PATOLOGIE CERVICALĂ

Modalităţi diagnostice şi principii terapeutice ale corpilor străini esofagieni - experienţa Clinicii ORL, Spitalul Clinic Judeţean de Urgenţă din Craiova

 Diagnostic modalities and therapeutic principles of esophageal foreign bodies - experience of ENT Clinic Craiova within the County Emergency Hospital

First published: 07 decembrie 2017

Editorial Group: MEDICHUB MEDIA

DOI: 10.26416/Orl.37.4.2017.1297

Abstract

The purpose of this paper. The importance of total dysphagia caused by esophageal foreign bodies with an impact upon the esophageal walls.
The objectives of this paper. Clinical and imagistic diagnosis in determining the technique that must be used for the extraction of foreign bodies: rigid esophagoscope or external cervicotomy.
Materials and method. Patients hospitalized in the ENT Clinic over a period of 5 years (2012-2016) with ingested foreign bodies, dysphagia and esophageal affectation.
Results and discussions. After an analysis of the 155 hospitalised patients, it could be noticed that enclavation was conducted on a normal esophagus in 58% of cases and on a pathological esophagus in 42% of cases. The foreign bodies enclaved on the normal esophagus were large-sized food items (meat, cartilages, pointed bones), dentures, usually stagnating, and were prevented from swallowing at the mouth of esophagus. On a stenosed post-caustic esophagus there have been small-sized food items (peas, beans, cherry stones), depending on whether it was a case of simple or multi-levelled stenosis. In children, the ingested foreign bodies were metallic (coins) or plastic (buttons, LEGO toys) stucked in cervical esophagus(2). It was not difficult to set the diagnosis of esophageal foreign body, as patients or relatives described how the foreign body was ingested. Radiological examination was compulsory in order to emphasise any potential parietal changes with mediastinal disorder of the pointed foreign bodies, and it was conducted urgently, consisting in esophagoscopy (the diagnosis method) and the extraction of the foreign body in a secure, painless manner.
Conclusions. The manoeuvres for the natural extraction of the foreign body by means of endoscopic control or external cervicotomy must be conducted as soon as possible after ingestion, with 24-hour hospital observation after the extraction of the foreign body.

Keywords
esophageal, foreign body, esophagoscopy

Rezumat

Scopul lucrării constă în studierea diagnosticului și tratamentului disfagiei totale prin corp străin esofagian și al răsunetului inclavării acestuia asupra pereților esofagieni.
Obiectivele lucrării au vizat implicarea diagnosticului clinic și imagistic în vederea stabilirii tacticii de extragere a corpilor străini sub esofagoscop rigid sau prin cervicotomie externă.
Materiale și metodă. Au fost incluși în studiu pacienţii internați de urgență în Clinica ORL Craiova pe o perioadă de 5 ani (2012-2016) cu corpi străini ingerați, cu suferință disfagică importantă esofagiană.
Rezultate și discuții. Analizând cei 155 de bolnavi internați, am constatat că inclavarea s-a făcut in 58% din cazuri pe esofag normal și în 42% din cazuri pe esofag patologic. Corpii străini inclavați pe esofag normal au fost de dimensiuni mari, de regulă stagnând la gura esofagului şi având natură alimentară (carne, cartilaj, oase ascuțite), proteză dentară etc. Pe esofag stenozat postcaustic fragmentele alimentare au fost mici (boabe de fasole, mazăre, sâmburi de cireșe), în funcție de gradul de stenoză, simplă sau supraetajată. La copii, corpii străini ingerați au fost metalici (monede) sau plastici (nasturi, piese LEGO), opriți în esofagul cervical(2). Stabilirea diagnosticului de corp străin esofagian a fost relativ ușoară, pacientul sau aparținătorii relatând accidentul ingerării corpului strain. Examenul radiologic a fost obligatoriu pentru evidențierea potențialelor modificări parietale cu răsunet mediastinal prin corpi străini ascuțiți. Rezolvarea corpilor străini s-a realizat prin esofagoscopie sau esofagotomie cervicală sub anestezie generală. Tratamentul s-a instituit de urgență și a constat în esofagoscopie (metodă diagnostică și terapeutică), cu extragerea corpului străin în condiții de securitate maximă și minimă traumă.
Concluzii. Manevrele de extragere a corpilor străini pe căi naturale, sub controlul endoscopului sau prin cervicotomie externă, trebuie efectuate la un timp cât mai scurt de la ingerare, cu urmărirea post-extracție timp de 24 de ore în spital.

Introduction

The symptoms of esophageal foreign bodies urge the patient to report to the medical rooms at any time of the day, and they require immediate attention. Another important role relies in the nature of the foreign body, as its shape and size may determine the extent of the patient’s sufferance.

Food-origin foreign bodies (meatballs) are relatively well tolerated, whereas pointed foreign bodies (blade bobes, pointed bones, splinters, dentures) can penetrate the esophageal wall, thus leading to suppurative complications.

Foreign bodies must be extracted as soon as possible, in a completely secure manner in order to avoid complications, by means of an esophagoscopy or of a cervical esophagotomy under general anesthesia.

Materials and method

In this paper we present a series of aspects related to esophageal foreign bodies in the adults and children hospitalised in the ENT Clinic of Craiova between 2012 and 2016.

As compared to the tracheo­bronchial foreign bodies, the esophageal ones are more common and they can be diagnosed through anamnesis or by radioscopic and endoscopic methods.

The anamnesis revealed the exact moment of the swallowing of the foreign body and its nature, the total dysphagia and sialorrhoea.

The thoracic cavity radiography was mandatory for any esophagoscopy to look for signs of mediastinal lesions and perforation (the Minnegerode sign).

Esofagoscopy with a rigid tube, maneuver performed in a highly reflexogenic area, in a septic, intolerant, weakly vascularised organ, located in full mediastinum, was the method of choice used for the extraction of oesophageal foreign bodies.

The treatment was primarily aimed at extracting the foreign body by natural means through rigid esophagoscopy, which was done in most cases; when this was impossible, left cervical external esophagotomy was performed.

Medical treatment preceded/accompanied the surgical treatment, depending on the preoperative condition of the patient - hydro-electrolytic and metabolic rebalancing, sedatives, musculoskeletal antispasmodics, painkillers, glycosides, anti-inflammatory (cortisone), antibiotics (depending on each case).

For the success of the extraction, the following general rules were strictly complied with: under the local/general anesthesia, the foreign body followed by the exposure in its ideal presentation for prehensive extraction by gentle manipulation of instruments or body itself (internal version). The correctly executed catchment consisted of a firm socket on the foreign body, with fine defibrating movements, while keeping the foreign body in intimate contact with the endoscope during the entire duration of the extraction, without resisting the retraction of the tube(3).

If increased resistance to extraction was found to protect the tissues against any injury, natural extraction in favor of the cervical esophagotomy surgery was discarded.

Results

After an analysis of the 155 hospitalised patients, it could be noticed that enclavation was conducted on a normal esophagus in 58% of cases and on a pathological esophagus in 42% of cases.

The foreign bodies originated in the rural area (73.5%), mostly in the case of female patients (54%), and the maximum incidence was over 40 years of age (86%).

The place where the foreign bodies were blocked were (in descending order): the broncho-aortic channel, the upper esophageal sphyncter, between the broncho-aortic channel and the diaphragmatic aperture.

The nature of the enclaved foreign body was mostly alimentary (98.9%), with merely 1.1% of metallic foreign bodies. The therapeutic management envisaged the diagnosis of esophageal foreign body, which was relatively easy, as patients explained how they had ingested the foreign body. Dysphagia settled later on, ranging from light to total, along with retrosternal discomfort(1). Anamnestically, we gathered information on the state of the esophagus and of the foreign body. A simple radiological examination revealed the radiopaque foreign bodies, the coins identified at the upper esophageal sphyncter were located in a frontal plan and they were easy to extract(2). The examination using a contrast material reavealed the location of the foreign body and its impact upon the mediastino-pulmonary organs(4).

The radiologic presence of an amount of air with retroesophageal location on the cervical and thoracic ultrasonography is a particularly important sign of esophageal perforation.

In one case, the ingested foreign body was a pointed fragment of glass, which the patient had accidentaly ingested while eating. The patient failed to notice the presence of the foreign body either on the slice of bread or in her own mouth. She only felt a sting during deglutition. The foreign body perforated the postero-lateral esophageal wall and was located near C7 by a CT scan. With pointed foreign bodies, complications occur quite rapidly, as in the case mentioned above. It was extremely important to attend these cases at once, therefore esophagoscopy was conducted in 97% of the cases. The patients were put under general anesthesia after having received anti-spastic medication. Only 3% of the cases required cervical esophagotomy.

The foreign bodies such as seeds (cherries, sour cherries, plums, olives, apricots) located in the diaphragmatic aperture and in the broncho-aortic channel were difficult to extract, as they were enclaved in the stenotic area and the clamp would slip away from the smooth surface of the body. At the upper esophageal sphyncter we were able to extract pointed foreign bodies, such as blade bones or cartilages.

The food ball blocked in the stenotic area or on a normal esophagus could only be extracted in several steps on account of the overlapping fragments.

The cases of foreign bodies enclaved in the esophageal wall - metallic dentures, animal vertebra or glass fragments - required external extraction by means of a cervical esophagotomy, followed by the placement of a feeding tube and antibiotic medication.

The glass fragment penetrating the cervical esophageal wall caused the onset of the laterocervical phlegmon by crossing the postero-lateral wall. The extraction of the foreign body was followed by the suture of the esophageal wall, a 21-day alimentation tube, drainage of the cervical collection and broad-spectrum antibiotics.

In other uncomplicated cases, the esophagotomy and removal of the foreign body were followed by esohageal suturing, a 10-day feeding drain and antibiotic medication.

Post-surgical evolution was favourable in all cases. There have been no particular incidents during the extraction of the foreign bodies.

Discussions

A foreign body blocked at the level of the esophagus is a real threat because it makes the esophagus contract and causes discomfort because of the esophago-salivary reflex.

The symptoms vary according to the nature of the ingested foreign body, to its location at the level of the esophageal segments, and to the degree of obstruction (total or partial)(5,6,10).

The food ball may consist of meat, as well as bone fragments. The location where the foreign bodies are blocked at the level of the esophagus depends on the volume and form thereof (smooth or not), and on the pathological state of the esophagus (post-caustic scars or affected motility caused by cerebral-vascular accidents).

Depending on their nature, the enclaved foreign bodies may generate lesions of the esophageal mucosa, with edema and ulceration favoring spasms and the retention thereof.

Foreign bodies are dangerous because they perforate the esophageal wall and lead to periesophageal and mediastina suppurations(7,8).

The smooth, alimentary foreign bodies are well tolerated, but in time they may cause local modifications. The management of a positive diagnosis of foreign bodies is based on anamnesis, with a detailed account of the incident and on the simple or CT cervical and thoracic radiography performed in order to highlight radiopaque foreign bodies or periesopha­geal modifications. Anamnesis emphasizes the moment and nature of deglutition.

In children or in patients suffering from mental disorders, the moment of deglutition may lack(9).

Both the dysphasic functional symptoms and painful deglutition are relevant for a correct diagnosis. Suprasternal or retrosternal and epigastric degluti­tion pain may respond to various areas of the thorax or throat, and their persistence may confirm the sus­picion of the presence of foreign bodies(9).

Dysphagia is a mechanic process and in cases of total blockage (alimentary foreign bodies blocked on a former scar structure, or a gigantic food ball), the patient is not even able to swallow its own saliva. If the foreign body is large-sized, there can be noticed evidence of extrinsic compression over the posterior wall of the trachea, which takes the form of coughing and suffocation.

Late presentation to the physician, after the onset of tolerance, with recurrence of dysphagia and pain, fever and general malaise, indicates a complicated development(9). Such was the case of a patient admitted in the clinic with a pointed esophageal foreign body (a pigeon’s wing) who waited for one week after the ingestion thereof, which led to the penetration of the thoracic esophagus and suppurative mediastinitis. The emergency extraction of the foreign body and the ensuing antibiotic treatment made him heal.

The exploration of the esophagus is performed by means of a radiologic and esophagoscopic examina­tion. The radiopaque (metallic) foreign bodies are easily identified from the profile or frontal incidence and we can detemine their location, form and volume. In the case of radiolucent foreign bodies, a mere radiography may reveal the presence of the foreign body by an enlarged distance between the spinal cord and the larynx, the trachea or air in the cervical esophagus.

Objective clinical examination (inspection, palpa­tion, bucopharyngoscopy, laryngoscopy) must precede the endoscopic exploration of the esophagus. Upon inspection it can be noticed the tendency to swallow air and the patient’s facial expression of pain caused by the esophageal foreign body.

The emphasis of a tumefaction in the lower part of the throat close the sternocleidomastoid muscle, caused by the inflammatory reaction induced by the foreign body, or the presence of an emphysema (a gaseous crepitus) are clear signs of an esophageal perforation.

Bucopharyngoscopy and laryngoscopy can re­veal signs of ulceration due to a foreign body which has been swallowed and retained at the level of the esophagus.

Endoscopic esophageal exploration is conducted after a careful exo- and endo-cervical clinical examination. All patients underwent clinical and paraclinical explorations by means of esophageal endoscopies with general anesthesia.

Rigid esophagoscopy is absolutely necessary in order to emphasize the presence of the foreign body. It is the most frequently used method of diagnosis and treatment. The esophagoscopic tube enables the doctors to view the foreign body, how it is blocked and the lesions it has caused. A long-term blockage of a foreign body leads to modifications of the mucosa with edema, making them covered with blood clogs, being necessary to extract them in an extremely careful manner.

After the extraction of the esophageal foreign body, its lumen is explored until the beginning of the stomach. In post-caustic esophagitis, the lumen is not intense and it does not allow for the tube to be inserted in the stenotic area.

The mere inspection after the extraction of the foreign body, with the entire lumen visible along the esophagus, is a clear sign of the absence of the foreign body.

Rigid esophagoscopy must be conducted extremely carefully, with the provision of professional care. The rigid esophagoscopic tube made of glass fibre provides the necessary visibility conditions and the telescopically guided clamp can directly grasp the foreign body (beyond its geometrical center).

The cervical surgery conducted in order to extract the foreign bodies which are either complicated or highly enclaved is performed by a team of chemists, ENT and anesthesia specialists. Post-surgical observation of the patients having undergone cervical esophagotomy is essential in order to ensure a proper healing of the esophagus with a 10 to 14 days period. In patients having undergone endoscopic extractions of a foreign body, the observation period ranges from 24 to 48 hours.

All patients hospitalized on account of a foreign body were healed upon discharge. The management of esophageal foreign bodies depends mainly on the diagnosis and corresponding therapy.

Conclusions

A correct diagnosis of foreign bodies implies a set of clinical, paraclinical and endoscopic elements.

Esophagoscopy is a specific examination used to set the diagnosis and extract the foreign body.

Cervical esophagotomy is recommended when the foreign body cannot be extracted by natural means.

Bibliografie

  1. Conners GP, Chamberlain JM, Ochsenschlager DW. Symptoms and spontaneous passage of esophageal coins. Arch Pediatr Adolesc Med 1995 Jan; 149(1): 36-9.
  2. Dokler ML, Bradshaw J, Mollitt DL. Selective management of pediatric esophageal foreign bodies. Am Surg 1995 Feb; 61(2): 132-4.
  3. Gârbea Ștefan și colaboratorii. Patologie ORL Traumatismele esofagului și corpii străini, pag. 710-20. Ed. Didactică și Pedagogică București, 1980.
  4. Jaramillo D, Cleveland RN, Blickman JG. Radiologic management of esophageal foreign bodies. Semin Intervent Radiol 1991; 8: 198-203.
  5. Macpherson RI, Hill JG, Otherson HB. Esophageal foreign bodies in children: diagnosis, treatment and complications. AJR Am J Roentgenol 1996 Apr; 166(4): 919-24.
  6. McGahren ED. Esophageal foreign bodies. Pediatr Rev 1999 Apr, 20(4): 129-33.
  7. Melzer-Lange M, Van Howe R, Losek JD. Esophageal foreign body presenting with altered consciousness. Am J Dis Child 1988 Sep; 142(9): 915-6.
  8. Nandi P, Ong GB. Foreign body in the oesophagus: review of 2394 eases. Br J Surg 1978 Jan; 65(1): 5-9.
  9. Obreja Savel și colaboratorii. Lexicon al Diagnosticului în Otorinolaringologie, vol. 1, pag. 273-6. Editura Didactică și Pedagogică, R.A. București, 1998.
  10.  Miorița Toader. Management of esophageal foreign bodies – ENT Clinic experience, p. 41-44. Redacția ORL, vol. XXIX, Nr. 1, 2007.

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