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Most foreign bodies (90%) that are ingested enter the gastrointestinal tract while 10% enter the tracheobronchial tree.1 Approximately 1500 people die annually in the United States from ingested foreign bodies in the upper gastrointestinal tract.2 Most objects (80% to 90%) usually pass spontaneously but about 10% to 20% must be removed endoscopically. Approximately 1% require surgical removal.3 Most (80%) esophageal foreign bodies occur in children followed by edentulous adults, prisoners, and psychiatric patients.4 Recurrent episodes of foreign body ingestion occur in 5% to 10% of patients, especially prisoners and psychiatric patients.1
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The presentations are best divided according to accidental and deliberate ingestors.1–5 The accidental ingestion patient is usually cooperative and has a single foreign body. Conversely, the deliberate ingestion patient is often uncooperative and the foreign bodies are multiple and often unusual. It is important to identify such individuals at their initial presentation since foreign body removal is usually performed under procedural sedation or general anesthesia.
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The patient's history is the most important part of the diagnostic evaluation.3 The identity of the object ingested is usually known to the patient. Persistent odynophagia, dysphagia, or foreign body sensation may indicate the presence of an esophageal foreign body despite negative radiographic results. A high index of suspicion must be maintained in younger children and mentally retarded adults. Patients with a history of eosinophilic esophagitis have a higher incidence of food impaction and higher risk of perforation associated with interventions.6
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The physical examination is most likely negative unless complications are present. Stridor, wheezing, signs of consolidation, and the absence of breath sounds should be sought. Subcutaneous emphysema in the neck or chest indicates perforation of the esophagus or the stomach. The most common sites for a foreign body to get trapped are where the esophagus is narrow: at the cricopharyngeus muscle, where the aortic arch crosses the esophagus, and at the gastroesophageal junction.
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Radiographic evaluation is often helpful in the evaluation of an esophageal foreign body.3–5,7 Obtain plain radiographs of the neck and chest in the posteroanterior and lateral positions. Evaluate the radiographs for the presence of a foreign body in all planes. Air in the subcutaneous tissues, mediastinum, and/or beneath the diaphragm is indicative of a perforation. Barium studies are undesirable in patients with a food bolus impaction and obscure endoscopic visualization. Esophagrams performed using a minimal amount of thin barium may be necessary in situations where the foreign body is made of wood, thin metals, aluminum can tops, and plastics. Meglumine diatrizoate (Gastrografin) is contraindicated in food bolus impactions because it is highly hypertonic and can lead to severe chemical pneumonitis if aspirated into the lungs.5 Toothpicks, wood, and fishbones may not be seen on radiographs. Food or meat bolus impaction may not be evident radiographically unless it contains bony tissue. Failure to locate an object on radiologic examination should ...