Disappearing intraesophageal foreign body: A case report

Abstract

BACKGROUND

Foreign body ingestion is a common emergency in clinical practice. While the majority of cases are resolved following successful removal, rare and unexpected complications can arise, such as the spontaneous displacement of a foreign body during the procedure. This report describes a unique case where a foreign body initially lodged in the esophagus was dropped during the procedure, leading to aspiration and migration to the airway.

CASE SUMMARY

A 69-year-old Chinese woman presented with a 6-hour history of throat pain and tightness after consuming rabbit meat. She had no fever or bloody stools but had a history of hypertension. Initial imaging, including a neck computed tomography scan, indicated a foreign body in the upper esophagus. Esophageal endoscopy was performed, during which the patient’s vital signs remained stable. The procedure showed a 14-cm mucosal erosion with food debris and a visible foreign body located in the gastric fundus. The foreign body was removed with forceps but unexpectedly dropped into the hypopharynx. Subsequent upper gastrointestinal endoscopy did not identify the foreign body. On awakening from anesthesia, the patient exhibited hypoxia and coarse breath sounds, but without coughing. A chest X-ray indicated that the foreign body had migrated into the airway. An emergency fiberoptic bronchoscopy was performed, successfully retrieving the foreign body. The patient recovered without complications.

CONCLUSION

Endoscopic removal of an esophageal foreign body can cause silent aspiration in elderly patients with absent cough reflexes, necessitating bedside imaging and prompt intervention.

Key Words: Esophageal foreign bodies; Endoscopic extraction; Asymptomatic aspiration; Fiberoptic bronchoscopy; Geriatric patients; Case report

Core Tip: This case report highlights the rare occurrence of aspiration during endoscopic foreign body removal, despite the absence of typical coughing reflexes. We emphasize the importance of bedside imaging for early detection of accidentally ingested foreign body and the role of emergency fiberoptic bronchoscopy in successful retrieval. These findings underscore the need for increased awareness and improved procedural strategies to prevent aspiration-related complications in high-risk patients.

INTRODUCTION

Foreign body ingestion is a frequent clinical emergency that often necessitates endoscopic intervention[1]. While the majority of cases are resolved following successful removal, rare and unexpected complications can arise, such as the spontaneous displacement of a foreign body during the procedure[2]. This report details a unique case in which a foreign body initially lodged in the esophagus was displaced during endoscopic removal, leading to aspiration and eventual migration into the airway. The foreign body was successfully retrieved using emergency fiberoptic bronchoscopy. Information from this case was organized into a timeline (Table 1). This case underscores the importance of understanding the risks associated with aspiration during endoscopic procedures, especially in older patients, where age-related attenuation of upper airway reflexes (particularly diminished cough responses) necessitates further mechanistic and clinical interventional studies[3,4].

Table 1 Clinical timeline of the patient.

Time	Event	Key findings
Pre-admission	Rabbit meat ingestion	Initiated FB event
Admission	Clinical evaluation	BP 206/74 mmHg; Pharyngeal FB sensation
02:00 am	Cervical CT	2.6 cm linear FB at C7-T2 with mural edema
11:00 am	EGD under sedation	Mucosal erosion (14 cm); FB dislodged to hypopharynx
Intra-procedure	Vital signs	SpO2 94%; ↓breath sounds (LLL)
Post-EGD	Chest X-ray	Left lower lobe atelectasis
Emergency phase	Bronchoscopy	FB retrieved from airway (8-minute GA)
24-hour post-op	Ward care	Rehydration, BP control, antibiotics
Discharge	Follow-up	Stable condition; hypertension regimen adjusted

FB: Foreign body; EGD: Esophagogastroduodenoscopy; LLL: Left lower lung; GA: General anesthesia; BP: Blood pressure; CT: Computed tomography.

CASE PRESENTATION

Chief complaints

A 69-year-old woman was admitted with the persistent sensation of a foreign body in her throat, along with throat pain and tightness over the past 6 hours.

History of present illness

The patient developed a persistent foreign body sensation in her throat, along with throat pain and tightness, six hours after consuming rabbit meat. She denied any additional symptoms such as nausea, vomiting, hematemesis, hemoptysis, or melena.

History of past illness

The patient had a history of hypertension, with fluctuating blood pressure measurements ranging from 180-210/70-90 mmHg, and had not been on regular treatment. She denied any history of diabetes mellitus, tuberculosis, typhoid fever, malaria, heart disease, cerebrovascular disease, or mental illness. There was no history of trauma or surgery, and she also denied any food or drug allergies.

Personal and family history

No special personal or family history was noted except a history of cesarean section under general anesthesia.

Physical examination

The patient’s vital signs were stable, with elevated blood pressure of 206/74 mmHg and oxygen saturation measured by pulse oximetry (SpO₂) of 97%. Upon auscultation, symmetrical, coarse breath sounds were heard bilaterally.

Laboratory examinations

All blood test results were within normal limits.

Imaging examinations

Computed tomography (CT) of the neck showed a 2.6 cm × 0.7 cm strip-shaped hyperdensity in the upper esophagus (C7-T2), along with swelling of the surrounding esophageal wall, suggestive of a foreign body (Figure 1). Chest CT revealed scattered chronic inflammation in both lungs, with partial interstitial changes.

Figure 1 Computed tomography of the neck. Foreign bodies can be seen in the upper digestive tract (orange arrow).

FINAL DIAGNOSIS

Esophageal foreign body and hypertension grade 3 (very high risk).

TREATMENT

The patient underwent esophageal endoscopy under deep sedation and analgesia induced by midazolam (1 mg), sufentanil (5 μg), and propofol (40 mg) (Figure 2). Her vital signs remained stable throughout the procedure. The examination revealed an esophageal mucosal erosion 14 cm from the incisors (Figure 2B), with food debris and a bone foreign body located in the gastric fundus (Figure 2D). No significant abnormalities were observed in the throat or inlet patch (Figure 2A and C). Using foreign body forceps, the object was successfully removed but unexpectedly dropped into the hypopharynx. During the procedure, the patient exhibited neither physical movement nor a choking sensation. She maintained spontaneous respiration with oxygen via a mask, with SpO₂ fluctuating between 97% and 100%, blood pressure ranging from 110-130/60-75 mmHg, and heart rate between 60-70 bpm. However, after the foreign body disappeared, the patient’s SpO₂ transiently dropped to 94%. On auscultation, rough breath sounds were heard bilaterally, with diminished breath sounds in the left lower lung. Shortly after awakening from anesthesia, the patient did not exhibit typical signs of aspiration, such as coughing or choking. The anesthesiologist suspected aspiration and ordered an emergency bedside chest X-ray, which displayed atelectasis of the left lower lobe, suggesting migration of the foreign body into the airway. An airway foreign body was suspected, prompting consultation with the fiberoptic bronchoscopy and emergency surgery teams. Given the patient's age and concerns for potential airway involvement, an emergency fiberoptic bronchoscopy was performed under general anesthesia. The procedure lasted 8 min, the foreign body was successfully retrieved from the airway, and her vital signs remained stable.

Figure 2 Esophageal endoscopy at different sites in the patient. A: Esophageal endoscopy of the throat; B: Esophageal endoscopy 14 cm from the incisors, showing esophageal mucosal erosion; C: Esophageal endoscopy of the inlet patch; D: Esophageal endoscopy of food debris and a foreign body bone lodged in the esophagus.

OUTCOME AND FOLLOW-UP

Postoperatively, the patient was transferred to the emergency ward, where she received rehydration, blood pressure management, and anti-infective therapy. Her vital signs remained stable throughout these interventions, and no complications occurred. The patient was discharged the following day in a stable condition, with instructions for follow-up care.

DISCUSSION

Foreign body ingestion and food impactions are common clinical emergencies. While most cases resolve spontaneously, approximately 10%-20% of cases require intervention[1]. While smooth-edged foreign bodies typically do not pose significant issues, sharp-edged ones can lead to serious complications. The most common symptoms include dysphagia, odynophagia, retrosternal pain, throat pain, sensation of a foreign body, retching, vomiting, choking, and hypersalivation. Endoscopy is a reliable and well-established method for removing various types of upper gastrointestinal foreign bodies, with careful pre-procedure evaluation of the foreign body size, shape, location, and its relationship to adjacent structures being essential for optimal management[5-7]. In the present case, dislodgement of the foreign body occurred during gastroscopic clamping, influenced by several contributing factors: First, the foreign body was a sharp bone fragment, a cervical CT scan demonstrated its initial lodgment in the proximal esophagus 14 cm from the incisors. Subsequent endoscopic evaluation revealed migration of the object to the gastric fundus. The fragment exhibited a surface coating with adherent debris and gastric secretions, making it smooth and more prone to dislodgement. Second, the narrow and angular lumen of the pharynx created increased friction against the sharp edges of the bone, facilitating its displacement. Finally, the angle at which the foreign body was clamped might not have aligned with the direction of the gastroscope's travel, which could also have contributed to its dislodgement. These factors underscore the complexities of foreign body retrieval and the critical importance of using a careful technique during endoscopic procedures. Aspiration is defined as the introduction of oropharyngeal or gastric contents into the lower respiratory tract. While coughing is the most common reflex, it is not always observed after aspiration[8,9]. Notably, the absence of coughing during endoscopy does not exclude aspiration. In the present case, aspiration occurred without the typical signs of coughing or choking. The use of propofol and sufentanil during sedation is known to suppress protective airway reflexes, increasing the risk of aspiration, particularly in older patients who may have diminished airway reflex sensitivity[3,10]. Advanced age has been associated with a decline in the integrity of physical barriers and the immune system's ability to defend against pathogens, which may also reduce the sensitivity of airway reflexes[3,4]. With advances in respiratory endoscopy, most aspirated foreign bodies can be effectively removed using fiberoptic bronchoscopy, emphasizing the importance of understanding factors that contribute to aspiration, especially in sedated or elderly patients[11-13]. To improve patient outcome, it is crucial to shorten the interval between diagnosis and intervention. In the present case, close monitoring of respiratory status, including SpO₂ levels and pulmonary auscultation, proved useful. When aspiration was suspected, a bedside chest X-ray was performed, revealing atelectasis in the left lower lobe and suggesting migration of the foreign body into the airway. Early identification of such complications enables faster intervention and minimizes potential damage. Additionally, bedside lung ultrasound can be a valuable tool in diagnosing aspiration, as it can detect early changes such as atelectasis or consolidation, which may not yet be visible on a chest X-ray examination[14]. In fact, this non-invasive technique aids in confirming the diagnosis and guiding further management, especially in emergency situations where time is critical.

CONCLUSION

This case highlights the complexities of foreign body ingestion and the potential for unexpected complications during endoscopic treatment, such as displacement and aspiration. The absence of typical signs, such as coughing, does not rule out aspiration, especially under deep sedation and analgesia. Older patients, with reduced airway reflex sensitivity, are at higher risk of aspiration. Timely interventions, including bedside imaging, play a critical role in diagnosing and managing complications. Early identification of aspiration can facilitate prompt treatment and improve patient outcomes.