OJHAS Vol. 9, Issue 1:
|An unusual foreign
body of esophagus
Surinder K Singhal, Associate Professor,
Vipin Arora, Assistant
Arjun Dass, Professor
of ENT, Head & Neck Surgery, Government Medical College & Hospital, Sector 32, Chandigarh
- 160030, India
|Dr Surinder K Singhal,
Address For Correspondence
Dept. of ENT, Head &
Government Medical College
Sector – 32B, Chandigarh - 160030, India.
Singhal SK, Arora V, Dass A. An unusual foreign body of esophagus. Online J Health Allied Scs.
Submitted: Feb 4,
Apr 2, 2010; Published: Jul 30, 2010
We report a rare case of
an unusually long foreign body (Datun) impacted in the esophagus of a 56 year-old
gentleman. He was literate, without any psychiatric illness and had been using
indica) stick for cleaning his teeth for the past twenty years. Neem sticks
are used for brushing teeth, perhaps one of the earliest and very effective dental care.
On closer questioning he revealed his habit of passing the Neem stick into his throat
with the aim of cleaning it too while cleaning his teeth. He presented to our emergency
early in the morning with this strange long foreign body impacted in his esophagus
which was removed successfully using a Jackson’s adult rigid oesophagoscope. We believe
this to be the first case of such an unusually long foreign body to be reported in the
Foreign body, Esophagus, Neem
of ingested foreign bodies, particularly if they are smooth or smaller
than 12 mm in diameter will pass safely through the gastrointestinal
tract. Severe problems such as perforation may occur in some
for instance, following ingestion of sharp objects, bone fragments,
pins or long foreign bodies (greater than 6.5 cms).1 The
postcricoid region is the site of impaction of foreign bodies in 84%
of the subjects. Impaction of a bolus of food in the distal esophagus
in adults is frequently related to pre-existing stricture, diverticulum
or tumour.2 Adult with non food foreign bodies have a high
incidence of psychiatric and social derangements.
objects will pass through the pylorus, although on occasion, some
may remain in the stomach for a long period. Once beyond the pyloric
canal most objects, even sharp edged foreign bodies such as pieces of
glass or nails, will pass without harm until the terminal ileum which
is again a site of predilection for impaction. Ingested foreign bodies
may occasionally remain fixed in the caecum, ascending colon or sigmoid
colon. Non contrast CT scan is indicated for diagnosing suspected upper
esophageal foreign bodies not expected to be visible on plain
in order to rule out perforation.2
year old gentleman, presented to the emergency services early morning
with complaints of difficulty in swallowing, pain on swallowing,
of saliva and pain in the chest following the accidental ingestion of
“datun” with which he was cleaning his teeth. Datun is nothing but
a wooden stick which is taken afresh from the branch of a tree usually
Neem (Azadirachta indica). The Neem has medicinal value in dental care.
One end of this stick is chewed and is used as brush to clean the teeth.
Usually it is about 12 – 15 cms long but this patient was in habit
of cleaning his throat and upper esophagus and hence was using an extra
long datun. He had been using this for the last twenty years & on
many occasions it got stuck inside but he could retrieve it. This time
he couldn’t retrieve it and landed in emergency department. He was
literate, without any chronic disease and at presentation there were
no symptoms of respiratory distress or hoarseness. The general physical
examination was unremarkable except that he was looking anxious.
of the ear, nose and throat was all within normal limits and on indirect
laryngoscopy there was pooling of saliva in both pyriform sinuses. An
X-ray of the neck and chest region AP and lateral view was unremarkable.
Subsequently a CT scan of the neck and chest region revealed a long
radio opaque foreign body in the whole length of the esophagus and also
impinging into the stomach. (Fig. 1, 2). So a diagnosis of foreign body
esophagus was made and the patient was subjected to rigid esophagoscopy
under general anaesthesia. Using an adult oesophagoscope, upper end
of the foreign body was encountered just beyond the cricopharynx and
it was grasped securely with a grasping forceps and 37.5 cm long
wooden foreign body was removed along with the Jackson’s rigid esophagoscope
( Fig. 3). A check esophagoscopy was done and revealed no injury to
the oesophageal mucosa .The post operative period was uneventful and
the patient was allowed orally after 12 hours.
Axial CT scan of Chest with foreign body in the esophagus.
Coronal CT scan of
Chest with foreign body in the esophagus
Figure 3: Removed foreign body.
body impacted in the esophagus requires immediate attention and
Review of literature reveals that dysphagia (92%) and tenderness in
neck (60%) are the most common clinical features. Majority (89%)
come to the hospital within 24 hours. X-ray of the neck (lateral view)
is the most useful investigation with presence of air in the esophagus
being a significant finding.4 Most foreign bodies are more
or less radio opaque and will be readily recognized on a plain
Their progress in the bowel, if needed can be checked periodically.
Ingested bone fragments appear as linear or slightly curved densities
with sharp margins. However, some foreign bodies such as small fish
bones or pieces of plastic and wood are only faintly radio opaque and
their detection may require a CT scan. Foreign bodies in hypopharynx
and cervical esophagus such as chicken & fish bones usually need
radiologic workup. Non contrast CT scan may demonstrate these small
calcified esophageal foreign bodies.5 Indirect signs visible
on plain radiography are soft tissue swelling and/or air due to oedema
or haematoma. In doubtful and suspected perforations oesophagography
should first be performed with hydrosoluble contrast medium to exclude
perforation & study can then be completed with a barium examination.
The contrast medium may impregnate the surface of the foreign body and
render it more conspicuous. Radiographic signs of impaction in the
esophagus are dilatation of the esophagus proximal to the obstruction
with air fluid level as well as absence of air in the fundus of the
stomach. Post-cricoid region is the site of impaction of foreign bodies
in 84% of the subjects. The procedure of esophagoscopy is successful
in 97% of the patients and fails in 3%. Coins are the most common
bodies (60%), followed by meat related foreign bodies (22.5%) and
in 5% cases. Complications occur in 18% patients and are more common
in adults (37.1%) compared to children (8.8%). The most serious
is pneumo-mediastinum. Maximum complications occur with dentures (80%)
and bone chips (42%).4 Foreign body in the esophagus is
a serious condition and early removal by rigid esophagoscopy is
which is a safe and effective procedure. The other modalities of
involve removal with a laryngoscope in case of foreign bodies impacted
in the pharynx, hypopharyngoscope for hypopharyngeal foreign bodies
and less easily foreign bodies are removed using a flexible
The common complications occurring while using a rigid oesophagoscope
are injury to the lips, teeth tongue, palate and esophageal perforation
which commonly occurs at the level of cricopharyngeal sphincter.
Complications can be reduced if treatment is started within 24 hours
of foreign body impaction.6
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- Mosca S, Manes G,
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AJ. Management of foreign bodies in the esophagus.
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T et al. Esophageal foreign bodies. Journal of Medical Association
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