The Science Journal of the American Association for Respiratory Care

2008 OPEN FORUM Abstracts

MISSED OPPORTUNITY FOR EARLY DIAGNOSIS OF A CORROSIVE ESOPHAGEAL FOREIGN BODY AND SUBSEQUENT COMPLICATIONS

James Coffman1, Richard T. Fiser2



Introduction: Diagnosis of an esophageal foreign body in a young child requires a high index of suspicion. Seemingly small details in the history can often heighten suspicion for this diagnosis, leading to earlier diagnosis and treatment. This case illustrates complications that may occur when this opportunity for early diagnosis is missed.

Case Summary:
A two year-ten month old female presented to her primary care physician with a several day history of dysphagia, nausea, vomiting, inability to take solid food by mouth, and fever to 102F. The parents reported that these symptoms began after the patient had choked on a hot dog. The patient was diagnosed with viral gastroenteritis, pharyngitis, and gastroesophageal reflux and treated with antibiotics. The symptoms worsened over the next few days and the patient presented to the emergency department, where a chest radiograph indicated a foreign body located at the thoracic inlet. The patient was then referred to this hospital for further evaluation and treatment Esophagogastroduodenoscopy was performed, at which time a 3 volt battery was removed. After the procedure, she was admitted to the PICU for observation, where she continued to have episodes of severe coughing and some desaturation when taking liquids. A barium swallow revealed presence of barium in both the esophagus and trachea. An 8-french catheter was placed into the esophagus and was found to be in the right main stem bronchus on chest radiography, confirming a tracheoesophageal fistula. The patient underwent surgical repair of the fistula and required mechanical ventilation for several days. Due to severe corrosive injury to the esophagus, she underwent placement of a gastrostomy tube. At the time of hospital discharge, she continued to exhibit dysphagia and also had suffered left vocal cord paralysis.

Discussion:
The patient's presenting symptoms, in this age group and with a history of choking on a hot dog, were strongly suggestive of foreign body aspiration. While nothing in the initial history would have led to the suspicion that this foreign body was a corrosive battery, a strong suspicion of foreign body aspiration would have led to earlier esopagogastroduodenoscopy, which would have revealed the battery earlier. Hopefully, the complications suffered by the patient would then have been minimized. Attention to historical details and a high index of suspicion are often necessary for early diagnosis of foreign body aspiration.