Foreign bodies in the cricopharyngeal region and oesophagus (a review of 226 cases).
Foreign bodies in the cricopharyngeal region and oesophagus appear less dangerous than those in the respiratory passages. However, failure to treat them immediately can cause complications such as retro-pharyngeal or retro-oesophageal perforation, ulcerative oesophagitis, oesophago-respiratory fistula, recurrent pneumonitis, stricture formation and impaction. We wish to present, in this paper, our experience of treating such foreign bodies during a 7 year period.
The records of 226 cases of foreign bodies enlodged in the cricopharyngeal region and oesophagus, treated at the E.N.T. Department, K.E.M. Hospital, Bombay over a period of 7 years were analysed.
The ages ranged from 3 months to 80 years. The incidence was highest in the first decade of life [Table - 1]. At all ages except over 50 years, there were more males than females. One hundred and eighty two cases presented within 24 hours of onset of symptoms, 32 between the first and seventh day while only 12 cases gave a history of more than a week's duration. The longest duration of enlodgement was 11 days.
The patients presented with various signs and symptoms which are shown in [Table - 2] Routine cervical and thoracic X-rays in the antero-posterior and lateral positions were obtained in most of the cases. The foreign body was visualized on plain X-rays in only 108 cases (48%) and by using a contrast medium like lipiodol or by asking the patient to swallow a capsule filled with barium powder in another 12 cases.
The foreign body passed spontaneously in 4 cases. Depending on the site of impaction of the foreign body, a short rigid oesophageal speculum or a 45 cm long oesophagoscope was used for endoscopy in 215 cases. Oesophagoscopy alone was performed in 64 cases, cricopharyngoscopy alone in 151 cases, whereas both procedures were carried out in 3 cases. Direct laryngoscopy was carried out in 3 cases. During endoscopy, the foreign body was removed at the first attempt in 213 cases and at the second attempt in 2 cases. The foreign body was advanced into the stomach in one case while it slipped into the stomach during endoscopy in 3 cases. No foreign body was found in 2 cases. Spontaneous passage in stools was noted in 4 cases. A middle-aged male who presented with a history of meat impaction when under the influence of alcohol, refused oesophagoscopy and was discharged against medical advice.
One hundred and fifty six (69%) foreign bodies were enlodged in the cricopharyngeal region, while oesophageal foreign bodies were found in 68 cases (31 in the upper third, 22 in the middle third and 15 in the lower third).
Types of foreign bodies
Organic foreign bodies were found in 129 cases; meat and fish bone impaction being the commonest. Inorganic foreign bodies were the frequent offending agents in the paediatric age group with coins featuring predominantly among them [Table - 3].
In 7 cases, an impacted foreign body was the symptom of an underlying disease in the oesophagus in the form of benign strictures, Plummer-Vinson's syndrome or carcinoma of the oesophagus.
Two cases presented with a retropharyngeal abscess while one case each developed bilateral pneumothorax with surgical emphysema and mediastinitis. In our series, only one patient died.
The duration of hospitalization was less than 24 hours in 120 patients, 2-7 days in 98 patients and more than 7 days in 8 patients.
Cricopharyngeal and oesophageal foreign bodies are potentially hazardous and may pose problems regarding their diagnosis and management. They may, sometimes, produce fatal complications or may be indicative of an underlying disease. It is generally accepted that oesophageal and cricopharyngeal foreign bodies are more common among adults than children. However, Brooks and Baraka and Bikhazi have reported paediatric age group preponderance. In our series, majority of the patients were adults; however, a decade-wise breakdown shows the hyper frequency in the first decade of life [Table - 1]. This concurs with the findings of Giordano et a1. Small objects left within a child's reach may often be swallowed. Poor children who are left to feed themselves at an early age are more likely to swallow a foreign body. Such a situation however seldom occurs below the age of one year and hence, in our, series, only 4 cases were recorded in the first year of life. In elderly edentulous patients, inadequate mastication leads to impaction of a bolus of food. An ill-fitting or broken denture may be accidently swallowed during a meal or an epileptic seizure. An artificial denture may obliterate tactile sensation in the roof of the mouth, so that the patient fails to detect a fish or meat bone in the mouth. It has been observed that males of the lower socio-economic strata often indulge in heavy drinking followed by a meal consisting predominantly of meat. In this inebriated state, food is improperly masticated and gulped down resulting in impaction of a bolus of meat.
It is tempting to attribute the higher frequency among males to the fact that the population which consumes alcohol is predominantly male. It, however, does not explain the high incidence of foreign bodies in male children. A possible explanation provided by Gupta et al is that male children are, by nature, more curious than female children. In this study, there was a progressive decrease in the male : female ratio with increasing age until there was a reversal of the ratio from the 6th decade onwards [Table - 1]. We cannot find any explanation for this finding.
Meat and fish bones were the commonest foreign bodies followed by coins. This agrees well with the published literature.,, 87.3% of the coins were found in children who have a tendency of putting coins in the mouth which may be inadvertently swallowed. In the lower socio-economic strata, a common tendency is to pacify children by giving them coins which contributes to the high incidence in this age group.
The frequency of foreign bodies in the cricopharyngeal and oesophageal regions in this series agrees with the findings of Nandi and Ong and Vella and Booth. Most of the foreign bodies were arrested at a distance of an inch below the cricopharyngeal sphincter. An explanation forwarded by Nandi and Ong for this phenomenon is that the strong propulsive pharyngeal muscles force an object this far while the less active oesophageal musculature cannot carry it further. The mobile redundant mucosa of this region, perhaps, adds to the hazard. At times, a large foreign body may directly compress the trachea and produce airway obstruction.
Tenderness over the trachea was a common sign in cases of cricopharyngeal foreign bodies. There was no clinical evidence of the foreign body in a fairly large number of cases. A detailed examination including intra-oral examination and indirect laryngoscopy helps to detect many foreign bodies and spares the patient further interference.
Negative radiological findings do not rule out the possibility of a foreign body in the crico-pharynx and oesophagus. Persistence of symptoms even in the absence of positive clinical or radiological signs warrants an endoscopic examination.
In our series, endoscopy by means of a rigid scope under general anaesthesia, was carried out in all cases except those where the foreign body had passed spontaneously. After removal of the foreign body was achieved, the scope was passed again in all cases and intrinsic pathology was detected in seven cases. Nandi and Ong have reported 9 cases of carcinoma of the oesophagus in a review of 2394 cases while according to Baraka and Bikhazi, 88% of the adults in their series revealed a predisposing disease in the form of an oesophageal stricture, myasthenia gravis or ankylosing spondylosis. However, it should be noted that the number of adults in their series was only nine.
Giordano et al have reported a perforation rate following oesophagoscopy of 9 in 2650 (0.34%) and mortality secondary to oesophagoscopic perforation as 0.05%. According to Nandi and Ong, 2.82% of the cases developed complications in the form of oesophageal perforation, subcutaneous emphysema, retrooesophageal abscess, oesophguo-aortic fistula, mediastinitis and lung abscess. In our series, 2 cases presented with a retropharyngeal abscess following foreign body impaction while 2 cases in the oesophagus developed bilateral pneumothorax with surgical emphysema following oesophagoscopy. Conservative treatment was employed resulting in complete recovery. A middle aged female with an impacted denture developed an oesophageal tea following oesophagoscopic removal and succumbed to mediastinitis in spite of treatment. Such complications can usually be anticipated in case of large, impacted or sharp foreign bodies and can be avoided if discretion is used and an external approach is preferred to endoscopy.
Thanks are due to Dr. C. K. Deshpande, Dean, K.E.M. Hospital and Seth G.S. Medical College, Bombay, for permitting us to publish the hospital data. We are grateful to Dr. Rakesh Ghildiyal and Dr. S. N. Merchant for their help in reviewing the medical records.