Saudi Journal of Otorhinolaryngology Head and Neck Surgery

ORIGINAL ARTICLE
Year
: 2022  |  Volume : 24  |  Issue : 3  |  Page : 99--105

Approach to pediatric esophageal foreign body ingestion: An experience of 117 cases in a tertiary care center


Talal AlKhatib1, Faisal Zawawi1, Yagoub BinTaleb2, Nasser Bustanji3, Ahlam AlMahmoudi1, Teaf AlZaidi1, Nada AlMarshadi1, Lama AlHarbi1, Reem Baawad1,  
1 Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
2 Department of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition Unit, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
3 Department of General Surgery, Division of Pediatric Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia

Correspondence Address:
Dr. Ahlam AlMahmoudi
Faculty of Medicine, King Abdulaziz University, P O Box 80215, Jeddah 21589
Saudi Arabia

Abstract

Background: Foreign body (FB) ingestion is a frequent home accident in the pediatric population and is one of the leading causes of morbidity and mortality in children. We aimed to describe the problem of pediatric esophageal FB ingestion at King Abdulaziz University Hospital over 10 years regarding patient, visit, and management characteristics and identify the pediatric specialty team that was called first to the emergency department in such cases. Materials and Methods: This retrospective study included 117 pediatric patients admitted for esophageal FB ingestion in a tertiary care center in Saudi Arabia from 2011 to 2020. We used Chi-squared and one-way analysis of variance tests to determine the associations. Data on demographic and clinical variables were compared between patients with and without neurodevelopmental disabilities, and their associations were assessed. Results: The mean age of patients was 4.7 ± 3.7 years, with slightly higher rates in males (57.3%). Six patients (5.1%) had a history of preexisting esophageal conditions, and five (4.3%) had previous FB ingestion. The most commonly ingested item was a coin (n = 53) and was mostly located in the upper esophagus (n = 56). Gastrointestinal and respiratory symptoms occurred in 78 and 29 patients, respectively. The Otolaryngology Department contributed the highest number of admissions (63.8%). Conclusion: FB ingestion is common in Saudi Arabian preschoolers. These data indicate the need for caregivers to be educated about FB ingestion. Additional investigations should emphasize addressing the consequences of FB ingestion.



How to cite this article:
AlKhatib T, Zawawi F, BinTaleb Y, Bustanji N, AlMahmoudi A, AlZaidi T, AlMarshadi N, AlHarbi L, Baawad R. Approach to pediatric esophageal foreign body ingestion: An experience of 117 cases in a tertiary care center.Saudi J Otorhinolaryngol Head Neck Surg 2022;24:99-105


How to cite this URL:
AlKhatib T, Zawawi F, BinTaleb Y, Bustanji N, AlMahmoudi A, AlZaidi T, AlMarshadi N, AlHarbi L, Baawad R. Approach to pediatric esophageal foreign body ingestion: An experience of 117 cases in a tertiary care center. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2022 [cited 2022 Nov 29 ];24:99-105
Available from: https://www.sjohns.org/text.asp?2022/24/3/99/353716


Full Text



 Introduction



Foreign body (FB) ingestion is a frequent home accident in children and one of the leading causes of mortality in children aged 6 months to 5 years.[1],[2],[3],[4] It is common worldwide, but FB types differ according to culture, geographical area, and healthcare specialty reporting the ingestion.[5] Ingestion of FB can affect the respiratory and gastrointestinal systems, although presentation may vary.[6] Items may be deposited in physiological esophageal constriction, including the superior and inferior sphincters, and the aortic arch level.[7] Rigid endoscopy (RE) is considered effective in extracting FBs from the hypopharynx, oropharynx, and upper esophagus, while different sections of the upper gastrointestinal system are better suited for flexible endoscopy (FE). Both treatments are safe and successful.[8]

A systematic review, including 17 studies, showed that coins were the most frequently ingested FBs. Further, clogs were found to most commonly occur in the upper third of the esophagus and that FB ingestion is linked to gastrointestinal and respiratory symptoms.[9] Demographic data, presenting symptoms, management, and complications have been reported for esophageal FB ingestion in children.[2],[6],[8],[10],[11],[12] Although there are many studies on esophageal FB ingestion among children, few have been conducted at a national level, with most being limited to case reports and series on esophageal FB ingestion.[13],[14] Additionally, there is no local research that focuses on which specialty should be responsible for these cases.

We aimed to describe esophageal FB ingestion in the pediatric population at King Abdulaziz University Hospital (KAUH) over 10 years, with a focus on FB characteristics, demographic data, clinical findings, management, and outcome and evaluate these in light of the relevant literature. Our secondary aim was to identify which pediatric specialty team is commonly called to the emergency department (ED) when encountering such cases.

 Materials and Methods



Study design, setting, and participant selection

In this retrospective chart review, we reviewed the records of patients who visited our urban tertiary care center for esophageal FB ingestion from January 2011 to December 2020. Inclusion criteria were (1) pediatric patient at KAUH, (2) age <18 years, 3) esophageal FB ingestion. Ethical approval was obtained from the Research Ethics Committee of KAUH (Reference No 704-20). Informed consent was waived due to the retrospective nature of this study.

Measurements

For each case, information on demographics, FB ingestion-related events, medical history, and treatment was collected. Demographic variables assessed were age and sex. FB ingestion-related information collected included duration from ingestion until arrival to the hospital, duration from admission until extraction, whether ingestion was witnessed, and presenting symptoms. Information collected on medical history included a history of congenital disease, gastroesophageal reflux disease, achalasia, neurodevelopmental disease, prior FB impaction elsewhere, or preexisting esophageal condition (esophageal stenosis). Information regarding previous FB ingestion, including time and location of ingestion, and type of FB were collected. Finally, information on follow-up imaging technique, FB location within the esophagus (e.g., upper, middle, and lower), admitting department, management and outcome, intensive care unit (ICU) admission, antibiotic use, duration of observation, and complications, including death, were collected.

Data collection and analysis

Data collection and analysis were conducted from December 2020 to September 2021. Statistical analysis was performed using IBM Corp. Released 2021. IBM SPSS Statistics for Windows, Version 28.0. Armonk, NY: IBM Corp. Means and standard deviations were calculated to describe continuous variables, whereas categorical variables, percentages, and numbers were utilized to describe categorical variables. Significance was set at P < 0.05.

Definitions

Age group was classified as newborn (0 days–1 month), infant (1 month–1 year), toddler (1–3 years), preschooler (3–6 years), school-age (6–12 years), and adolescent (12–18 years)Duration from FB ingestion until ED visit (hours): 0–12 h, 12–24 h, or >24 hDuration from ED visit until removal (hours): 0–6 h, 6–12 h, 12–24 h, or >24 hComplications: Minor complication, including regional trauma at the location of FB impaction (erosion or ulcer). Major complications, including esophageal perforation, lacerating injury, extensive necrosis, and pressure necrotic ulcers.

 Results



Of 119 analyzed patients, two were excluded due to misclassification as a pediatric patient and missing data. Among the 117 patients, 67 (57.3%) were male. Preschoolers comprised 38 (32.5%) participants (mean age: 4.7 ± 3.7 years) [Table 1]. The duration from ingestion until admission for most patients was 0–12 h (n = 73, 73.7%). Moreover, the duration from arrival until extraction was 0–6 h for most patients (n = 82, 76.6%) [Table 2]. In bivariate analysis, we found that the duration from ingestion until arrival was not associated with an increased duration of observation (P = 0.77). In forty (34.5%) cases ingestion of the FB was not observed. Gastrointestinal symptoms occurred in 78 (67.2%) patients, including vomiting and drooling. Respiratory symptoms, including choking and cough, occurred in 29 (25%) patients. Moreover, 20 (17.2%) patients had asymptomatic FB ingestion [Table 3]. Preexisting esophageal conditions were found in 6 (5.1%) patients [Table 4], and 3 (2.6%) had preexisting neurodevelopmental syndromes. A history of FB ingestion was found in 5 (4.3%) patients. Three (2.6%) patients had a history of FB impaction elsewhere. In all three patients, FB was found in the respiratory tract; in 2, the duration was less than a year after the previous episode; in 1, it was more than a year. The most common FB type was a coin (n = 53, 48.2%), followed by a battery (n = 19, 17.3%) [Figure 1]. Bivariate analysis was conducted using Chi-square test to determine the relationship between the FB type and various findings. We found that age group, procedure type, and complications were significantly associated with the FB type, with P values of 0.017, 0.028, and 0.000, respectively. In contrast, there was no association between FB type and location (P = 0.281) or follow-up radiological technique (P = 0.098).{Table 1}{Table 2}{Table 3}{Table 4}{Figure 1}

Of the 117 patients admitted, 105 (92.9%) underwent plain radiography as a follow-up imaging technique, 4 (3.5%) underwent contrast swallow, 3 (2.7%) underwent both plain radiography and contrast swallow, and 1 (0.9%) underwent computed tomography (CT). Admission to the otolaryngology department was most common (n = 74, 63.8%), followed by the gastroenterology department (n = 42, 36.2%). Furthermore, the most commonly used procedure for FB retrieval was endoscopy, performed in 111 (94.9%) patients: RE (n = 72, 64.9%) versus FE (n = 39, 35.1%). Optical forceps were the most common retrieval tool (n = 17, 25%). Extraction was successful in 105 (94.6%) patients, and 6 (5.4%) had negative endoscopic results. In 4 (3.4%) patients, the FB had already passed into the gastrointestinal tract, necessitating laparotomy in 1 (0.9%) patient and observation for FB passage in 1 (0.9%). Additionally, the most frequent location of impaction was the upper third (n = 56, 63.6%), and the least frequent was the lower third (n = 10, 11.4%) of the esophagus [Table 5]. FB location within the esophagus was associated with the admitting department (P = 0.002, Chi-squared test). Three (2.6%) patients were admitted to the ICU, and 14 (12%) received antibiotics. Complications developed in 16 (13.7%) patients, as noted on endoscopy; 9 (56.3%) had major complications, including esophageal perforation, lacerating injury, necrosis, and pressure necrotic ulcers [Table 6]. The observation period ranged from 1 to 16 days (mean 3.57 ± 3.4 days). In bivariate analysis, complications had no association with age (P = 0.197), FB location (P = 0.354), duration since FB ingestion (P = 0.766), and procedure type (P = 1).{Table 5}{Table 6}

 Discussion



Given its high frequency, FB ingestion is a public health problem, particularly in children and older patients.[15] Children inadvertently place FBs in their mouths and accidentally ingest them.[1],[2],[3] Out study included a higher number of male children due to FB ingestion, similar to previously reported data,[3],[5],[16] which is possibly linked to their hyperactive behavior compared with female children.[17] We found that the mean age at FB ingestion was 4.7 ± 3.7 years, and most were preschool children. This age distribution has been documented in many studies, with most patients being preschoolers.[3],[5],[8],[16] Postoperative complications increased when the diagnosis was delayed for >24 h.[18] Similar to previous literature, the duration from ingestion until admission in most patients was within 24 h and was most common within the first 12 h after ingestion.[4],[5],[6],[19],[20] Interestingly, in bivariate analysis, we found that the duration from ingestion until arrival was not associated with increased duration of observation (P = 0.77) contrary to previous reports where patients were investigated for late presentation and had an extended hospital stay that often required long-term medication. This may be due to the smaller sample size in our study compared with earlier studies.[10],[15] Repeated pneumonia, perforation, and pneumomediastinum are all indications of long-term FB within the aerodigestive tract.[15] Sink et al. noted that the duration from presentation to extraction was 12 ± 16.8 h.[16] Similarly, a local study reported that most FBs were extracted during the first 12 h of presenting to the ED, with 30% during the first 6 h.[12] Meanwhile, at our institution, extraction occurred within 6 h from the presentation (mean: 5.4 ± 9.98 h). These results indicate that FBs were extracted before any serious problems could arise.

FB types deposited in the alimentary tract vary depending on feeding patterns, cultural values, religious beliefs, and lifestyles.[21] Several studies have found that coins were the most frequently encountered FBs in different populations.[4],[5],[6],[16],[19],[20],[21] Even in our study, coins were the most prevalent FB type, followed by batteries. We also found that age was significantly associated with FB type (P = 0.017), as noted in previous studies.[19],[22] The age-specific predilection for specific toys reflects the types of toys ingested: Acoustic and mobile toys used by children aged <3 years and construction toys used by older children.[3] Moreover, based on our results, there was no association between FB type and location of impaction (P = 0.281), in contrast to a previous study.[22] Our research demonstrated that FB type is significantly associated with management procedure (P = 0.028), in contrast to McNeill et al.'s reports.[22]

In the absence of choking, precise diagnosis may take time. Delayed manifestations may mirror other widespread disorders, including repeated pneumonia, upper respiratory tract infection, and asthma.[15] In our study, FB ingestion was largely not observed; thus, patients were not brought to the hospital as ingestion was not observed or suspected, which is consistent with previous study results.[22] However, other studies have reported that most cases were witnessed.[5],[15],[16] Symptoms vary depending on FB type, location in the digestive tract, age, and simultaneous complications.[5],[6] Patients who have ingested FB are sometimes asymptomatic or may exhibit diverse symptoms.[23] In our study, only a few patients were asymptomatic, consistent with previous studies.[16],[22],[24] Moreover, over half the patients presented with gastrointestinal symptoms, most commonly vomiting, drooling, and dysphagia. This also supports the findings of several studies, wherein vomiting and dysphagia were the most common symptoms.[5],[6],[15],[23] Some patients presented with respiratory symptoms, most commonly choking, cough, and cyanosis, as previously reported.[15],[16] Children with neurodevelopmental disabilities or underlying anatomical disorders of the esophagus, such as stenosis, have a high likelihood of FB impaction.[25] Altokhais et al. showed that preexisting esophageal conditions were found in 13 patients admitted for esophageal FB ingestion.[5] Other studies have shown that esophageal FB impaction is frequently associated with preexisting esophageal diseases, such as atresia, stricture, or dysmotility.[4],[8],[16],[19],[20] Similarly, we reported that some patients had a previous history of FB ingestion and preexisting esophageal conditions, including stenosis, achalasia, and congenital diseases such as esophageal atresia, and tracheoesophageal fistula. For half of these patients, food bolus was the main FB. In contrast, a few children in this investigation had a previous history of FB ingestion or aspiration at the time of presentation, consistent with a previous study.[16] A few of our patients had a history of neurodevelopmental problems, similar to other studies.[16],[19] All patients with neurodevelopmental disabilities were of school age, and in most cases, the FB was lodged in the upper third of the esophagus. Furthermore, the ingestion was largely unwitnessed. One patient experienced two previous episodes of FB ingestion and one episode of FB aspiration.

Frontal and lateral radiographs of the neck, thorax, and abdomen are needed to confirm the diagnosis and localize the FB.[4] Plain radiography is the most frequently used imaging technique.[4],[5],[6],[16],[26] We found that imaging technique was not associated with FB type (P = 0.098). However, Pugmire et al. reported that coins are recognizable on radiographs because of their metallic opacity and flattened disk appearance. When viewed on radiographs, disk batteries have a bilaminar design that gives them the shape of a dual ring. Magnets, on the other hand, have opacity equivalent to that of other metallic substances. Thus, clinical data on suspected FBs are crucial for accurate diagnosis. Clinical symptoms dictate the treatment of individuals with suspected FB ingestion, despite negative radiography. Advanced imaging screening using CT or fluoroscopy may be necessary in cases of suspected complications, but asymptomatic children can usually be managed conservatively.[27] Moreover, a previous study showed a significant statistical correlation between FB type and radiological findings.[26]

Most children with esophageal FB ingestion required an invasive operation to remove the FB. As expected, cases of FB impaction at the proximal esophagus were referred to the otolaryngology department. This referral was independent of FB type. This distinction was most likely related to concerns regarding airway control and FB acquisition related to the trachea, which may be the favored method for such cases. However, gastroenterology and otolaryngology experts were able to retrieve proximally impacted FBs.[22] At our institution, the otolaryngology department was the most common admitting department for such cases. Moreover, we reported that FB location was significantly associated with the admitting department (P = 0.002), which is either otolaryngology or pediatric gastroenterology. Consistent with previous studies, if the FB is in the region of the superior esophagus, the procedure is usually performed by an otolaryngologist, but gastroenterology experts are also commonly consulted.[16],[22],[24] FB management varies depending on where they are located. Clinical management must be promptly determined, and FB must be removed as soon as possible. Most FBs in the aerodigestive tract are treated and diagnosed through endoscopy.[20] The most commonly used procedure in the present study was endoscopic removal, specifically RE. Optical forceps were the most frequently used retrieval tool in our center, similar to previously reported data.[4],[5],[8],[12],[15],[16],[19],[20],[28],[29] Endoscopic removal was successful in all our patients except in a 2-year-old girl who ingested a battery. In this case, the pediatric otolaryngologist tried to remove it using an endoscope; however, the removal failed and the patient was referred to a pediatric surgeon for open surgical removal. Because the upper esophagus is the narrowest part of the pediatric gastrointestinal canal, FBs are usually trapped in this location.[30] In our study, the most common esophageal site of FB lodging was the upper-third esophagus, as previously reported.[4],[6],[16],[22] Anti-reflux therapy, antibiotics, steroids, and esophageal stenting are debatable postoperative treatment choices.[31] Despite the paucity of evidence of treatment efficacy, many researchers have provided intravenous antibiotics to children who ingest batteries as they are afraid of esophageal perforation and other consequences.[31] A similar study showed that antibiotics are administered in complicated cases.[5] Our data showed that half of the 14 patients administered antibiotics had ingested button batteries. Relatedly, previous studies have shown that ICU admission is limited to complicated cases, including button battery ingestion.[32] These previous findings correspond to the current study results wherein two of three cases admitted to the ICU were due to button battery ingestion.

FB type, duration since consumption, and location of impaction all play a role in morbidity from FB ingestion.[19],[21],[25] Moreover, food (29%), coins (29%), and batteries (14%) were reported as the most prevalent FBs that led to significant problems.[24] Compared with previous studies, few patients in the current study developed complications secondary to FB ingestion, and most of them had major consequences.[4],[5],[19] The most common complication developed in our center was necrosis of the involved area, followed by laceration. Additionally, a 1-year-old boy who ingested a battery developed esophageal perforation. All complications were noted on endoscopy. Therefore, prompt diagnosis and treatment are crucial.[24] Regarding the possible consequences of endoscopic procedures and the use of general anesthesia, our patients needed at least an overnight hospital stay to monitor these complications, similar to that in prior studies.[5],[20],[24] Numerous studies have reported that complications are rare; however, serious problems are related to FB characteristics, location, and duration length between ingestion and admission.[4] As reported previously, coin ingestion was linked to an increased risk of adverse consequences and hospitalization. Contrarily, battery ingestion has been linked to an increased risk of complications. Moreover, ingestion of pins, needles, and nails is linked to increased hospitalization risk.[24] Batteries and metallic objects contributed to most of the complications in our patients (P < 0.001), in agreement with other studies.[9],[16] Furthermore, our study showed that FB location was significantly associated with complications (P = 0.354), similar to previous findings.[9],[16] We found that age was not associated with increased complication risk (P = 0.197), as reported previously.[19] Surprisingly, our data showed no association between long duration of FB lodging and complications (P = 0.766), contrary to previous studies.[9],[16],[19] This difference could be because most of our patients were admitted early compared to the prior studies. RE for esophageal FB has a low complication (0.2%–5%) and mortality rates (<0.1%).[10],[33] Similarly, based on our results, we observed no association between procedure type and complication occurrence (P = 1).

 Conclusion



FB ingestion is a serious public health issue. We found that preschoolers most commonly ingest FBs. Coins were the most frequent FB ingested, and it was usually lodged in the upper esophagus. Most patients were admitted to the otolaryngology service. FB type was significantly associated with age, management, and complications, but not with FB location and radiological follow-up technique. These findings indicate that parents and caregivers should be educated about FB ingestion. Furthermore, instead of improving treatment approaches, the most critical issue is to enhance preventative techniques.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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