Accidental ingestion of coins by children: management of the ENT Department of João XXIII Hospital | Brazilian Journal of Otorhinolaryngology

presentation Cases of accidental foreign body consumption by children are frequent in emergency rooms. The ent man is the most qualify professional to manage ear, nose and oropharynx foreign bodies, and he/she may besides manage the ones located in the esophagus. Coins, because of their shape and ease of reach, are the foreign bodies most frequently found in the latter 1-3. These patients have to be carefully assessed and if the mint remains lodged in the esophagus after 8 hours of fasting – time necessary for a safe procedure – the extraneous body should be removed under general anesthesia in order to avoid complications 3. Besides patients and families ’ stress, particularly considering the erstwhile ‘s age and the difficulties brought about by the minute human body of their respiratory tract, the removal can be even more dangerous than the foreign torso itself. To avoid complications, experience and skill acquired in specific aim, together with the help oneself from early specialists such as pediatricians, general and pectoral ; and the anesthesiology team, all most needed when complications arise . objective Describe affected role care and the development of seven children who were consecutive seen at the emergency ENT department at the Hospital João XXIII, in Belo Horizonte – MG, after having ingested a mint. We considered mint size, patient ‘s age and the removal method for this type of foreign torso in our institution.

MATERIALS AND METHODS We assessed seven consecutive cases of children who swallowed coins and were seen from June 15th, 2004 through August 18th, 2004, during the day shift ( 7am through 7pm ) on Wednesdays, at the ENT Department of the Hospital João XXIII ( Public State Emergency Hospital for polytraumatized patients and clinical/surgical hand brake cases from different specialties ), located downtown Belo Horizonte – MG- Brazil. Care is based on a detail clinical history, physical examination, simple neck-chest-abdominal antero-posterior-view X-Rays. It is of the extreme importance to establish the probable clock time of consumption and that of the last meal, deoxyadenosine monophosphate well as past history of esophagus diseases and diseases that may increase the risk of a procedure under general anesthesia, if needed be. If the coin is seen in the gastrointestinal track at the initial x-ray evaluation, the patient is discharged ; however, if the alien body is hush located in the esophagus, the affected role should remain under observation until 8 hours of fasting have passed. If the X-Ray taken after 8 hours of fast shows the alien consistency in the gastrointestinal tract, the patient is discharged and instructed to look and see if the coin comes out in the feces, and he/she should return to the hospital if the coin is not seen, or if any complication get up, for example -abdominal pain. If the mint remains in the esophagus, the patient is then taken to the surgery center for removal under cosmopolitan anesthesia. When the coin remains lodged in the esophagus upper third, the patient is anesthetized and monitored without orotracheal cannulation in order to undergo extraction through a true laryngoscope and long forceps. If that is not possible, the patient is intubated and rigid esophagoscopes may be necessity ( Figure 1 ). After coin removal in the surgical center, the patient remains under observation for up to four hours and, provided there are no complications, the affected role is discharged .

figure 1. Instruments used : aspirator, straight laryngoscope, understanding forceps and fixed esophagoscopes. ( 0.12MB ). The coins were measured with a ruler. The size of the coins that ad lib passed through to the gastrointestinal nerve pathway was estimated and measured by comparison with coins of like monetary measure, according to the description given by the patients ’ relatives . leave Patients were consecutive ordered in Table 1, including long time, gender, status in the class, coin size, approach used and evolution. table 1. distribution of patients in consecutive order of their care .

These accidents involved seven children with ages varying between one and nine years. The historic period of those patients in whom the mint remained in the esophagus varied from one class and seven months to four years and seven months, two boys and one girl. The long time of the four children in whom the mint descended ad lib, varied from two years and six months to nine years and five months, two boys and two girls. Of the seven children, two were only children and five were the youngest in the family. Of the seven alien body consumption cases, three ( cases 1, 2 and 3 ) required removal at the surgical concentrate because the X-Ray carried out after eight hours of observation during fasting showed the mint still in the esophagus, at the upper fortune of the cricopharynx. Due to the localization pinpointed by the radiography barely ahead operation, the initial routine was inhaling anesthesia and exploration with straightaway laryngoscope in a removal undertake without cannulation. Cases 1 and 3 needed orotracheal cannulation and inflexible esophagoscope for mint removal, because it had descended beyond the scope of the laryngoscope. In subject 2, the coin remained at the cricopharynx area, allowing its removal without the motivation for orotracheal cannulation ( Figures 2 and 3 ) .

figure 2. character 2 : 1.9cm coin in the crichopharyngeal area at affected role admission. ( 0.08MB ).

calculate 3. case 2 : 1.9cm mint in the crichopharyngeal sphere after 8 hours of fast. ( 0.08MB ). For cases 4, 5, 6 and 7, the mint ad lib descended after 8 hours of fasting and notice. The patients were educated and discharged. The coin size varied from 1.9cm to 2.5cm. Cases 2, 3, 4 and 7 were related to 1.9cm coins ( cases 2 and 3 evolved with the coin impacted in the esophagus, while cases 4 and 7 resolved spontaneously ). Cases 5 and 6 are related to bigger coins ( 2.3 and 2.5cm in diameter, respectively ) and besides resolved spontaneously ( Figures 4 and 5 ) ; however, they were besides the eldest children in the group ( 6 years and 10 months and 9 years and 5 months of senesce, respectively ).

name 4. case 5 : 2.3cm coin that spontaneously descended to the gastrointestinal nerve pathway. ( 0.07MB ).

figure 5. case 6 : 2.5cm coin that spontaneously descended to the gastrointestinal tract. ( 0.07MB ). discussion Children normally ingest foreign bodies, particularly coins, thus making it a frequent happening in the pediatric emergency and urgency departments 1. Coins are the most common extraneous bodies ingested by children and they normally lodge at the cricopharynx 1-3. Its flimsy and circle determine normally facilitate consumption, and rarely brings about complications 1. Complications relate to extraneous consistency ingestions are low, however unwholesomeness may be severe, or even put the affected role ‘s life in danger 4. Younger children are more prone to accidental consumption of alien bodies because their dentition is not yet complete, the neuromuscular mechanisms related to swallowing and upper berth air passage protection are not however fully developed, and furthermore, children tend to explore the universe around them through their mouths. In older children, cases of esophagus extraneous bodies happen more rarely because there is less of a gamble they would ingest something inadequate 3 . Anatomy of the esophagus The esophagus is a muscular, thin and vertical tubular organ ( it starts in the center and lento twists to the leave, returning to the in-between at the level of the fifth pectoral vertebra ), that goes from the hypopharynx to the abdomen. Its is internally lined by graded epithelial mucous membrane. It starts in the inferior border of the cricoid cartilage ( 6th cervical vertebra ), goes through the neck, through the upper mediastinum and ends at the cardia orifice, in the digest ( 11th pectoral vertebra ), averaging 23 to 25 centimeter in length, in adults. In the abdomen it turns to the bequeath and then fore, averaging 1.5 to 3cm in length 5. The esophagus presents four narrowing sites : 1 ) cricopharynx ( besides known as amphetamine esophagic sphincter, 15cm off from the incisive tooth – where most frequently the foreign bodies are found and where iatrogenic perforations happen more often ), 2 ) aortal cross ( located 7cm from the beginning ) ; 3 ) left bronchus compression ( 4cm from the 2nd ) and 4 ) cardia ( known as lower esophagic sphincter, located some 40 cm aside from the incisive tooth ) 5 . management management options for coins in the esophagus are : 1 ) observation, 2 ) extraction by Foley catheter, guided or not by fluoroscopy, 3 ) rigid or flexible esophagoscopy, 4 ) extraction by a Magill forceps, or 5 ) tug the mint to the stomach 2,6. The method acting of choice depends on the efficacy, condom and the monetary value of the procedure 7. asymptomatic patients who go to the hand brake room after having ingested a coin with less than twenty hours of development have little chances of complication, however if it remains stick, removal is recomended 7. Any foreign body, in any dowry of the esophagus should not remain there for more than two days, because then we have an addition in the likelihood of complications occurring 4. Foreign bodies that remain stand by for longer periods, or that causal agent important local anesthetic inflammatory reaction increase morbidity 3. In 1996 Conners et alabama. recommended that patients with coins lodged in the distal assign of the esophagus should be observed for 24 hours because these coins can spontaneously migrate to the stomach. Soprano et alabama. showed that asymptomatic patients have a 28 % find of spontaneously passing a mint to the stomach within a 24 hour period. Coins located in the middle third or distal third of the esophagus have 33 % and 37 % prospect of spontaneously migrating to the stomach, respectively 7. This survey recommends that the asymptomatic cases of coins lodged in the in-between and distal thirds may be observed at home for a period of 24 hours, however if they remain in the esophagus they should be removed. Home watch have a better cost-benefit ratio than hospital stay for observation 8. In cases of coins located at the cricopharynx, watching alone does not bear good results 2. X-rays should be always done good prior to any operation, because the coin may descend to the abdomen 5. In those cases of coins located at the cricopharynx, Mahahafz starts the routine using a breathe masquerade and inhalant, if calculate view removal is not possible ; he then proceeds to orotracheal cannulation and either rigid or elastic esophagoscopy 2. The Magill forceps may be used when the coin is lodged in the cricopharynx as an initial procedure or after failure in using the Foley catheter 2. In regulate to avoid esophagus perforations, rigid or flexible endoscopic removal should be carried out by the pediatric surgeon or endoscopy specialist under general anesthesia 3,4. When the coin is located at the distal third base, knowledge about the human body is fundamental for patient base hit. In general, one should avoid to blindly push the foreign body towards the abdomen 4. Pushing the mint towards the stomach requires monitoring after the procedure 3. 80-90 % of all extraneous bodies that fall in the abdomen will spontaneously pass through the digestive tract, however 10-20 % will require non-surgical interventions and 1 % will require surgery 4. Coin extraction through the use of the Foley balloon is a method described over 25 years ago and should be used by a pediatric radiologist, without sedation, and physically restraining the patient if necessary. such method requires an know radiologist in order to make the operation safe. A 12F or 14F balloon is inserted through the nose, having the patient put in 15° Trendelenburg decubitus. The cost of esophagoscopy comes to 400 times higher than that of the Foley balloon 7. In general, the method chosen depends on procedure efficiency, efficacy, guard and price, and besides the have of the department 7 . Procedure-related Complications Complications rarely happen, however there may be aspiration and upper respiratory tract obstruction, mucosal damage, esophageal corrosion and trachea-esophageal fistulas. Complications occur chiefly because of encroaching removal attempts. 1.8 % of the patients who undergo Foley catheter removal attempt present some complications ( nosebleed, vomits and ephemeral respiratory failure ) 8. esophageal perforations have not been described in the cases in which the Magill forceps was used. The risk of esophageal perforation with the rigid or flexible endoscope varies between 5-10 %, although published papers stated that there were no coin-extraction-related perforations in the samples studied 2.

FINAL remark The cases of esophageal extraneous bodies reported by the introduce cogitation were all coin-related, and they may be managed by the ent man, ampere long as he/she has the proper train and the avail of other specialists such as endoscopists, pediatricians and general surgeons. Although some papers mention the extraction by the Foley balloon as being the method of choice ascribable to its guard and cost 7, the Department of Otorhinolaryngology of the João XXIII Hospital has enjoyed dependable results with the straightaway laryngoscope and forceps in those foreign bodies located in the cricopharynx ; and rigid esophagoscopy for those distally positioned. It is identical important to have the defend from the anesthesiology team in order to avoid transoperative complications. The initial approach is to confirm the presence of the coin through an x-ray and repeat it after eight hours – time necessary to add guard to the anesthesia and judgment of the affected role ‘s general status by the baby doctor if operating room become necessary. During this observation time period, the patient is preferably kept in the hospital, because frequently times in these cases the patients come from identical unfortunate social and economic situations. The operation should be carried out by know otorhinolaryngologists and the department should count on the confirm of cosmopolitan and pectoral surgeons in case iatrogenic esophageal perforations should happen. In this little series of patients, it was not possible to conclude whether or not coin size or patient age may influence the ad-lib ephemeral of the alien soundbox. It was besides not possible to determine if the only children or the youngest ones in the families are more susceptible to this character of accident. In agreement with other authors 3, we believe prevention and parents ’ education considering the children ‘s age and their own characteristics to be fundamental in the prevention of such family accidents, like the accidental consumption of coins .