
duration between ingestion or aspiration and presentation
(Koempel et al., 1997).
Oesophageal foreign body may be asymptomatic or
characterized by garging, dysphagia, regurgitation of
recent meals, drooling of saliva. There may be dysphonia
or
respiratory
distress due to laryngeal
or
tracheobronchial compression (Athanassiadi et al., 2002)
Characteristic symptoms usually consist of airway
obstruction and hoarseness or aphonia for the larynx,
airway obstruction without hoarseness or aphonia for the
trachea and cough, unilateral wheezing and reduced
breath sounds for the bronchus.
Clinical diagnosis of FB in the aerodigestive tract can
be easy and straight forward but however, accurate
diagnosis may elude even the very experienced
physician (Ozguner et al., 2004).
The most sensitive of diagnostic factors is the eye
witness account of caregiver. When this is unavailable,
the history of the initial phase of choking and gasping,
coughing or airway obstruction in FB aspiration or
retching in oesophageal impaction, may be missing
(Okafor, 1995). The child may then present in the
asymptomatic phase usually lasting hours to weeks thus
mimicking respiratory problems.
Our index patient had a disk battery in the esophagus
mimicking a respiratory problem to the Family Physician,
and to the otolaryngologist a FB in the trachea. A 13
month old baby, still breast feeding and rejecting
introduction to solid bolus meals in preference to only
breast milk and semisolid diet is not uncommon in our
society. Therefore, the mother and family physician may
see no cause for suspicion of FB ingestion and lodgment.
However, notwithstanding a negative history of FB
ingestion or aspiration, the presence of mild biphasic
stridor, clear voice, bilateral transmitted tracheal breath
sounds are sufficient for a clinical suspicion of
Aerodigestive FB.
A soft tissue neck X-Ray –PA view revealed a highly
radio-opaque FB located 12 cm from upper incisor at
endoscopy and partially embedded in granulation tissue.
716 J. Med. Med. Sci.
Figure 1. Plain radiograph AP- View of the Neck
and Chest
Figure2a
Figure2B
Figure 2a and 2b. Disk battery after endoscopic removal.
These findings explained the clinical presentation of our
patient.
Firstly, the oesophagus and tracheobronchial tree are
direct anatomical relations, the later being anterior.
Therefore, extrinsic compression of the trachea by
esophageal FB may cause airway obstruction mimicking
FB in the airway or respiratory problem such as asthma.
Partial oesophageal obstruction may cause pooling of
secretion and feeds resulting in regurgitation and
aspiration especially in the supine position when patient
is asleep. Chronic aspiration may cause laryngitis,
tracheobronchitis with wheezes mimicking asthma.
Leakage from disk battery may cause chemical
tracheoesophagitis, with edema of respiratory mucosa
and partial airway obstruction producing noisy difficult
breathing. Chemical tracheoesophagitis or ischeamia
from local pressure may result in tracheoesophageal
fistula and its attendant respiratory complications.
The presence of FB and Granulation tissue may cause
dysphagia to solid bolus meals hence rejection of
introduction to solid meals.
Our patent mimicked a lower respiratory tract problem,
presenting a dilemma to the family physician. So we must
always remember that “that entire wheeze is not asthma”
if delayed diagnosis and referral is to be avoided.
Simple plain radiographs of the chest and neck are not
adequate in identifying clinically suspected foreign bodies
in the aerodigestive tract. Its specificity in radioluscent
foreign bodies are low (Nworgu et al., 2004) thus
presenting a diagnostic challenge (Bloom et al., 2005;
Svedstrom et al.,1989). Inspiratory chest and lateral neck
x-ray films usually appear normal in radioluscent airway
foreign bodies (Griffith et al.,1984) while diagnosis in the
eosophagus depends on air entrapment and increased
prevertebral soft tissue shadow. However, the delayed
diagnosis and referral of our index patient, highlights the
Umana et al. 717
inexcusability and cost effectiveness of simple plain chest
and neck radiographs as a diagnostic tool in the
management of respiratory problems. Therefore simple
plain chest and neck radiographs must never be
regarded as constituting additional financial burden on
the patient. Bloom et al (2005)
Prevention of morbidity and mortality in young children
depend on early diagnosis and endoscopic removal and
follow up management. With a careful clinical history
and physical examination appropriate radiograph and
endoscopic evaluation diagnosis may be hard but not
missed.Takada et al (2000)
Delayed diagnosis and referral often leads to the
complications phase of aerodigestive foreign bodies with
consequent severe morbidity and mortality.Murray(2009)
These may include pneumonia, atelectasis in bronchial
obstruction, pneumothorax and pneumomediastinum
from airway tear, bleeding from granulation tissue or
erosion into a major vessel. Others include obstruction,
granulation tissue, paraesophageal abscess and
tracheoesophageal fistula in esophageal foreign bodies
etc). Oesophageal burns and perforation has been
recorded in as early as 4 and 6 hours following ingestion
and lodgment of data batteriesOzguner etal (2004)
In conclusion, FB in the Aerodigestive tract could be
both a diagnostic and management challenge. A careful
history physical examination and chest and neck
radiograph are invaluable and inexcusable in the
diagnosis of respiratory problems in very young
children.Ibekwe et al (1999)
FB in the oesophagus may mimic FB in the airway or
respiratory problem. Early recognition and treatment is
imperative because the complications are serious and
can be life-threatening. Radiology plays an important role
in the initial diagnosis, in recognition of complications,
and in treatment.Macpherson et al (1996)
Early diagnosis or referral to the otorhinolaryngologist
for prompt diagnostic and therapeutic endoscopy is
advocated.
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