Esophageal foreign body aspiration presenting as asthma in the pediatric patient.

Abstract: This report describes three cases of foreign body ingestion incorrectly diagnosed as asthma and/or upper respiratory tract infection. These cases demonstrate the need for further clinical investigations in any child who does not improve with adequate therapy. Many of our patients had symptoms of asthma and/or respiratory tract infection for at least 1 month before correct diagnosis.

**********

Respiratory distress secondary to esophageal foreign body ingestion is an unusual occurrence. Wheezing secondary to foreign body ingestion that is diagnosed as asthma may lead to a delayed diagnosis and potentially life-threatening complications. We report three patients who presented to our institution and in whom a foreign body was found in the esophagus. These cases had been diagnosed and treated as asthma for a number of weeks before arrival at our institution. The first case involved a boy who was brought to the emergency department in respiratory distress and in whom a chest radiograph revealed an esophageal foreign body. The second case was a boy seen in our ear, nose, and throat clinic whose chest radiograph revealed a foreign body in the esophagus. The third case we report was a 10-month-old boy who was treated for upper respiratory tract infections and asthma before a chest radiograph revealed a foreign body.

Discussion

Foreign body aspiration/ingestion continues to present challenges to primary care physicians, otolaryngologists, and anesthesiologists. Timely and experienced intervention for esophageal foreign bodies usually allows for removal with minimal morbidity. Foreign body ingestion and food bolus impaction commonly occur. The majority of ingested foreign bodies pass spontaneously. However, 10 to 20% require non-operative intervention, and 1% or less require surgical intervention. (1), (2) Although esophageal foreign bodies are considered less serious than bronchial foreign bodies, 1,500 people die each year secondary to complications from esophageal foreign body ingestion. (3)

The majority of foreign body ingestions occur in the pediatric population, with a peak incidence between ages 6 months and 6 years. (1), (4), (5) In adults, foreign body ingestion occurs more commonly among patients with psychiatric disorders or mental retardation, or while under the influence of alcohol. (1), (6), (7)

Esophageal foreign bodies most commonly lodge at the normal anatomic narrowing--most frequently at the level of the cricopharyngeal muscle or at C6 and at the ileocecal valve. Impaction, perforation, or obstruction most often occurs at these areas. (8)

Foreign body ingestion can go unrecognized or unreported, particularly in young children and mentally impaired adults, until the onset of symptoms, which may be remote from the time of ingestion. (9), (10) Coins are the most frequently found esophageal foreign body in children, although undigested food, fish bones, and safety pins are also common. In the pediatric population, esophageal foreign bodies may present with wheezing, coughing, or laryngeal irritation and may be diagnosed and treated incorrectly as bronchial asthma by the primary care physician. (11), (12) In our institution, we have had numerous patients undergo radiographic examination for an unrelated medical condition who subsequently were found to have a foreign body in the esophagus.

Wheezing, coughing, laryngeal irritation, or even choking may occur due to the highly compliant partition wall between the trachea and esophagus, leading to significant tracheal compression secondary to foreign body impaction. This can further lead to partial or complete esophageal blockage, with superimposed edema of the esophageal wall and adjacent tracheal tissue, further deteriorating the symptoms mimicking asthma. Aspiration with further worsening of symptoms can occur as a consequence of the pooling of secretions secondary to esophageal wall edema.

Conclusion

Foreign body ingestion accounts for substantial morbidity and mortality. It is therefore our recommendation that if there is any suspicion of foreign body ingestion in a pediatric patient, the child should undergo a complete evaluation, including chest radiography, before labeling the symptoms as asthma or upper respiratory tract infection.

I am a great believer in luck, and I find the harder I work the more I have of it.

--Stephen Butler Leacock

From the Department of Anesthesiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR.

Financial support has not been given other than by the respective institutions. The authors hold no proprietary or commercial interest in any drug, device, or equipment mentioned in this article.

Reprint requests to Mary Anne Gunter, Management Project Analyst II, Arkansas Children's Hospital, 800 Marshall Street, Slot 203, Little Rock, AR 72202-3591. Email: [e-mail]

Accepted July 14, 2003.

Copyright [c] 2004 by The Southern Medical Association 0038-4348/04/9701-0093

References

(1.) Webb WA. Management of foreign bodies of the upper gastrointestinal tract: Update. Gastrointest Endosc 1995;41:39-51.

(2.) Nandi P, Ong GB. Foreign body in the oesophagus: Review of 2394 cases. Br J Surg 1978;65:5-9.

(3.) Webb WA. Management of foreign bodies of the upper gastrointestinal tract. Gastroenterology 1988;94:204-216.

(4.) Cheng W, Tam PK. Foreign-body ingestion in children: Experience with 1,265 cases. J Pediatr Surg 1999;34:1472-1476.

(5.) Hachimi-Idrissi S, Corne L, Vandenplas Y. Management of ingested foreign bodies in childhood: Our experience and review of the literature. Eur J Emerg Med 1998;5:319-323.

(6.) Blaho KE, Merigian KS, Winbery SL, et al. Foreign body ingestions in the emergency department: Case reports and review of treatment. J Emerg Med 1998;16:21-26.

(7.) Kamal I, Thompson J, Paquette DM. The hazards of vinyl glove ingestion in the mentally retarded patient with pica: New implications for surgical management. Can J Surg 1999;42:201-204.

(8.) Ginsberg GG. Management of ingested foreign objects and food bolus impactions. Gastrointest Endosc 1995;41:33-38.

(9.) Adams DB. Endoscopic removal of entrapped coins from an intraluminal duodenal diverticulum 20 years after ingestion. Gastrointest Endosc 1986;32:415-416.

(10.) Tsui BC, Mossey J. Occult liver abscess following clinically unsuspected ingestion of foreign bodies. Can J Gastroenterol 1997;11:445-448.

(11.) Schneider BM, Khorov OG. Esophageal foreign body in a child simulating the clinical picture of bronchial asthma [in Russian]. Vestn Otorinolaringol 1987;1:70-71.

(12.) Puig-Abuli M, Rodriguez de la Nuez A, Arcas-Meca R, et al. Esophageal foreign body as a cause of respiratory symptoms. Acta Paediatr Belg 1980;33:183-184.

Key Points

* In pediatric patients, foreign body aspiration may mimic asthma.

* Not all that wheezes is asthma, and foreign body aspiration must first be ruled out in the patient.

* Esophageal foreign body aspiration may contribute to significant morbidity in pediatric patients.

RELATED ARTICLE: Case Reports

Patient 1

A 10-month-old boy was transferred to the emergency department in the early morning after being diagnosed with coin ingestion with respiratory distress at an outside hospital. History revealed that he had been experiencing respiratory symptoms of coughing and wheezing for more than 1 month. He had initially been diagnosed with bronchiolitis and/or asthma and was treated with antibiotics and [beta]-agonists. When the symptoms did not subside, a chest radiograph was obtained that revealed a coin in the esophagus compressing the trachea. At admission to the emergency department, he was in moderate respiratory distress. His respiratory rate was high, with bilateral wheezing on chest auscultation and with increased oral secretions. His oxygen saturation was 100% on room air. He was most comfortable in the seated position.

In the operating room, when we attempted to place him in a supine position, the patient started coughing and was unable to maintain his own airway. An IV induction was performed while he was in the sitting position without complications, and the trachea was easily intubated. The coin was removed successfully with a flexible endoscope. At the conclusion of the case, the trachea was extubated uneventfully after the patient awakened. In the recovery room, his breathing became much easier, but wheezing continued. Racemic epinephrine was administered, which resulted in improvement in his respiratory status. The patient was subsequently discharged to the floor without respiratory distress. Postoperatively, the patient was fed a regular diet, and he was discharged to home the next day. At a subsequent follow-up visit, he no longer exhibited any wheezing and was medication-free.

Patient 2

An 11-month-old boy who had been treated for asthma for several weeks presented to the ear, nose, and throat clinic with a history of snoring and acute recurrent otitis media. A lateral neck radiograph was ordered to evaluate adenoid size, which revealed the presence of a metallic foreign body at the thoracic inlet. A more detailed history from the parents revealed that the child had a history of wheezing and had been treated for asthma for more than 1 month. The parents thought that there might have been coin ingestion a few weeks earlier.

The patient was taken to the operating room, and after placement of standard monitors (Sp[O.sub.2], noninvasive blood pressure cuff, and electrocardiograph), anesthesia was induced with nitrous oxide, oxygen, and sevoflurane. Endoscopy revealed a coin that was easily removed. Postoperatively, the patient's wheezing was no longer present, and he made an uneventful recovery.

Patient 3

A 10-month-old boy was transferred to the emergency department after discovery of a foreign body in his esophagus. He had been treated for an upper respiratory tract infection for the past month with over-the-counter cold medicines, decongestants, [beta]-agonists, and antibiotics. When no improvement in symptoms occurred, a chest radiograph was obtained that revealed the foreign body. At admission, he was not in acute distress, but his breathing was noisy. He was afebrile, and his room air oxygen saturation was 98%.

In the operating room, all standard monitors were placed, including electrocardiograph, noninvasive blood pressure cuff, pulse oximetry, and precordial stethoscope. Anesthesia was induced with propofol, and his trachea was intubated without difficulty. The foreign body was removed easily with a fiberoptic gastroscope. The endotracheal tube was removed when the patient was fully awake. He was administered IV dexamethasone and racemic epinephrine in the postanesthesia care unit. The patient was discharged in much improved condition.

Shireen Mohiuddin, MD, M. Saif-ur-Rehman Siddiqui, MD, and James F. Mayhew, MD, FAAP