Ingested (Oesophageal) Hard Foreign Body
RED FLAGS
Patients with symptoms and signs of oesophageal perforation (severe neck or chest pain, tachycardia, tachypnoea or surgical emphysema)
Patients with recurrent dysphagia/food bolus obstruction
WHY IS THIS IMPORTANT?
This is a common emergency presentation to ENT. The patient is usually in considerable discomfort and may need to go to theatre if the foreign body does not pass spontaneously. Many cases are uncomplicated and settle with medical management alone. However there is always a risk of oesophageal perforation and mediastinitis.
WHEN TO INVOLVE THE ENT REGISTRAR
Immediately: If the patient has any signs of airway compromise
Immediately: If the patient shows a high level of pain or distress (ie impending perforation), or there are signs that an oesophageal perforation has already occurred
Immediately: Any suspicion of ingestion of a button battery (usually in children)
Soon: If the patient is well but there are clear signs and symptoms of impaction of the foreign body
WHO TO ADMIT
Any patient who has got an impacted foreign body.
If the symptoms are suggestive of an upper oesophageal obstruction, then the patient is admitted under ENT; those with symptoms in keeping with lower oesophageal obstruction are admitted under gastroenterology or general surgery.
ASSESSMENT AND RECOGNITION
Common hard foreign bodies
Blunt objects eg coins or dentures
Sharp pointed objects eg fish bones, chicken bones, needles
Button or other batteries
For soft food bolus (no bones etc.), see Food bolus obstruction
Assessment
Check first that the airway is not compromised: if the patient is not short of breath and can speak normally, you can be reasonably reassured that the airway is not immediately compromised.
Accidental foreign body ingestion tends to occur more commonly in children or adults with learning difficulties. Intentional foreign body ingestion can also occur in patients with psychiatric history or in prison inmates.
History
All batteries can cause caustic burns, ulceration and perforation within hours; button batteries are commonly swallowed by younger children as they are small and appear interesting.
Take a detailed history: what was swallowed, when, what were the immediate symptoms and how are they feeling now? Can they swallow now or are they drooling?
Timing of ingestion is important as some foreign bodies may spontaneously pass.
Batteries must be removed as soon as practical.
Examination
Oropharynx – the tonsils and base of tongue are common sites for fish bones to become lodged; look carefully around all the nooks and crannies; wrap a piece of folded gauze around the tip of the tongue and ask the patient to pull it forwards and down to help you get a better view. Use a headlight and a proper Lack's tongue depressor!
Neck – examine for swelling, erythema or crepitus suggesting oesophageal perforation.
Chest examination may reveal evidence of inspiratory noise/stridor suggesting lodged oesophageal foreign body with tracheal compression.
Abdominal examination may demonstrate small bowel obstruction/perforation – speak to the general surgeons.
Flexible nasoendoscopy is vital to examine the pharynx and larynx for foreign bodies.
The typical patient with perforation has a good history of foreign body ingestion along with:
Severe chest and/or neck pain
Odynophagia
Aphagia or drooling
Tachycardia
Tachypnoea
Pyrexia
Sometimes surgical emphysema, torticollis or trismus
Imaging
Plain AP and lateral chest and lateral neck radiographs may aid diagnosis, however not all foreign bodies are radio-opaque. (There are lists of radio-opaque versus radio-lucent fish bones in some EDs but in our experience, you should not rely on this. Bottom line: If a patient feels pain or the foreign body every time they swallow, it is probably still stuck, regardless of negative imaging.)
Look for:
The foreign body!
Surgical emphysema
Widening of the mediastinum
Widening of the retropharyngeal soft tissue
Gas trapped in the oesophagus
CT imaging may be required if plain radiographs are negative
IMMEDIATE AND OVERNIGHT MANAGEMENT
If there is an airway problem, then proceed as for airway obstruction.
Admit the patient overnight and give IV fluids and analgesia. Oesophagoscopy is usually performed soon (ideally within 12-24 hours of ingestion) to remove hard foreign bodies.
If there is a button battery and you are waiting for theatre space, consider giving the patient a tablespoon of honey to coat the battery and prevent further erosion (make sure you discuss this with the anaesthetist).
Emergency endoscopy is required if the following are present
Foreign body is sharp, long (>5cm) or superabsorbent polymer
Lithium/button batteries
Signs of airway compromise
Urgent Endoscopy (within 24 hours) indicated in patients with
Evidence of near complete or complete oesophageal obstruction eg unable to swallow secretions
Oesophageal food bolus without complete obstruction
Oesophageal foreign bodies that are not sharp-pointed
Sharp- pointed objects in stomach or duodenum
Magnets within endoscopic reach
Objects >6cm in length or above the proximal duodenum
Non-urgent endoscopy
Coins in oesophagus may be observed for 12-24hours before endoscopic removal if asymptomatic
Objects within stomach >2.5cm
Disk batteries or cylindrical batteries which have passed into stomach without signs of GI injury
FURTHER MANAGEMENT
If the patient becomes unwell either following initial admission or rigid oesophagoscopy, re-assess them urgently and seek a senior opinion if necessary.
Serial X-ray imaging may be useful to ensure radio-opaque foreign bodies such as coins have passed into the stomach.
Following a rigid oeosophagoscopy, patients should be observed. Once the patient’s symptoms have settled completely, the patient can introduce water, slowly leading to a soft diet. The patient can be discharged later if well.
The patient may require follow-up in clinic or a follow-up contrast study if there is any concern over underlying pathology.
Page last reviewed: 1 December 2022