Etiology
The occurrence of esophageal foreign bodies is associated with factors such as age, gender, dietary habits, mental state, and esophageal conditions. It is most commonly seen in the elderly and children. In the elderly, missing teeth or the use of dentures, reduced chewing ability, decreased oral sensitivity, and a more relaxed esophageal entrance increase the risk of accidental swallowing of teeth or large pieces of food. In children, accidental swallowing often occurs due to placing toys or other objects in the mouth. Adults may also experience accidental ingestion of large or sharp objects due to playful behavior, mental distress, improper eating habits, or altered consciousness. Additionally, esophageal diseases, such as esophageal strictures or esophageal cancer, also predispose individuals to esophageal foreign bodies.
Foreign bodies come in many forms, with animal-derived objects being the most common, such as fish bones, chicken bones, or chunks of meat. Metals, such as coins and nails, are the second most frequent, followed by synthetic materials and plant-derived objects, such as dentures, plastic bottle caps, or jujube pits.
The most common site of foreign body retention is the esophageal inlet, followed by the second narrowing at the mid-esophagus. Retention in the lower esophagus is less commonly observed.
Clinical Manifestations
The clinical presentation is often related to the nature, size, and shape of the foreign body, the location and duration of retention, and the presence or absence of secondary infections.
Difficulty Swallowing
When a foreign body becomes lodged in the post-cricoid area or esophageal inlet, dysphagia is pronounced. Mild cases may allow the ingestion of semi-liquid or liquid foods, while severe cases may result in difficulty swallowing even water. In pediatric patients, drooling is often observed.
Painful Swallowing
For smaller or rounder, less sharp foreign bodies, pain during swallowing may be minimal or present only as a sensation of blockage. Sharp foreign bodies or those causing secondary infection typically result in more severe pain during swallowing. When lodged in the upper esophagus, pain tends to localize to the base of the neck or the suprasternal notch. If located in the mid-esophagus, pain often presents behind the sternum and may radiate to the shoulders or back.
Respiratory Symptoms
Larger foreign bodies may press against the posterior wall of the trachea or, if located higher in the esophagus with partial entry into the larynx, compress the throat, potentially causing respiratory distress. This is particularly concerning in young children, as there may even be a risk of asphyxiation. Prompt intervention is required to ensure airway patency.
Diagnosis
Comprehensive Medical History
A detailed patient history is critical for diagnosing esophageal foreign bodies. Most patients are able to directly or indirectly confirm a history of accidental swallowing or obstruction. Combined with symptoms such as dysphagia or painful swallowing, diagnosis is generally straightforward. It is important to ascertain the nature, shape, and size of the foreign body, the duration of retention, and the presence of other symptoms to provide guidance for esophagoscopy and surgical treatment. In cases of altered mental state or psychiatric disorders, accurate history may be unavailable, and further diagnostic evaluation is necessary if symptoms are evident.
Indirect Laryngoscopy
In cases where foreign bodies are located in the upper esophagus, especially in patients with dysphagia, pooling of saliva in the piriform recess may sometimes be observed.
Imaging Studies
Radiopaque foreign bodies can be located using anteroposterior and lateral X-rays of the neck and chest. Non-radiopaque foreign bodies require a barium esophagography for visualization. Small, sharp foreign bodies such as bone fragments may require ingestion of a small amount of barium-soaked cotton to confirm their presence and location. For suspected complications or to determine the relationship between the foreign body and vital structures such as major blood vessels in the neck, CT scanning is useful. Migrating foreign bodies located outside the esophagus may be localized via multiplanar reconstruction (MPR) imaging. This technique considers horizontal, coronal, and sagittal orientations and allows position adjustment along different axes. Foreign bodies can be precisely positioned relative to surrounding structures such as the thyroid cartilage, thyroid gland, vertebral bodies, cricoid cartilage, hyoid bone, or tonsils, with measurements of relative distance, angles, and direction.
Esophagoscopy
For patients with a confirmed history of foreign body ingestion presenting symptoms such as dysphagia or painful swallowing, but without definitive findings on X-ray or CT imaging, esophagoscopy is recommended. This can confirm the diagnosis and allow for immediate removal of the foreign body.
Special Types of Esophageal Foreign Bodies
Migratory Esophageal Foreign Bodies
In cases where CT imaging before surgery indicates a foreign body that has penetrated the full thickness of the esophageal wall and is no longer visible during esophagoscopy, the foreign body may have migrated to surrounding structures. These may include the thyroid gland, common carotid artery, prevertebral space, parapharyngeal space, or paraglottic space, with or without complications.
Complications
The presence of esophageal foreign bodies without timely treatment or continued consumption of food can cause complications.
Esophageal Perforation or Traumatic Esophagitis
Sharp and rigid foreign bodies, such as hooked dentures, may puncture the esophageal wall during swallowing, leading to esophageal perforation. Rough or impacted foreign bodies can cause direct compression and injury to the esophageal mucosa. Additionally, retained food and saliva can promote bacterial growth, resulting in secondary infections, edema, necrosis, or ulceration of the esophageal wall.
Cervical Subcutaneous Emphysema or Mediastinal Emphysema
Esophageal perforation may allow swallowed air to escape through the perforation and enter the subcutaneous tissues of the neck or the mediastinum, leading to the formation of emphysema.
Periesophagitis, Cervical Infection, or Mediastinitis
Traumatic esophagitis and infections may spread deeper or extend through the perforation to surrounding esophageal tissues, causing periesophagitis. Severe cases may involve the formation of periesophageal abscesses. If the perforation is located in the cervical area, the infection may spread along the cervical fascial spaces to form retropharyngeal or parapharyngeal abscesses. Thoracic esophageal perforations may lead to mediastinitis, resulting in mediastinal abscess formation, often accompanied by systemic symptoms such as fever in severe cases.
Rupture of Major Blood Vessels
A sharp foreign body in the mid-esophagus can directly penetrate the esophageal wall and puncture major blood vessels such as the aortic arch or subclavian artery, causing life-threatening hemorrhage. Infections may also involve these vessels, leading to rupture and bleeding. The primary manifestations include massive hematemesis (vomiting blood) or hematochezia (bloody stools). Once this complication occurs, treatment becomes extremely challenging with a high mortality rate, necessitating immediate aggressive intervention.
Tracheoesophageal Fistula
When a foreign body becomes impacted and compresses the anterior wall of the esophagus, necrosis of the esophageal wall can occur. If the trachea or bronchi are subsequently involved, a tracheoesophageal fistula can form, leading to recurrent pulmonary infections.
Treatment
When an esophageal foreign body is definitively diagnosed or highly suspected, esophagoscopy should be performed promptly to identify and remove the foreign body in order to prevent complications.
Esophagoscopy and Foreign Body Removal
Rigid Esophagoscopy
This is the most commonly used method. The size and type of esophagoscope and forceps are selected based on the size, shape, and location of the foreign body, as well as the age of the patient. General anesthesia is frequently used. After inserting the esophagoscope and locating the foreign body, the relationship between the foreign body and the esophageal wall is assessed. If a sharp foreign body is found embedded in the esophageal wall, an appropriate forceps is used to grip the foreign body, retract its embedded part from the wall, align its long axis with the longitudinal axis of the esophagus, and remove it together with the rigid esophagoscope. For large foreign bodies such as dentures, especially those with hooks, if they are tightly impacted and cannot be removed easily, forceful extraction is avoided to prevent life-threatening complications such as vascular rupture. In such cases, cervical incision or thoracotomy may be required to remove the foreign body. Occasionally, a direct laryngoscope can be used instead of an esophagoscope to try to remove foreign bodies located at the esophageal inlet. The shorter and thicker design of the direct laryngoscope allows better lifting of the cricoid cartilage to expose the esophageal entrance, facilitating the removal of the foreign body. For children, excessive elevation of the cricoid cartilage is avoided to prevent respiratory distress.
Fiberoptic or Electronic Esophagoscopy
This is advantageous for removing smaller or more slender foreign bodies. It can be performed under topical anesthesia of the mucosal surface in adult patients. Sharp foreign bodies may be encapsulated with a pouch or cage for removal, which reduces the risk of injury to the esophageal wall.
Foley Catheter Method
This method involves the use of a catheter with an inflatable hidden balloon at the end. The catheter is inserted into the esophagus past the foreign body if complete obstruction has not occurred. After the balloon passes the foreign body, it is inflated with air to expand and occupy the esophageal lumen. The foreign body is then withdrawn along with the balloon as the catheter is pulled upward. This technique is only suitable for foreign bodies with regular shapes and smooth surfaces.
Cervical Incision or Thoracotomy for Foreign Body Removal
For large or tightly impacted foreign bodies, or those with metal hooks that cannot be removed using the above methods, cervical incision or thoracotomy may be considered.
General Treatment
If the foreign body has been present for more than 24 hours and the patient is experiencing difficulty eating, preoperative fluid administration is indicated. If there is a risk of esophageal mucosal injury during surgery, postoperative fasting for 1 to 2 days is recommended, supplemented with intravenous fluid therapy and systemic supportive care. If perforation is suspected, a nasogastric tube may be inserted for feeding. In cases of local infection, sufficient antibiotics are administered.
Other Management
For esophageal abscesses, retropharyngeal abscesses, or parapharyngeal abscesses, cervical incision and drainage may be performed. For esophageal perforation or mediastinal abscess, thoracic surgery consultation is considered.
Prevention
Eating too quickly should be avoided, especially when consuming food containing bone spurs. Mixed intake of such food with other dishes is not recommended. Thorough chewing and spitting out bone spurs are necessary to prevent accidental swallowing.
Elderly individuals with dentures should exercise caution while eating and avoid sticky foods. Loose or damaged dentures should be repaired promptly, and dentures should be removed before sleep. Dentures in patients under general anesthesia or in a comatose state should also be removed in a timely manner.
Children should be educated and discouraged from developing the habit of putting coins, toys, or other objects in their mouths.
Following accidental swallowing of foreign objects, medical attention should be sought promptly to have the object removed. Attempting to force the object down by swallowing rice balls, buns, or leeks should be strictly avoided. While such methods may occasionally succeed by chance, they more often exacerbate injuries to the esophageal wall and nearby structures such as the heart and major blood vessels, increasing the risk of life-threatening complications and complicating subsequent surgical treatment.