Cervical Esophageal Foreign Body Removal

Video Type: CVideo
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Author: Olivia Twu
Published:
Specialties: Otolaryngology, Pediatric Otolaryngology
Schools: Kaiser San Francisco
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Basic Info

Contributors: Christopher G Tang

Rigid cervical esophagoscopy is an excellent procedure for removing cervical esophageal foreign bodies. In this video, it was used to removal an unknown foreign body.

DOI:

http://dx.doi.org/10.17797/kzn2ovjuve

Advanced

Procedure

Esophageal foreign body removal has been known for many years and was pioneered by Chevalier Jackson over 100 years ago. There are several review articles that discuss the technique over the years.

Rigid cervical esophagoscopy and foreign body removal has been around for over a century and really became modernized when Chevalier Jackson pioneered the field laryngology in the early 20th century. With the advent of optical telescopes, especially the rigid 0 degree hopkins rods, visualization within the lumen of the esophagoscope has improved dramatically and has help facilitate the easy of foreign body removal. Moreover, with finer optical instruments, foreign body removal as well as biopsies of endo-esophageal lesions has much improved.� 

Indications

Indications for the procedure: Foreign body in the esophagus on radiography, or esophagoscopy as means to rule out the presence of a non-radiopaque foreign body.

Contraindications

Obvious esophageal perforation is a contraindication as esophagoscopy can make the perforation worse and in these cases, may want to be pursued with an open procedure.

Instrumentation

Setup

Care should be taken to select instruments and scopes for the appropriate patient ahead of time. For example, children should have shorter, more narrow instruments compared to adults. All equipment (scopes, cables, graspers) should be laid out on the sterile field and inspected prior to the operation. A glass of boiling hot water should be readily available for the aquaplast thermasplint if that is utilized.

Preoperative Workup

The patient should have evidence of an esophageal foreign body either by history and physical examination and/or radiographic evidence. If the foreign body is radiopaque a simple anterior-posterior and lateral cervical X-ray should be able to locate the foreign body within the cervical esophagus. Risks and benefits of the procedure should be explained to the patient who needs to provide informed consent.

Anatomy and Landmarks

The esophagus is a tubular structure with three areas of narrowing likely to entrap foreign bodies: the upper esophageal sphincter, the crossover of the aorta, and the lower esophageal sphincter. Structural abnormalities such as strictures, diverticula, webs, or malignancies may increase the risk of foreign body entrapment. Care must be taken if there is altered anatomy especially if there are strictures or previous repairs or perforations as this can increase the risk of perforation. Additionally, due to the patient positioning requirements for successful rigid esophagoscopy,this method is contraindicated in patients with severe kyphoscoliosis, restricted jaw movement, or unstable cervical spines.

Advantages/Disadvantages

Advantages- Rigid cervical esophagoscopy is able to remove large items that are unable to be removed by GI as more force can be exerted when utilizing a rigid instrument. Additionally, a rigid esophagoscope may provide better visualization of masses or foreign bodies located just below the cricopharyngeus.
Disadvantage- It is more difficult to remove distal esophageal foreign bodies with a rigid instrument hence foreign bodies located distally would require GI intervention.

Complications/Risks

An early complication would be the inability to remove a foreign body via this method or chipping of teeth. Potential complications intra-op include esophageal or pharyngeal abrasions, lacerations, punctures, and perforations resulting in bleeding. Later, these mucosal injuries can become infected with spread to surrounding structrues resulting in abscesses, mediastinitis, pericarditis, tamponade, pneumothorax, pneumomediastinum, tracheoesophageal fistula formation or even aortoesophageal fistulas. Other later complications would include formation of esophageal strictures and dysphagia.

Disclosure of Conflicts

An early complication would be the inability to remove a foreign body via this method or chipping of teeth. Potential complications intra-op include esophageal or pharyngeal abrasions, lacerations, punctures, and perforations resulting in bleeding. Later, these mucosal injuries can become infected with spread to surrounding structrues resulting in abscesses, mediastinitis, pericarditis, tamponade, pneumothorax, pneumomediastinum, tracheoesophageal fistula formation or even aortoesophageal fistulas. Other later complications would include formation of esophageal strictures and dysphagia.

Acknowledgements

None

References

1. Shinhar S, Strabbing R, Madgy D. Esophagoscopy for removal of foreign bodies in the pediatric population. International Journal of Pediatric Otorhinolaryngology. 2003;67(9)977-979. http://dx.doi.org/10.1016/s0165-5876(03)00189-7
2. Wylie R. Foreign bodies in the gastrointestinal tract. Current Opinion in Pediatrics. 2006;18(5):563-564. http://dx.doi.org/10.1097/01.mop.0000245359.13949.1c
3. Gmeiner D, von Rahden B, Meco C, Hutter J, Oberascher G, Stein H. Flexible versus rigid endoscopy for treatment of foreign body impaction in the esophagus. Surgical Endoscopy. 2007;21(11):2026-2029. http://dx.doi.org/10.1007/s00464-007-9252-6
4. Waltzman M. Management of Esophageal Coins. Pediatric Emergency Care. 2006;22(5):367-370. http://dx.doi.org/10.1097/01.pec.0000225275.20735.69
5. Kumar M, Joesph G, Kumar S, Clayton M. Fish bone as a foreign body. The Journal of laryngology & Otology. 2003; 117 (07). http://dx.doi.org/10.1258/002221503322113058.
6. Wu W, Chiu C, Kuo C et al. endoscopic management of suspected esophageal foreign body in adults. Diseases of the Esophagus. 2010;24(3):131-137. http://dx.doi.org/10.1111/j.1442-2050.2010.01116.x
7. Seo J. Endoscopic management of gastrointestinal foreign bodies in children. Indian Journal of Pediatrics. 1999;66(1):s75-s80.
8. Evans S. Surgical Pitfalls. Philadelphia, PA: Saunders/Elsevier, 2009.

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