Foreign Body Oesophagus

Foreign Body in the Oesophagus

The oesophagus and surrounding regions are common sites for lodging of ingested foreign bodies (FBs). These objects can become stuck in the tonsils, base of the tongue, posterior pharyngeal wall, pyriform fossa, or the oesophagus itself. Below is an explanation of the key areas and associated clinical considerations.

Key Epidemiological Facts

1. Peak age: Most cases happen in children younger than 3 years because they explore objects by mouth and do not have full teeth for proper chewing.
2. Most common foreign body in children: Coins are the most commonly swallowed object and cause about 70% of cases.
3. Prognosis: More than 90% of swallowed objects pass through the gastrointestinal tract without any problem. However, objects stuck in the oesophagus need urgent treatment.
4. High-risk adults: Adults with dentures, alcohol intoxication, psychiatric illness, or oesophageal diseases like strictures or cancer have a higher chance of foreign body ingestion.

Anatomical Sites of Impaction in the Oesophagus 

The oesophagus has four natural anatomic constrictions, and foreign bodies commonly get stuck at these points: Read  🔗Anatomy of Oesophagus:

1. Cricopharyngeal Sphincter (Upper Oesophageal Sphincter): This is at the C5–C6 level and is the most common site of impaction (about 80%). Flat objects like coins often get stuck here.
2. Aortic Arch: A foreign body may lodge where the aortic arch crosses the oesophagus, around the T4–T5 level.
3. Left Main Bronchus: The oesophagus is slightly compressed as it passes under the left main bronchus at the T6 level, making this another site where objects can get stuck.
4. Diaphragm (Lower Oesophageal Sphincter): This narrowing is located at the T10 level and can trap foreign bodies that pass through the upper oesophagus.

Site	Level	Common Foreign Body Types	Clinical Significance
Cricopharyngeal Sphincter	C5-C6	Coins, food bolus, dentures	Most common site (80%), most urgent due to tracheal compression risk in children.
Aortic Arch	T4-T5	Sharp objects, pins	Requires advanced thoracic endoscopy/surgery if impacted.
Left Main Bronchus	T6	Sharp/pointed objects	Less common, but deep impaction is challenging.
Diaphragmatic Hiatus	T10	Meat bolus (often indicating underlying pathology like stricture/cancer)	Lodgment here often warrants a workup for underlying disease.

Other Common Sites of Foreign Body Lodgment

1. Tonsils: Foreign bodies such as sharp fish bones or needles often lodge in tonsillar crypts. These can be easily identified through oropharyngeal examination and removed.
2. Base of Tongue or Vallecula: Commonly affected by fish bones or needles and diagnosed using a laryngeal mirror or flexible endoscope. Removal often involves the patient holding their tongue while the examiner uses curved forceps. Embedded objects might require radiological confirmation and, in rare cases, pharyngotomy for extraction.
3. Posterior Pharyngeal Wall: Objects such as wires, needles, or staples can adhere to this area, often taken accidentally with food. Visible on examination and removed with forceps under good illumination.
4. Pyriform Fossa: Objects like fish or chicken bones, needles, or dentures are commonly lodged here. Small items can be removed under local anaesthesia, while large or impacted objects may require endoscopic removal under general anaesthesia.

Aetiology and Predisposing Factors

Foreign body ingestion happens when the normal swallowing protection fails or when the swallowed object is too big or sharp to pass safely.

Causes of Foreign Body Ingestion 

1. Age: Children under five years often swallow objects because they explore with their mouths and do not chew well.
2. Loss of Protective Reflexes: Dentures reduce sensation, and conditions like alcohol intoxication, unconsciousness, or neurological diseases weaken the cough and swallow reflexes, increasing the risk.
3. Carelessness: Eating too fast, chewing poorly, or talking and laughing while eating can lead to accidental swallowing of foreign bodies.
4. Pre-existing Oesophageal Diseases (Most important cause in adults): Strictures, webs, rings, or cancer narrow the oesophagus. A sudden blockage by a meat piece may be the first sign of oesophageal cancer, so careful evaluation is needed.
5. Psychiatric Disorders: People with mental health conditions or prisoners may intentionally swallow objects (pica).

Clinical Features

Symptoms:

1. History of Choking or Gagging: Initial symptoms often include these reactions.
2. Pain or Discomfort: Discomfort may localise to the neck or chest and worsen with swallowing.
3. Dysphagia and Odynophagia: Partial or total swallowing obstruction often progresses due to oedema.
4. Drooling of Saliva: Seen in cases of total obstruction, sometimes leading to aspiration and pneumonitis.
5. Respiratory Distress: Foreign bodies in the upper oesophagus can compress the trachea, especially in children, causing airway obstruction.
6. Substernal or Epigastric Pain: Indicative of oesophageal spasm or potential perforation.

Signs:

1. Tenderness: Palpable in the lower neck on either side of the trachea.
2. Pooling of Secretions in the pyriform fossa: Observed during indirect laryngoscopy, indicating obstruction.
3. Protruding Foreign Body: Occasionally visible in the post-cricoid region during an examination.

Diagnostic Investigations

1. Radiographic Imaging: Posteroanterior and lateral X-rays of the neck, chest, and abdomen help identify radio-opaque objects and their locations. Radiolucent objects may appear as air bubbles in the cervical oesophagus. Identification of the location of a swallowed or inhaled coin on X-ray depends on how it appears in AP and lateral views. In the trachea, the appearance is the opposite: it looks like a line on AP view and round on lateral view. In the oesophagus, the coin usually looks round on AP view and is seen end-on or as a line on lateral view. This difference is because the oesophagus is wider from side to side than front to back, whereas the trachea is wider from front to back than side to side. Disc/Button Battery exhibits a “Double Ring” or “Halo Sign” on the PA view, which is due to the central electrode separator and outer casing. This is a critical sign for early identification!
2. Flexible Nasendoscopy: Useful for identifying foreign bodies or saliva pooling in the pyriform fossae, indicating oesophageal obstruction.
3. Contrast Studies: Barium swallow is avoided initially due to aspiration risk and interference with endoscopy. It is reserved for follow-up to check for stricture/underlying pathology after FB removal.

Treatment of Oesophageal Foreign Bodies

1. Rigid Oesophagoscopy. This is the gold standard for removing most sharp, large, or stuck foreign bodies, especially in the upper oesophagus. It is done under general anaesthesia (GA). It gives excellent visibility, good control, and allows the use of many instruments for safe removal.
2. Flexible Endoscopy. It can be used for smooth and non-impacted objects such as coins, especially when they are in the lower oesophagus. It is usually done under conscious sedation or GA.
3. Surgical Intervention (Rare). Cervical oesophagotomy: Needed when a sharp or deeply stuck object in the upper oesophagus cannot be removed safely by endoscopy. Transthoracic oesophagotomy: Needed for objects deeply stuck in the thoracic oesophagus. This is a major surgery and is used only when all other options fail.
4. Post-Pyloric Foreign Bodies. Most objects that enter the stomach and pass through the pylorus move through the intestines and come out naturally. However, surgery may be needed if:
   • The child develops abdominal pain or tenderness
   • X-rays show that the object has not moved for several days
   • The object is sharp, long (more than 5 cm in children), or dangerous (such as disc batteries). 

Key Guidelines

1. Avoid Blind Removal: Always perform removal under direct visualisation to prevent further complications.
2. Do Not Push Objects Further: Attempts to push objects into the stomach for natural expulsion are discouraged.
3. Avoid Use of Papain: Meat tenderisers can digest the oesophageal wall and should not be used.
4. Avoid Glucagon: It is ineffective in relaxing the lower oesophageal sphincter if obstruction is due to stricture or other pathologies.

•  

Complications

1. Respiratory Obstruction: Due to tracheal compression or laryngeal oedema.
2. Perioesophageal Cellulitis or Abscess: Infections that may occur in the neck.
3. Perforation: Sharp objects can cause mediastinitis, pericarditis, or empyema.
4. Tracheoesophageal Fistula: Rare but serious.
5. Ulceration and Stricture: Long-term presence of foreign bodies can lead to these complications.

Special Considerations: Disc Batteries 

Swallowing a button battery is a surgical emergency. The battery can damage the oesophagus very quickly, so early identification and immediate removal are essential. Read more  🔗Corrosive Burns of the Oesophagus 

Pathophysiology of Battery Injury

Button batteries cause rapid and severe injury primarily through three mechanisms:

1. Electrical Current Injury: The battery, when moist (in the oesophagus), forms an electrical circuit with the surrounding tissue. This causes hydrolysis of tissue by generating hydroxide at the negative pole, leading to alkaline corrosive burn.
2. Chemical Injury: Leakage of alkaline contents (Potassium Hydroxide, Sodium Hydroxide) from the battery casing further contributes to a liquefaction necrosis of the oesophageal wall.
3. Pressure Necrosis: Simple pressure from the object can cause local ischaemia and necrosis.

Timeline of Damage: Mucosal injury in 1 hour – Muscle coat damage in 2-4 hours – Oesophageal perforation in 8-12 hours. Urgent removal is mandatory.

First Aid for Button Battery Ingestion

• • Do Not Induce Vomiting.
  • Give Oral Honey: Administer 10 mL (2 teaspoons) of honey immediately, then repeat every 10 minutes for up to 6 doses. Honey coats the battery, thereby preventing current leakage and hydroxide generation, thus delaying alkaline burns.
  • Alternative: If honey is unavailable, Sucralfate slurry can be given in the same dose (acts as a protective coating).
  • Management: Immediate Rigid Oesophagoscopy and removal.

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High-Yield Points for Quick Revision

1. Gold Standard Treatment: Rigid Oesophagoscopy under GA.
2. Most Common Site: Cricopharyngeal Sphincter (C5–C6)—Highest risk of airway compromise.
3. Coin X-ray Sign: Round on PA view – Oesophagus (Lies in coronal plane).
4. Button Battery Sign: Double Ring/Halo Sign on PA X-ray – Surgical Emergency.
5. Meat Bolus Impaction: Always investigate for underlying oesophageal pathology (e.g., stricture, cancer) after removal.
6. Absolute Contraindication: Blind removal and Papain administration.
7. First Aid for Battery: Oral Honey (10 mL) every 10 minutes (max 6 doses) to neutralise alkaline burn.

NEET PG Style MCQs

1. The most common site of impaction for an ingested foreign body in the oesophagus is: A. Aortic Arch B. Diaphragmatic Hiatus C. Cricopharyngeal Sphincter D. Left Main Bronchus
2. A 3-year-old child presents with drooling and respiratory distress after accidentally swallowing a coin. On X-ray, the coin appears circular on the PA view. The coin is most likely lodged in the: A. Trachea, necessitating bronchoscopy. B. Oesophagus, necessitating oesophagoscopy. C. Larynx, necessitating laryngoscopy. D. Stomach, necessitating observation.
3. The ‘Double Ring’ or ‘Halo Sign’ on an X-ray of a child who ingested a foreign body is pathognomonic for a: A. Fish bone impaction. B. Coin in the trachea. C. Button battery. D. Denture impaction.
4. All of the following are contraindications or discouraged practices in the management of an oesophageal foreign body EXCEPT: A. Administration of Papain. B. Blind removal with a scope. C. Immediate rigid oesophagoscopy for a sharp object. D. Attempting to push the object into the stomach.
5. The main and most dangerous mechanism of tissue injury caused by an impacted button battery in the oesophagus is: A. Pressure necrosis causes ischaemia. B. Leakage of acidic contents causing coagulative necrosis. C. Generation of hydroxide ions via electrical current, causing liquefaction necrosis. D. Thermal burn from the battery short-circuiting.
6. A meat bolus impacted at the lower oesophageal sphincter (LES) in a 65-year-old male with no prior GI symptoms most commonly warrants a follow-up investigation for: A. Chronic Gastroesophageal Reflux Disease (GERD). B. Oesophageal varices. C. Underlying oesophageal cancer or stricture. D. Oesophageal candidiasis.
7. Which of the following is considered the most important predisposing factor for foreign body impaction in adults? A. Poor oral hygiene. B. Psychiatric disorders. C. Pre-existing oesophageal diseases. D. Eating too quickly.
8. The correct immediate first-aid measure recommended for a child who has just swallowed a button battery is: A. Induce vomiting immediately. B. Administering 10 mL of milk or honey orally. C. Immediate administration of an H2 blocker. D. Giving a meat tenderiser (Papain) to soften the tissue.
9. Pooling of secretions in the pyriform fossa, observed on indirect laryngoscopy, strongly suggests: A. Laryngeal nerve paralysis. B. Oesophageal obstruction. C. Hypopharyngeal cancer. D. Acute tonsillitis.
10. In a case of a coin lodged in the cervical oesophagus, the coin will lie in which anatomical plane? A. Sagittal plane. B. Coronal (Frontal) plane. C. Transverse plane. D. Oblique plane.

MCQ Answers and Explanations

1. C. Cricopharyngeal Sphincter. This is the narrowest point and, therefore, the most common site (80%).
2. B. Oesophagus, necessitating oesophagoscopy. A coin circular on PA view means it is lying in the coronal plane, which is the wider dimension of the oesophagus.
3. C. Button battery. The sign is created by the casing and central separator, indicating the critical diagnosis of a button battery.
4. C. Immediate rigid oesophagoscopy for a sharp object. Sharp objects, large objects, and batteries mandate urgent rigid oesophagoscopy. All other options are discouraged due to high complication rates.
5. C. Generation of hydroxide ions via electrical current causing liquefaction necrosis. The electrical mechanism is the fastest and most destructive, causing alkaline burn.
6. C. Underlying oesophageal cancer or stricture. A sudden impaction in an adult must be presumed to be due to a pre-existing narrowing until proven otherwise, making cancer/stricture the top differential.
7. C. Pre-existing oesophageal diseases. This is the most significant predisposing factor in adults, as it creates an anatomical narrowing.
8. B. Administering 10 mL of milk or honey orally. Honey/milk are recommended to coat the battery, delaying the alkaline burn. Vomiting is contraindicated.
9. B. Oesophageal obstruction. Obstruction prevents normal swallowing, causing secretions to collect above the level of the obstruction in the pyriform fossae.
10. B. Coronal (Frontal) plane. The oesophagus is wider side-to-side (coronal), so the coin rotates to lie in this plane for maximum fit.

Clinical Case Scenarios

Scenario 1: The Drooling Child

A 2-year-old male is brought to the emergency department by his parents, who report he suddenly choked and has been persistently drooling saliva for the last 4 hours, refusing to take any liquids. He has mild stridor on examination. The mother suspects he swallowed a toy piece.

Viva/Practical Questions:

1. What is the most likely location of the foreign body, given the symptoms?
   • Answer: The upper oesophagus (cricopharyngeal sphincter). Drooling indicates near-total obstruction, and stridor/respiratory symptoms point to the upper oesophagus, where the FB can cause tracheal compression (due to the shared fibro-elastic wall).
2. What is the immediate next step in investigation and management?
   • Answer: PA and Lateral X-rays of the neck and chest immediately to confirm the location and nature (radio-opaque vs. radiolucent). Management must be immediate rigid oesophagoscopy under GA, prioritizing airway management first if needed.
3. How would you present this case to your examiner?
   • Answer: “This is a case of an acute foreign body oesophagus in a child, likely at the cricopharyngeal level, presenting with signs of complete obstruction (drooling) and potential airway compromise (stridor). My immediate plan is to secure the airway if required, confirm the diagnosis with X-ray, and proceed to urgent rigid oesophagoscopy—the gold standard for upper oesophageal foreign bodies.”

Scenario 2: The Elderly Man with a Meat Bolus

A 70-year-old male with a history of hypertension presents with sudden-onset dysphagia after rapidly eating a piece of chicken. He has no history of previous swallowing difficulties. A plain X-ray is negative for a radio-opaque object.

Viva/Practical Questions:

1. What type of foreign body is most likely and what is its significance?
   • Answer: A meat bolus, which is radiolucent. Its significance in an elderly adult with no prior history of dysphagia is that it acts as a sentinel sign for an underlying narrowing (pathology).
2. What is the definitive management, and what is the crucial follow-up?
   • Answer: Management is rigid or flexible oesophagoscopy to safely remove the bolus. Crucial Follow-up is a Barium Swallow or repeat endoscopy with biopsy a few weeks later to rule out an underlying cause, specifically an oesophageal web, stricture, or, most critically, carcinoma.
3. Why must Barium Swallow be avoided immediately?
   • Answer: It carries an aspiration risk in an obstructed patient and obscures the visual field for the subsequent endoscopy.

Frequently Asked Questions in Viva

• What is the gold standard procedure for removing a foreign body from the oesophagus? The gold standard procedure is Rigid Oesophagoscopy, performed under General Anaesthesia, because it offers superior control and visualization for safe removal, especially of sharp or impacted objects.
• How can I differentiate a coin in the trachea from a coin in the oesophagus on an X-ray? A coin in the oesophagus appears round on the PA view because it lies in the wider coronal plane; a coin in the trachea appears line-like on the PA view because it lies in the wider sagittal plane.
• Why is the cricopharyngeal sphincter the most common site of foreign body impaction? The cricopharyngeal sphincter is the narrowest anatomical constriction of the entire oesophagus, hence it traps most foreign bodies attempting to pass.
• Is it safe to give Papain (meat tenderizer) to dissolve an impacted meat bolus? No, it is absolutely contraindicated because Papain is a proteolytic enzyme that can digest the already compromised oesophageal wall, leading to a high risk of fatal perforation (Papain Perforation).
• What is the immediate first-aid for a child who has swallowed a button battery? The immediate first aid is to administer 10 mL of honey or milk orally every 10 minutes for up to 6 doses, followed by immediate transportation for urgent rigid oesophagoscopy.

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Download full PDF Link:

Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Cummings, Otolaryngology-Head and Neck Surgery.
• Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
• Ballenger’s, Otorhinolaryngology Head And Neck Surgery
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
• Ganong’s Review of Medical Physiology.
• Guyton & Hall Textbook of Medical Physiology.

Author:

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

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