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15 month old child who presents with coughing for several days and irritability.
AP and lateral radiographs demonstrate a round metallic density overlying the superior mediastinum.
Esophageal vs. tracheal foreign body.
Dx: Esophageal foreign body - Coin ingestion
Dx Confirmed by: Characteristic radiographic appearance
- Read The orientation of the metallic coin is consistent with a foreign body in the esophagus due to its orientation. Conversely, a foreign body in the TRACHEA typically would be seen oriented in the saggital plane. The reason for this is the presence of cartilage rings in the trachea that are incomplete in the posterior section, allowing the coin to distend this portion and orient in this fashion.
Coins are the most common foreign body swallowed by children younger than five years old. Initial clinical manifestations may include cough, drooling, choking, pain, dysphagia, and occasionally dyspnea and stridor (secondary to compression of the trachea). Pain, fever, and shock are suggestive of esophageal perforation. Esophageal foreign bodies are associated with a number of complications, including lacerations, perforations, impaction, and irritation following removal. Symptomatic patients should be treated by endoscopy both to remove the object and to examine the esophagus for mucosal injury. Alternative measures include observation for 24 hours with the expectation that the coin will pass, or a foley catheter may be passed distal to the coin, the balloon inflated, and coin removed with the catheter.
Findings that allow localization of the coin to the esophagus are:
1. Coronal orientation of coin on PA film. If the coin were in the trachea, one would expect a sagittal orientation because the incomplete cartilaginous rings of the trachea open posteriorly.
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2. Lack of evidence of air trapping or obstruction (atelectasis, pneumonia, mediastinal shift).
3. Lack of clinical signs of airway compromise(cough, wheeze, respiratory distress).
4. Location of a relatively large object below the level of the larynx.
Two frontal views of the chest show a round metal object in the midline at the thoracic inlet. A lateral view shows the object behind the trachea, confirming the object is in the esophagus.
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Treatment of Esophageal Coins:
Endoscopic removal vs. Observation for spontaneous passage into stomach. Spontaneous passage occurs in 25-30%.
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Gastrointestinal Foreign Bodies:
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