Irreversible hydrocolloid: an unusual presentation of esophageal obstruction.

Abstract

Upper digestive tract obstruction can occur after ingestion of various types of foreign bodies. However, to the best of our knowledge, no case of a near-total obstruction caused by an irreversible hydrocolloid has heretofore been reported in the literature. We present just such a case, and we discuss our preferred method of removing foreign bodies from the cervical esophagus.

Introduction

Obstructing foreign bodies of the upper digestive tract may cause life-threatening complications. Reports of esophageal perforation, parapharyngeal and retropharyngeal abscess, mediastinitis, and aortoesophageal fistula are not uncommon. (1)

The most common upper digestive tract foreign bodies in the adult population are solid food boluses and animal bones. (2) Reports of ingested dental objects (e.g., dentures and amalgam) are less common, but dentures have been associated with numerous complications, including airway obstruction and piriform, esophageal, and gastrointestinal tract perforations that have led to peritonitis, septicemia, hemorrhage, foreign-body reactions, fistula development, and abscess formation. (3-7) The standard workup for a patient with a possible upper digestive tract foreign body includes a thorough history and physical examination and radiographic studies. Other diagnostic and treatment modalities may include direct laryngoscopy and esophagoscopy.

In this article, we describe what we believe is the only reported case of a near-total obstruction of the upper digestive tract caused by an irreversible hydrocolloid. We also discuss our preferred methods of evaluation and management of foreign bodies in the upper digestive tract.

Case report

A 70-year-old man presented with a 2-week history of dysphagia for both solids and liquids and an inability to tolerate his own secretions. As a result, he had lost 5 lbs. He denied hoarseness, dyspnea, fevers, and chills. The patient said his symptoms developed after his dentist had taken impressions in preparation for making dentures. He noted some throat discomfort and dysphagia after he had inadvertently swallowed some of the molding material. When his symptoms failed to resolve, he presented to an emergency room, where a lateral neck x-ray detected a large radiopaque foreign body at the level of C4 and C5 (figure).

Findings on our physical examination of the head and neck were unremarkable. Flexible nasopharyngoscopy identified a blue foreign body in the postcricoid area. The appearance of the remainder of the pharynx and larynx was normal, and no evidence of airway obstruction was seen.

The patient was taken to the operating room for removal of the foreign body. Direct laryngoscopy was initially performed to evaluate the oral cavity, oropharynx, glottis, and postcricoid area. The object was visualized on the posterior pharyngeal wall just above the level of the arytenoids. It had become impacted in the postcricoid area and the upper esophagus. The laryngoscope was placed in suspension, and laryngeal forceps were used to grasp the 1 x 3-cm piece of synthetic denture-impression material. After the material was removed, flexible esophagoscopy revealed no additional foreign bodies or any injuries to the esophagus and stomach.

The patient did well during the immediate postoperative period, and he was able to resume a normal oral diet. He was admitted for overnight observation and discharged the following morning. On the final pathology report, the foreign body was identified as dental alginate, which is an irreversible hydrocolloid.

Discussion

Our patient presented with an unusual cause of obstruction. Alginate is used primarily as impression material in the manufacture of dentures. Unlike most dental prosthetic materials, irreversible hydrocolloid is radiopaque and easily visible on radiography because of its calcium content. (8) The literature contains reports of airway obstruction caused by only small fragments of dental material. (9) As far as we know, no other case of upper esophageal obstruction by an irreversible hydrocolloid has been reported. Given the paucity of information on this type of obstruction, we postulate that the complications caused by this type of foreign body would be similar to those caused by other dental prosthetic materials.

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The diagnosis and removal of esophageal foreign bodies have classically been accomplished with rigid endoscopy. (1) The flexible esophagoscope has only limited applicability for removal of upper esophageal foreign bodies, but it is superior to rigid esophagoscopy for circumferential visualization of the esophageal mucosa. (1) The most serious complication of either method is esophageal perforation, which may lead to mediastinitis, abscess formation, fistula development, septicemia, and even death. The reported incidence of esophageal perforation with flexible esophagoscopy is 0.018 to 0.03%; rigid esophagoscopy carries a substantially higher risk of perforation: 0.11 to 1.1%. (10-13) Given the difference in complication rates, we prefer to use the flexible esophagoscope to evaluate the esophagus for additional objects or mucosal injuries following removal of an upper esophageal foreign body.

This case illustrates an unusual cause of cervical esophageal obstruction by a foreign body and a safe and effective method of evaluating the esophagus and removing the object. The use of a laryngoscope allows for adequate visualization of the larynx, hypopharynx, and cervical esophagus for foreign bodies in these areas. Placing the laryngoscope in suspension allows for bimanual retrieval of foreign bodies. Compared with rigid techniques, flexible esophagoscopy provides superior visualization for assessment of the esophageal mucosa with a substantially lower risk of perforation.

References

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(9.) Chate RA. A report on the hazards encountered when taking neonatal cleft palate impressions (1983-1992). Br J Orthod 1995;22: 299-307.

(10.) Prinsley PR, Murrant NJ. Cervical esophageal perforation caused by diagnostic flexible esophagoscopy. J Otolaryngol 1989;18: 314-16.

(11.) Silvis SE, Nebel O, Rogers G, et al. Endoscopic complications. Results of the 1974 American Society for Gastrointestinal Endoscopy Survey. JAMA 1976;235:928-30.

(12.) Katz D. Morbidity and mortality in standard and flexible gastrointestinal endoscopy. Gastrointest Endosc 1969;15:134-41.

(13.)Radmark T, Sandberg N, Pettersson G. Instrumental perforation of the oesophagus: A ten-year study from two ENT clinics. J Laryngol Otol 1986;100:461-5.

Sihun Alex Kim, MD; Robert J. Meleca, MD

From the Department of Otolaryngology--Head and Neck Surgery, Wayne State University School of Medicine, Detroit.

Reprint requests: Sihun Alex Kim, MD, Affiliated ENT Physicians Ltd., 583 Glen Ridge Ct., Crystal Lake, IL 60014-1302. Phone: [phone]; fax: [phone]; e-mail: [e-mail]