Two infants who presented with stridor were found to have radiotranslucent plastic objects impacted in the oesophagus at the level of the cricoid cartilage. From these 2 cases the lessons to be learnt are that oesophageal foreign bodies retained for even a short period may be a cause of stridor and that when these foreign bodies are not radiographically visible investigation must include the swallowing of contrast medium in which the foreign body should be visible as a translucency.S. Afr. Med. J., 48, 831 (1974)

le Roux, B.T.

le Roux, P.D.

Winship, W.S.

English

AJOL - African Journals Online

20 April 1974 S.A. MEDICAL JOURNAL 831Retention of Radiotranslucent Foreign Bodies inthe Oesophagus as a Cause of Stridorw. s. WINSHIP, P. D. LE ROUX, B. T. LE ROUXSUMMARYTwo infants who presented with stridor were found tohave radiotranslucent plastic objects impacted in theoesophagus at the level of the cricoid cartilage.From these 2 cases the lessons to be learnt are thatoesophageal foreign bodies retained for even a shortperiod may be a cause of stridor and that when theseforeign bodies are not radiographically visible investigationmust include the swallowing of contrast medium in whichthe foreign body should be visible as a translucency.s. Afr. Med. J., 48, 831 (1974).Infants instinctively put objects into their mouths.Most inedible materials are rejected but occasionallysolid objects are swallowed or inhaled, usually in relationto efforts of elders at extraction of the foreign materialfrom the mouth of the infant. Inhaled foreign bodiesnearly always cause respiratory symptoms. Many smallobjects which are swallowed pass through the proximalpart of the alimentary tract without symptoms, but somemay lodge in the oesophagus at one of its narrowerpoints,' often at the level of the cricoid cartilage. Thoseforeign bodies retained in the oesophagus that are radio-opaque are easily localised radiographically. The manysmall ra<tiotranslucent plastic objects which abound inmost households constitute a greater risk to the child.The purpose of this article is to relate briefly thepresentation and investigation of 2 infants with increasingstridor-the consequence of impaction of small plasticforeign bodies in the oesophagus.CASE REPORTSCase 1Six weeks before admission to hospital a girl, 18 monthsold, was seen by her parents to have an unidentifiedobject in her mouth. When an attempt was made to.remove this, the child gagged and the foreign object wasDepartment of Paediatrics, Addington Hospital, DurbanW. S. WINSHIP, M.B. CH.B., M. MED. (PAED.)Department of Radiology, Addington and Wentworth Hos-pitals, DurbanP. D. LE ROUX, M.B. CH.B., D.M.R.D.Department of. Thoracic Surgery, Wentworth Hospital,DurbanB. T. LE ROUX, CH.M., F.R.C.S.Date received: 25 October 1973.not found. A doctor who examined the child shortly afterthe episode did not find any abnormality. Over the nextdays the parents noticed that the child was intermittentlyre/llctant to take solid feeds and appeared to have difficultyin >wallowing these. Three weeks after the initial episodethe child developed stridor, at first intermittent, but witheach episode becoming progressively more severe. andultimately almost continuous.A postero-anterior chest radiograph showed the uppermediastinum to be a little broad. A lateral radiograph ofthe neck showed only anterior displacement of the trachea.At bronchoscopy the forward bowing of the trachea wasconfirmed and a tracheogram recorded this. An aortogram.made to exclude a vascular ring, was normal. The childwas encouraged to swallow barium and the barium-filledoesophagus looked normal on anteroposterior views. Alateral view showed a persistent translucent area in thecolumn of barium at the cricopharyngeus level (Fig. 1).At oesophagoscopy a plastic coin (Fig. 2) was removedwithout difficulty. The stridor disappeared by the followingday, and with the exhibition of an antibiotic for a shortperiod, in the management of what was presumed to beperi-oesophagitis, the radiographic appearances quicklybecame normal.Fig. 1. Case 1. Lateral radiograph showing a linear trans-lucency in the barium-filled oesophagus at the level ofthe cricopharyngeus.832 S.-A. MEDIESE TYDSKRIF 20 April 1974Fig. 2. Right: the plastic coin, inscribed 'Candy Cash',measuring 1,5 cm in diameter removed from case 1.Left: the plastic cuff stud, measuring 1,5 cm x 1 cm X1 cm removed from case 2.Case 2A male child, 14 months old, had what was presumedto be ab upper respiratory tract infection for several daysbefore admission to hospital. The mother said that thechild had been coughing. On the evening before admissionthe mother had found the child with a foreign object inhis mouth and in an attempt to extract this the childhad gagged and swallowed it. A few hours later the mothernoticed that the child was wheezing. On admission tohospital, stridor was not recognised but the child wastachypnoeic and feverish. The pharynx was red but therewere no other signs of respiratory disease. Chest radio-graphy and fluoroscopy were normal. Laryngoscopy showedsome redness of the trachea and larynx; a foreign bodywas not seen. The child was regarded as having laryngo-tracheobronchitis, and the story of inhalation of a foreignbody was discounted. The child was treated with anantibiotic and nursed in a steam tent.Twenty-four hours later the child was clearly stridulousand stridor was ingravescent. A further 24 hours later thechild was greatly distressed, with marked indrawina ofribs and sternum on inspiration. Tracheostomy was u;der-taken and there was immediate relief of respiratoryobstruction. On further examination of the larynx onlyredness of the trachea and larynx was noted. Oesophago-scopy was undertaken and a plastic cuff stud (Fig. 2) wasfound impacted at the level of the cricoid cartilage.This. was removed and recovery was uneventful.DISCUSSIONThe common causes of stridor in infancy are infectionsof the tpiglGttis, trachea and larynx; but the inhalationof a foreign body is not uncommon and must always besuspected if there is a history which in any way pointsto this likelihood.It is less well known, perhaps, that a foreign bodyimpacted in the oesophagus may be a cause of severestridor. R3dio-opaque foreign bodies are usually quicklyrecognised on radi'Jgraphic examination and removedbefore peri-oesopbagili.s complicates their presence andcauses. stridor. Plastic foreign bodies are usually notrecognIsable on routine plain films and may causepartial oesophageal obstruction for many weeks beforethe consequent peri-oesophagitis extends to involve thetrachea, with the production of stridor as a result ofdisplacement and a diminished lumen.Foreign bodies retained in the 0esophagus for a longtime are inevitably associated with peri-oesophagitis' andmay be associated with perforation of the oesophagus anda mediastinal abscess. The wall of such an abscess mayinclude a major vessel and pre~entation may therefore bewith a baematemesis,' which is sometimes fatal.Dysphagia and excessive salivation are clinical featuresassociated with retention of foreign bodies in the oeso-phagus, and the swallowing of a radiographic contrastmedium will usually reveal the presence of a plastic foreignbody as a translucency within the column of contrastmedium. The oesophagus must be viewed in more than oneplane to detect flat foreign bodies such as coins, since thecontrast may flow past on either side of a flat object in oneview, making it unrecognisable as a translucency.That the manufacturers of sweets should include smallplastic objects such as 'Candy Cash' in the packets isdeplorable.REFERENCES1. Davies, D. V. (1967): Gray's Anatomy, 34th ed., pp. 1442 - J.London: Longmans Green.2. Turner, G. G. (1964): Injuries and Diseases 0/ the Oesr,phagusPp. 31 and 35. London: Cassell. '3. Le ROIL<, B. T. (1964): Thorax, 19, 203.

Retention of radiotranslucent foreign bodies in the oesophagus as a cause of stridor

Two infants who presented with stridor were found to have radiotranslucent plastic objects impacted in the oesophagus at the level of the cricoid cartilage. From these 2 cases the lessons to be learnt are that oesophageal foreign bodies retained for even a short period may be a cause of stridor and that when these foreign bodies are not radiographically visible investigation must include the swallowing of contrast medium in which the foreign body should be visible as a translucency.S. Afr. Med. J., 48, 831 (1974)

Winship, WS

le Roux, PD

le Roux, BT

Retention of Radiotranslucent Foreign Bodies in the Oesophagus as a Cause of Stridor

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Retention of radiotranslucent foreign bodies in the oesophagus as a cause of stridor

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