CASE REPORT – OPEN ACCESS

International Journal of Surgery Case Reports 36 (2017) 179–181

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International Journal of Surgery Case Reports

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Delayed diagnosis of esophageal foreign body: A case report

Salem Yahyaoui a,∗ , Imen Jahaouat b , Ines Brini b , Azza Sammoud a
a
Department of Pediatrics C, Children Hospital of Tunis, Faculty of Medicine of Tunis, Tunis El Manar University, Tunisia
b
Department of Pediatrics B, Children Hospital of Tunis, Faculty of Medicine of Tunis, Tunis El Manar University, Tunisia

a r t i c l e i n f o a b s t r a c t

Article history: INTRODUCTION: Foreign body (FB) ingestion, a common and serious problem in children, can present with
Received 10 April 2017 a wide variety of symptoms. This paper describes and discusses the case of an esophageal foreign body
Received in revised form 16 May 2017 (EFB), in which the patient presented with primarily respiratory clinical signs causing delayed diagnosis.
Accepted 19 May 2017
PRESENTATION OF CASE: A six month old boy presented with three months history of harsh cough, stri-
Available online 29 May 2017
dor and pulmonary congestion. He was repeatedly treated with steroids and antibiotics. His symptoms
worsened progressively. On examination, he was tachypneic with suprasternal recession, scattered crepi-
Keywords:
tations, diffuse wheeze and a continuous stridor. Chest X-ray was normal. The flexible bronchoscopy
Esophagus
Foreign body
showed a posterior external compression on the middle wall of the trachea. The CT scan was normal.
Endoscopy The contrast X-ray study of the esophagus revealed an endoluminal filling defect. The esophagoscopy
Case report revealed narrowing at 12 cm of dental arch, and a bourgeoning yellow mass easily bleeding on contact.
Esophageal biopsies were obtained, and histology was inconclusive. A surgical exploration was planned,
but the infant forced out a pistachio shell after a chest physiotherapy session.
DISCUSSION: Ingestion of FB by small children is a common problem. The majority of EFBs pass harmlessly
through the gastrointestinal tract; however, some EFBs can cause significant morbidities. The diagnosis
may be delayed leading to several complications especially if the ingestion of the FB is unwitnessed and
when the clinician does not think of FB ingestion as part of the differential diagnosis of chronic respiratory
signs.
CONCLUSION: This case highlights, the importance of recognizing, the rare and often forgotten respiratory
symptoms of EFB body to avoid diagnostic delay especially in unwitnessed FB ingestion.
© 2017 The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Intrduction episodes or ingestion of foreign body witnessed by the parents and

he had never experienced dysphagia. He was treated on multiple
The natural inclination of children to explore their environ- occasions with corticosteroid and antibiotics. However stridor and
ment orally makes the ingestion of FBs common, especially in cough got progressively worse. During the last 48 h before admis-
those less than six years old. Upper respiratory tract infections sion, he had repeated attacks of cough and breathlessness without
and stridor secondary to esophageal foreign body ingestion is an history of dysphagia or drooling. On examination, he was eutrophic.
unusual occurrence. The diagnosis can be missed or delayed when He had a temperature of 38.5 ◦ C and oxygen saturations of 95%
the presenting symptoms are mainly respiratory. This work has in air. Respiratory rate was of 50/mn with marked suprasternal
been reported in line with the SCARE criteria [1] recession, scattered crepitations, diffuse wheeze and a continu-
ous stridor. Cardiovascular examination was normal. Blood tests
2. Presentation of case showed a normal complete blood count and a C-reactive protein
of 20 mg/l. Chest- X-ray was normal. The child was managed with
A 6-month-old boy was referred to the hospital with dysp- intravenous cefotaxim 100 mg/kg/day, nebulised adrenaline, sup-
nea and stridor. He had a three months history of stridor, harsh plementary oxygen and chest physiotherapy. The improvement
cough and pulmonary congestion. There was no history of choking was slow and partial. The flexible bronchoscopy revealed a nar-
rowing of the trachea about 30%, due to an external compression.
Cervical and thoracic CT seeking bronchopulmonary malformations
Abbreviations: FB, foreign body; EFB, esophageal foreign body.
or lymphadenopathy was normal. An abnormality of the aortic
∗ Corresponding author. Present adress: Department of Pediatric Medicine C, Chil- arches was suspected and contrast X-ray study of the esophagus
dren Hospital Bab Saadoun 1017 Tunis, Tunisia. revealed an endoluminal filling defect (Fig. 1). The esophagoscopy
E-mail addresses: [email protected] (S. Yahyaoui), revealed the narrowing of the esophagus at 12 cm of dental arch,
[email protected] (I. Jahaouat), [email protected] (I. Brini),
and anterior bourgeoning yellow mass bleeding easily on contact
[email protected] (A. Sammoud).

http://dx.doi.org/10.1016/j.ijscr.2017.05.028
2210-2612/© 2017 The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
 CASE REPORT – OPEN ACCESS
180 S. Yahyaoui et al. / International Journal of Surgery Case Reports 36 (2017) 179–181

Fig. 1. Contrast X-ray study of the esophagus showing an endoluminal filling defect.

Fig. 3. The foreign body forced out: a pistachio shell.

(Fig. 2). There was also no evidence of mucosal breach or foreign
body. Esophageal biopsies were obtained, and histology was incon-
neath the cricopharyngeal muscle because of the weak peristalsis
clusive. A surgical exploration was planned, but the infant after a
in that region. The rest are found in the physiological narrowing
chest physiotherapy session forced out a pistachio shell (Fig. 3).
of the esophagus at the level of the aortic arch, the left main stem
Over the ensuing 2 years, the child has been well and gaining weight
bronchus and the lower esophageal sphincter [2,10]. Sharp objects
satisfactorily.
have a tendency to get stuck at the level of upper esophagus [2].
Respiratory difficulties may be caused by compression of the
3. Discussion membranous trachea. Periesophagitis, frank abcesses, cricoids
pericondritis, spill-over of secretions into the trachea and tracheoe-
This case report describes an unusual presentation of a FB in sophageal fistulas [10].
the esophagus. In fact the vast majority of EFBs bodies will pass The most likely mechanism for stridor is direct compression of
spontaneously through gastrointestinal tract without any symp- the posterior wall of trachea by the impacted upper EFB as illus-
toms or complications. In cases where it is impacted, clinical signs trated by our case. The compressive effect on the trachea is due to
are variable. In children, it may present with respiratory symptoms the soft pliable nature and the narrower diameter of the trachea in
or dysphagia. Delay in diagnosis can be the result of several fac- children, compared to adults [11].
tors such as unwitnessed or initially asymptomatic FB ingestion The degree of damage depends on the nature of the impacted
and in cases of radiolucent objects. In our case, clinicians had not EFB, duration, pre-existing esophageal/tracheal pathology, site of
thought of EFB as part of the differential diagnosis of chronic respi- impaction and the age of the child [12,13].
ratory signs. Long-standing EFBs may cause recurrent pneumonia The management of esophageal foreign bodies is removal by
or more serious consequences ranging from ulceration to fistulae, means of a rigid or flexible endoscope wherever possible. Alter-
mediastinitis, pneumothorax, abscess and stricture [2–7]. native methods such as dislodgment into the stomach have been
The majority of FB ingestions occur in the pediatric population, described [14]. When endoscopic retrieval is not possible, imme-
with a peak incidence between six months and six years of age [8,9]. diate open surgical extraction should be performed. A few rare
This is due to increasing curiosity and because of hand-mouth inter- cases have been reported in which esophagotomy was required to
actions with a natural instinct to place everything in the mouth remove an impacted esophageal foreign body, and this approach
[10]. The majority of impacted FB tends to be found just under- is indicated if signs of life-threatening complications occur or

Fig 2. Esophagoscopy showing anterior yellowish burgeoning mass obstructing almost all of the esophageal lumen at 12 cm of dental arch.
 CASE REPORT – OPEN ACCESS
S. Yahyaoui et al. / International Journal of Surgery Case Reports 36 (2017) 179–181 181

appear imminent [15]. In the case presented here, the patient Registration of research studies
had forced out spontaneously the pistachio shell. Physiother-
apy is not intended nor recommended for the management of researchregistry2544.
ingested foreign bodies. In the presented case, chest physiotherapy
was prescribed for bronchial congestion. However, the maneuvers Guarantor
were slightly aggressive causing sudden cough and vomiting with
increased intra-abdominal pressure facilitating the expulsion of the Salem Yahyaoui has full responsibility for the work.
foreign body
Acknowledgement
4. Conclusion
This research did not receive any specific grant from funding
The facts that the accident of ingestion was not witnessed, the agencies in the public, commercial, or not-for-profit sectors.
infant was at the time of the beginning of symptoms just 3 months
old and the foreign body was covered by granulation tissue hence References
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Azza Sammoud supervised the work.

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