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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 72-76

Pharyngoesophageal foreign bodies: clinical presentation and treatment outcome in a tertiary health center


Department of Otolaryngology, Faculty of Clinical Sciences, College of Health Sciences, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Web Publication04-Nov-2019

Correspondence Address:
Abdulrazak Ajiya
Department of Otolaryngology, Faculty of clinical sciences, College of Health Sciences, Bayero University/Aminu Kano Teaching Hospital, Kano
Nigeria
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DOI: 10.4103/ssajm.ssajm_17_19

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  Abstract 


Background: Foreign body (FB) ingestion is a commonly encountered problem in both children and adults in emergency departments. Aim and Objective: This study reviewed the pattern and outcome of rigid esophagoscopic management of pharyngoesophageal FBs in our center. Materials and Methods: The records of patients managed for impacted pharyngoesophageal FBs at the study center over a period of 10 years were reviewed. Information obtained was collated and analyzed using SPSS version 18. Results: A total of 153 patients were reviewed. Among these, 96 (62.7%) were males with sex ratio (M:F) of 1.6:1. The mean age was 23.5 ± 2.3 years. The main presenting complaint was dysphagia 127 (83%). Coin was the most common FB, 33 (21.6%). The most common site of impaction was at the cricopharyngeal sphincter, 58 (37.9%). Complication was encountered in 43 (28.1%) patients. The most common complication encountered during rigid esophagoscopy was mucosal tear, 35 (22.9%). Most patients [97 (63.4%)] stayed for 1 to 3 days on admission; 151 (98.7%) had successful rigid esophagoscopic removal of their FBs. There is a statistically significant correlation between type of FB and duration of impaction with development of complication following rigid esophagoscopy (P value = 0.006 and 0.014, respectively). Conclusion: Rigid esophagoscopy was highlighted in this study as an effective method of removal of pharyngoesophageal FBs; however, ion disc battery and artificial denture are relatively associated with increased complications.

Keywords: Foreign bodies, outcome, pharyngoesophageal impaction, rigid esophagoscopy


How to cite this article:
Ajiya A, Hamisu A. Pharyngoesophageal foreign bodies: clinical presentation and treatment outcome in a tertiary health center. Sub-Saharan Afr J Med 2019;6:72-6

How to cite this URL:
Ajiya A, Hamisu A. Pharyngoesophageal foreign bodies: clinical presentation and treatment outcome in a tertiary health center. Sub-Saharan Afr J Med [serial online] 2019 [cited 2019 Nov 17];6:72-6. Available from: http://www.ssajm.org/text.asp?2019/6/2/72/270244




  Introduction Top


Ingestion of foreign body (FB) is a common problem irrespective of age groups, particularly among infants. Children have innate tendency to put objects in their mouth and other orifices in the head and neck region. Those in the mouth may be ingested accidentally. Some of the common sites for lodgment of these FBs include the tonsil, base of tongue, piriform fossae, and the esophagus. Removal of these pharyngoesophageal FBs is a common procedure performed by otolaryngologists across the world.

An estimated 1500 to 2750 individuals die annually in the United States following ingestion of foreign objects.[1] In Nigeria, reported prevalence of impaction of acrylic dentures in the esophagus ranged between 1.3% and 38.6%.[2],[3],[4],[5]

A vast majority of FBs like coins, marbles, buttons, batteries, bottle tops, peas, beans, grains, and seeds are found in infants and children, whereas bones, dentures, and metallic pins/wires have been reported more often in adults.[6] Fishbone is perhaps the most common FB in the pharynx in adult population and could occasionally be associated with complications including vocal cord fixation.[7],[8]

The diagnosis of pharyngoesophageal FBs is based on history, and clinical and radiological examination. Although there are various modalities of treatment/extraction of pharyngoesophageal FBs reported in the literature, rigid esophagoscopy under general anesthesia remains the best mode of treatment.[9],[10] Other methods include flexible esophagoscopy, cervical esophagostomy, open thoracotomy, and the use of Foley’s catheter under fluoroscopic guidance.[2],[9],[11]

Most of the FBs in the pharynx usually get stuck at the level of the cricopharynx. Some authors have hypothesized that patient-guided localization of ingested FBs is better, more so, where the FB is located above the cricopharynx.[12]

Kussmaul was the first to perform an esophagoscopy in 1868 in a professional sword swallower. FB in the pharyngoesophagus is a condition in which early removal by rigid esophagoscopy is recommended that is a safe and effective procedure.[9] Delayed intervention is associated with complications and worsens the outcome in the patients.

FB embedded in the pharyngeal wall might not be located even by fiberoptic endoscopy and esophagoscopy. In such a situation, endoscopy enhanced with microscope can help remove such difficult embedded FBs.[11]

Occasionally, FBs may be associated with complications that could be fatal. Pharyngoesophageal FBs may lead to compression or displacement of the laryngotracheal airway, leading to airway emergency. Many studies have reported various complications of pharyngoesophageal FBs. These include esophagoaortic perforation, esophageal perforation, retropharyngeal abscess, and mediastinal abscess.[13],[14],[15]

This study reviewed the pattern and outcome of management of pharyngoesophageal FBs using rigid endoscopy as the main therapeutic option in our center.


  Materials and methods Top


This is a retrospective review of all the patients who were managed for pharyngoesophageal FB impaction and had rigid esophagoscopy under general anesthesia for removal at the Department of Ear, Nose, and Throat of Aminu Kano Teaching Hospital, Kano State, Nigeria, over a 10-year period (January 2005 to December 2014). Ethical approval was sought and obtained from the ethical review committee of Aminu Kano Teaching Hospital, Kano, Nigeria.

All the patients included had clinical and radiological confirmation of pharyngoesophageal FB impaction and underwent rigid esophagoscopy under general anesthesia for extraction of the FB. The patients excluded were 13 patients whose case records could not be located or had missing vital information such as operation notes.

Patient’s data were collected from the theater register and ward admission records, and the case notes retrieved from the medical records department of the hospital. Information obtained from the case notes included patient’s age, gender, symptoms at presentation, types of ingested FB, duration of FB impaction before presentation, radiologic findings, intervention, level of FB impaction, complications encountered during the removal process, outcome of intervention, duration of hospital stay after surgical intervention, and final outcome. The level of the FB impaction were as follows: cricopharyngeal sphincter (15 cm from the upper incisors), upper esophagus (15–20 cm), mid-esophagus (20–30 cm), and lower esophagus (30–40 cm). Measurements of position of FBs as depicted above are for adults. Pediatric measurements are slightly different.

The information was entered into a spreadsheet and the data generated were analyzed using SPSS version 18 (SPSS Inc., Chicago, IL, USA). Qualitative data were summarized using frequencies and percentages and presented as tables. Fisher’s exact test was used to determine P value and test statistical significance, which was set at P < 0.05.


  Results Top


Within the 10-year period of review, a total of 166 patients with impacted pharyngoesophageal FBs were managed with rigid esophagoscopy. Among these patients, the case files of 153 patients were reviewed and included in the study. Among the patients, 96 (62.7%) were males whereas 57 (37.3%) were females, with sex ratio (M:F) of 1.6:1. The age ranged from 6 months to 95 years with a mean age of 23.5 ± 2.3 years. The 0 to 9 years’ age group constituted the largest group of patients managed [71 (46.4%)], followed by 40 to 49 years’ age group, 17 (11.1%) [Table 1].
Table 1 Patient age group distribution with respect to gender (n = 153)

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Dysphagia was the most common symptom presented by the patients [127 (83%)], followed by odynophagia [95 (62.1%)]. Up to 16 (10.5%) patients presented with respiratory difficulty. Majority of the patients [101 (66%)] presented within 24 hours of ingestion of the FB whereas 10 (6.5%) presented after 1 week of ingestion [Table 2].
Table 2 Clinical features of the patients (n = 153)

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Coin was the most frequently swallowed FB [33 (21.6%)], followed by artificial denture [28 (18.3%)]. Seven (4.6%) patients swallowed ion disc battery. The cricopharyngeal area (15 cm from the upper incisor teeth in adults) was the most common anatomical site of impaction [58 (37.9%)], with only one (0.7%) FB found at the distal esophagus (close to 40 cm from the upper incisor teeth) [Table 3].
Table 3 Distribution of foreign bodies (n = 153)

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The most common complication of rigid esophagoscopy encountered during the period under review was mucosal tear [35 (22.9%)], although two (1.3%) patients had airway obstruction necessitating tracheostomy [Table 3].

Complications were recorded in 43 (28.1%) of the patients with only two (1.3%) of the patients still on follow-up (still on tracheostomy). Majority of the patients stayed for between 1 and 3 days on admission [97 (63.4%)], whereas 25 (16.3%) stayed on admission for more than a week. Moreover, up to 151 (98.7%) had their FB successfully removed by rigid esophagoscopy [Table 4].
Table 4 Outcome of treatment (n = 153)

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Removal of ion disc battery and artificial denture by rigid esophagoscopy were the most associated with complications, four (57.1%) and 21 (75%), respectively. There is a statistically significantly correlation between the type of FB and development of complications during rigid esophagoscopy (exact test, P = 0.006) [Table 5].
Table 5 Type of foreign body and occurrence of complications

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Patients with pharyngoesophageal FB impaction presenting later than 1 week for removal had higher risks of complications during rigid esophagoscopy. There is a statistically significant correlation between duration of impaction of pharyngoesophageal FBs and development of complication during rigid esophagoscopy (exact test, P = 0.014) [Table 6].
Table 6 Duration of FB before removal and occurrence of complication

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  Discussion Top


This observational retrospective study included 153 patients managed for impacted pharyngoesophageal FBs over a 10-year period. In the study, majority of the patients were males. This agrees with the findings by several authors worldwide.[5],[16],[17],[18],[19],[20],[21] It could be attributed to the relative aggressiveness of male children.

Children below 10 years constituted the majority in our study. This is consistent with the finding by several authors.[5],[6],[16],[17],[19],[20],[21],[22],[23] Children are very inquisitive and have tendency to explore every available cavity in their body.

Dysphagia and odynophagia were the dominant presenting symptoms in our patients. Several authors had reported the same in their series.[17],[18],[21] Presentation for hospital care within 24 hours of ingestion of FB was a common finding in some reports on management of pharyngoesophageal FBs.[19],[20] Findings from our study also revealed the majority reporting to us within 24 hours of ingestion. This could be explained by the unbearable effect of inability to swallow or painful swallowing by the patients as a result of impaction of the FB.

Coin in agreement with several other similar reports was the most accidentally swallowed FB in children,[5],[16],[17],[21],[22] whereas denture was most swallowed by adults[6],[18],[19] in our study. This could be explained by possibility of children having unrestricted access to coins at home, as it has no more monetary value in Nigeria. Also due to the proximity of the study area to Niger republic, parents who travel could bring back the coins as it is still in use there. Conversely, some studies have reported low incidence of artificial denture as a pharyngoesophageal FB.[5],[16],[22]

Cricopharyngeal sphincter as the most common site of impaction of pharyngoesophageal FBs was found in this study and reported by several other similar studies.[17],[22] This could be explained by the anatomical position of the sphincter as the narrowest part of the upper gastrointestinal tract.

Although several authors reported low or no complications following rigid endoscopic removal of pharyngoesophageal FBs,[16],[17],[19],[23] this study, in contrast, revealed minor complications in almost half of the patients in our series similar to findings by some studies.[18],[20] The relatively large number of impacted denture in our series could explain this. Among the FBs encountered in our review, ion disc batteries and dentures were most associated with complications. This agrees with a similar study[18] and underscores the importance of public health education on the menace of these potential FBs.Type of FB and late presentation were found to have statistically significant correlation with development of complications following rigid endoscopic removal of pharyngoesophageal FB in our series (P = 0.006 and 0.014, respectively). Loh et al.[24] reported prolonged history of a FB in the esophagus and a raised white blood cell count to be significantly associated with major complication. A few of our patients presented with respiratory distress necessitating a tracheostomy. This was as a result of either the corrosive nature of the swallowed object or its size. Garcia et al.[25] also reported significant respiratory distress necessitating endotracheal intubation in a mentally retarded adult who swallowed a large chicken piece.

Moreover, despite the attendant high minor complications reported in our series, there was an overall success rate of 98.7% as similarly reported by several other authors.[10],[18],[20],[23] Gmeiner et al.[10] reported higher success rate and complications when rigid esophagoscopy was compared with flexible esophagoscopy in the removal of pharyngoesophageal FBs.


  Conclusion Top


This study revealed rigid esophagoscopy as an effective method of removal of pharyngoesophageal FBs though associated with minor complications commonly related to the type of FB and duration of impaction. Special emphasis should be on ion disc battery and artificial denture because of their relative association with increased incidence of complications. However, the role of parents in the prevention of pharyngoesophageal FBs cannot be overemphasized.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Okeowo PA. Foreign bodies in pharynx and oesophagus: a 10-year review of patients seen in Lagos. Niger Quart J Hosp Med 1985;3:46-50.  Back to cited text no. 3
    
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Nwafo DC, Anyanwu CH, Egbue MO. Impacted oesophageal foreign bodies of dental origin. Ann Otol Rhinol Laryngol 1980; 89(2 pt 1):129-31.  Back to cited text no. 4
    
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Ahmad BM, Dogo D, Abubakar Y. Pharyngo-oesophageal foreign bodies in Maiduguri. Niger J Surg Res 2001;3:62-5.  Back to cited text no. 5
    
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Panigrahi R, Sarangi TR, Behera SK, Biswal RN. Unusual foreign body in the throat. Indian J Otolaryngol Head Neck Surg 2007;59:384-5.  Back to cited text no. 7
    
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Honda K, Tanaka S, Tamura Y, Asato R, Hirano S, Ito J. Vocal cord fixation caused by an impacted fish bone in the hypopharynx: report of a rare case. Am J Otolaryngol 2007;28:257-9.  Back to cited text no. 8
    
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Sekib U, Fuad B, Sefika U, Samir H. Foreign body impaction in esophagus: experiences at Ear-Nose-Throat clinic in Tuzla, 2003-2013. Kulak Burun Bogaz Ihtiz Derg 2015;25:214-8.  Back to cited text no. 9
    
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Gmeiner D, von Rahden BH, Meco C, Hutter J, Oberasher G, Stein HJ. Flexible versus rigid endoscopy for treatment of foreign body impaction in the esophagus. Surg Endosc 2007;21:2026-9.  Back to cited text no. 10
    
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Shu MT, Leu TS. Microscopic removal of an embedded foreign body from the hypopharynx: report of two cases. Ear Nose Throat J 2001;80:889-90.  Back to cited text no. 11
    
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Connolly AA, Birchall M, Walsh-Waring GP, Moore-Gillon V. Ingested foreign bodies: patient-guided localization is a useful clinical tool. Clin Otolaryngol Alied Sci 1992;17:520-4.  Back to cited text no. 12
    
13.
Dahiya M, Denton JS. Oesophagoaortic perforation by foreign body (coin) causing sudden death in a 3-year old child. Am J Forensic Med Pathol 1999;20:184-8.  Back to cited text no. 13
    
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Aronberg RM, Punekar SR, Adam SI, Judson BL, Mehra S, Yarbough WG. Esophageal perforation caused by edible foreign bodies: a systematic review of the literature. Laryngoscope 2015;125:371-8.  Back to cited text no. 14
    
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Nwaorgu OG, Onakoya PA, Fasunla JA, Ibekwe TS. Retropharyngeal abscess: a clinical experience at University College Ibadan. Niger J Med 2005;14:415-8.  Back to cited text no. 15
    
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Iseh KR, Oyedepo OB, Aliyu D. Pharyngo-oesophageal foreign bodies: impact for health care services in Nigeria. Ann Afr Med 2006;5:52-5.  Back to cited text no. 16
    
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Alabi BS, Ologe FE, Dunmade AD, Segun-Busari S, Olagide TG. Review of oesophageal foreign bodies impaction in a Nigerian Hospital. Eurn J Sci Res 2005;11:578-84.  Back to cited text no. 17
    
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Adedeji TO, Olaosun AO, Sogebi OA, Tobih JE. Denture impaction in the oesophagus experience of a young ENT practice in Nigeria. Pan Afr Med J 2014;18:330.  Back to cited text no. 18
    
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Kirfi AM, Mohammed GM, Abubakar TS, Labaran AS, Samdi MT, Fufore MB. Clinical profile and management of aerodigestive foreign bodies in North-western Nigeria. Sudan Med Monit 2014;9:39-43.  Back to cited text no. 19
  [Full text]  
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Adedeji TO, Haastrup AA. Oesophageal foreign bodies: an experience with rigid oesophagoscopy in a developing country. East Cent Afr J Surg 2014;19:25-35.  Back to cited text no. 20
    
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Raza M, Zakir K, Aisha J, Sohail M, Tahir H, Farida K et al. Frequency of esophageal foreign bodies and their sites of impaction in patients presenting with foreign body aerodigestive tract. Eur Sci J 2013;9:152-60.  Back to cited text no. 21
    
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Asif M, Haroon T, Khan Z, Muhammad R, Malik S, Khan F. Foreign body oesophagus: types and site of impaction. Gomal J Med Sci 2013;11:163-6.  Back to cited text no. 22
    
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Rybojad B, Niedzieiski G, Niedzieiski A, Rudnicka-Drozak E, Rybojad P. Esophageal foreign bodies in paediatric patients: a thirteen year retrospective study. Sci World J 2012;2012:102642.  Back to cited text no. 23
    
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Loh KS, Tan LK, Smith JD, Yeoh KH, Dong F. Complications of foreign bodies in the esophagus. Otolaryngol Head Neck Surg 2000;123:613-6.  Back to cited text no. 24
    
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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