| Author | Affiliation |
|---|---|
| Ryan McCreery, DO | Orange Regional Medical Center, Department of Emergency Medicine, Middletown, New York; New York Colleges Osteopathic Medicine Educational Consortium, Department of Emergency Medicine, Middletown, New York |
| Matthew Meigh, DO | Orange Regional Medical Center, Department of Emergency Medicine, Middletown, New York; New York Colleges Osteopathic Medicine Educational Consortium, Department of Emergency Medicine, Middletown, New York |
ABSTRACT
Foreign body impaction (FBI) in the esophagus has the potential to be a serious condition with a high mortality rate. Although the majority of foreign bodies trapped within the esophagus pass spontaneously, some do require endoscopic intervention. This case discusses a 95-year-old-female with a history of cerebral vascular accident who presented with acute onset respiratory distress with inspiratory stridor. The patient denied any episodes of choking or foreign body sensation. Further imaging revealed a large food bolus within the esophagus with extensive tracheal narrowing. The patient was diagnosed promptly and successfully managed endoscopically. This case presentation emphasizes the need to maintain a high index of clinical suspicion for FBI in high-risk populations, especially when the patient’s history makes it unlikely. In the setting of respiratory complications, airway protection remains a priority, but an accurate diagnosis with timely intervention is paramount.
CASE PRESENTATION
A 95-year-old female with history of cerebral vascular accident presented to our emergency department for acute onset respiratory distress with inspiratory stridor. Vital signs revealed the patient to be hypertensive, tachycardic and tachypneic with intermittent episodes of mild hypoxia. On physical exam, she was unable to phonate with audible stridor but without drooling or trismus. Lung sounds were clear to auscultation bilaterally. She denied any choking or foreign body sensation. Radiography of the soft tissue of the neck and chest were unremarkable. Bedside transnasal flexible laryngobronchoscopy was normal to the level of the cords.
Contrast-enhanced computed tomography (CT) chest revealed significant tracheal compromise from marked distention of the esophagus (Images 1 and 2). The patient was intubated and underwent an emergent therapeutic bronchoscopy and esophagogastroduodenoscopy (EGD). While bronchoscopy was unremarkable, EGD showed a large food bolus extending from the upper to lower esophageal sphincters. Food bolus removal resolved her respiratory symptoms, and subsequent esophagram showed marked esophageal dysmotility.
DISCUSSION
Esophageal foreign body impaction (FBI) can be a serious condition carrying high mortality when not properly diagnosed or if management is delayed. While 80–90% of FBIs spontaneously pass from the esophagus to the stomach, an estimated 10–20% require endoscopic intervention.1 Life-threatening complications include airway compromise and esophageal wall perforation, which can lead to mediastinitis, fistula, abscess, empyema, or death.2 In adults, stridor due to esophageal FBI is a rare complication that not only requires airway protection but an accurate diagnosis with timely intervention.3
CPC-EM Capsule
What do we already know about this clinical entity?
In the setting of respiratory compromise, an accurate diagnosis of esophageal foreign body impaction with timely intervention is paramount to reduce mortality.
What is the major impact of the image(s)?
These images clearly depict severe tracheal narrowing from esophageal food impaction and help raise awareness for this particular process.
How might this improve emergency medicine practice?
Consider esophageal food impaction in the differential diagnosis for stridor in the awake, adult patient without localizing signs or symptoms of dysphagia.
Footnotes
Section Editor: Rick A. McPheeters, DO
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
Documented patient informed consent and/or Institutional Review Board approval has been obtained and filed for publication of this case report.
Address for Correspondence: Ryan McCreery, DO, Orange Regional Medical Center, Department of Emergency Medicine, 707 East Main Street, Middletown, NY 10940. Email: rmccreery@ghvhs.org. 3:314 – 315
Submission history: Revision received March 9, 2019; Submitted May 29, 2019; Accepted May 29, 2019
Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.
REFERENCES
1. Heger P, Weber TF, Rehm J, et al. Cervical esophagotomy for foreign body extraction: case report and comprehensive review of the literature. Ann Med Surg (Lond). 2016;7:87-91.
2. Loh KS, Tan LK, Smith JD, et al. Complications of foreign bodies in the esophagus. Otolaryngol Head Neck Surg. 2000;123(5):613-6.
3. Muthucumaru M, Clarnette T. Oesophageal foreign body causing stridor in an infant: Is a rare forgotten cause. J Pediatr Surg Case Rep. 2014;2(6):284-6.