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| CASE REPORT |
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| Year : 2022 | Volume
: 12
| Issue : 1 | Page : 11-14 |
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The triad of denial, neglect, behavioral disorder causing to habitual multiple foreign body ingestion – A surgeon's nightmare
Roshan K Verma, Kirubakaran Kothandaraman
Department of Otolaryngology and Head and Neck Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| Date of Submission | 04-May-2022 |
| Date of Acceptance | 08-Sep-2022 |
| Date of Web Publication | 8-Nov-2022 |
Correspondence Address:
Roshan K Verma
Department of Otolaryngology, Head and Neck Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jlv.jlv_2_22
 Abstract | | |
Behavioral disorders in children can sometimes lead to habitual and deliberate ingestion of multiple foreign bodies that may be neglected for longer periods and require a multidisciplinary team approach to remove it successfully.
Keywords: Dysphagia, gastrostomy, multiple foreign bodies, rigid esophagoscopy, upper gastrointestinal endoscopy
How to cite this article:
Verma RK, Kothandaraman K. The triad of denial, neglect, behavioral disorder causing to habitual multiple foreign body ingestion – A surgeon's nightmare. J Laryngol Voice 2022;12:11-4 |
How to cite this URL:
Verma RK, Kothandaraman K. The triad of denial, neglect, behavioral disorder causing to habitual multiple foreign body ingestion – A surgeon's nightmare. J Laryngol Voice [serial online] 2022 [cited 2023 May 30];12:11-4. Available from: https://www.laryngologyandvoice.org/text.asp?2022/12/1/11/360572 |
| Introduction | |  |
Foreign body ingestion is common among children and less common among adults.[1] The most common foreign body ingested is fishbone.[2] The incidence of the foreign body is more among patients with psychiatric illnesses.[3],[4] Foreign body ingestion in adults is usually accidental, except for patients with psychiatric illnesses. The management of foreign body at multiple sites often necessitates multidisciplinary approach. A delay in diagnosis can result in complications.[1],[5]
| Case Report | | |
A 19-year-old male with behavioral disorder presented to ENT emergency with absolute dysphagia for 5 days. He did not have any voice change or respiratory difficulty. He had a seizure episode 5 days back. The patient denied abdominal pain, fever, intoxication with drugs or alcohol. He presented late because his parents initially ignored his complaints as a part of his attention-seeking behavior. However, the attendants gave a history that the child had behavioral issues and had a history of foreign body ingestion in the past also.
On examination, he was conscious, comfortable, afebrile, and had stable vitals. Indirect laryngoscopy revealed congestion over the left pyriform sinus (PFS) region with pooling of secretions. Bilateral cords were mobile. On neck examination, there was no swelling, emphysema, or tenderness. The rest of the general and systemic examination was normal. The abdomen was soft and nontender. Foreign body ingestion was suspected and X-ray soft-tissue neck lateral view was done. X-ray soft-tissue neck revealed the presence of a metallic foreign body (? razor with a screw) in the upper end of esophagus [Figure 1]. | Figure 1: X-ray STN and X-ray chest AP view and CT neck: Showing metallic foreign body in the neck. X-ray abdomen: Showing suspected metallic foreign body (necklace) in the abdomen. STN = Soft tissue neck, AP = Anteroposterior, CT = Computed tomography
Click here to view |
X-ray abdomen also done and revealed another radiopaque coiled foreign body (suspicious of a pendant) in the stomach [Figure 1].
A contrast computed tomography (CT) scan of the neck was done which showed a metallic artifact posterior to the cricoid cartilage extending into the esophagus [Figure 1].
Upper gastrointestinal (GI) endoscopy revealed an impacted pencil sharpener in the PFS, postcricoid region, and upper esophageal sphincter region. Endoscopic removal failed due to difficulty in instrumentation.
The patient was taken to operation theatre (OT) and was then intubated. Initially, the removal of the foreign body was attempted. Hypopharyngoscope was introduced and a metallic foreign body (sharpener) was found in postcricoid region pushing the arytenoid anteriorly. It was pulled into the lumen of the hypopharyngoscope (acting as an overtube) and was removed. Postremoval, examination revealed ulceration in the posterior wall of the esophagus [Figure 2]. | Figure 2: Intraoperative picture showing sharpener lodged just below cricopharynx
Click here to view |
The abdominal foreign was removed by surgical gastroenterologist gastrostomy was performed and two separate foreign bodies – A toothbrush and a charging wire were removed from the stomach [Figure 3]. | Figure 3: Intraoperative picture of laparotomy showing tooth brush and mobile charger wire removed from stomach
Click here to view |
A total of three foreign bodies were removed.
- Sharpener – measuring 3 cm × 2 cm × 1.5 cm
- Toothbrush – length measuring 22 cm
- Charging wire – 4 mm circumference and 20 cm in length.
Postsurgery, extubation was uneventful and the patient was shifted to the ward. He was discharged in a satisfactory condition after observation
| Discussion | | |
Diagnosis of foreign body ingestion in adults is often straightforward. Intentional ingestion of foreign body is uncommon. It is seen in patients with psychiatric illnesses which include schizophrenia, autism, pica, and personality disorders.[3],[6] In our case, the patient did not complain of ingestion but had multiple foreign bodies present in his gastrointestinal tract. A psychiatric evaluation revealed the presence of behavioral problems since childhood. Hence, his complaint of absolute dysphagia was considered an attention-seeking behavior and ignored by his parents leading to delay in receiving medical attention. It is important to get a psychiatric evaluation in such peculiar cases. Delay in presentation often leads to complications such as mediastinitis, perforation peritonitis, hemorrhage, abscesses, and leakage of toxic substance from the foreign body.[1],[2],[7]
Radiology is vital for the diagnosis of foreign body and also helps in identifying complications such as mediastinitis and intestinal perforation.[8],[9],[10],[11] The evaluation of the whole GIT from pharynx till rectum is often necessary to rule out the presence of multiple objects. However, radiology can be misleading as only radiopaque objects are readily identifiable.[11] In our case, the plastic covering the blade of the sharpener was not identified as it was radiolucent. Similarly, only the bristles of the brush were identifiable.
The most common and noninvasive method for foreign body removal is flexible endoscopy.[7],[12],[13],[14] It is often preferred in cooperative individuals without any complications. Various endoscopic modalities available include overtube technique, dormia basket, radial jaw forceps, and polypectomy snare.[12] It is not useful if the object is large or has sharp edges which might result in trauma.
Rigid esophagoscopy is the instrument of choice for esophageal foreign body.[13],[14] In our case, the lumen of the esophagoscope was inadequate for both complete visualization as well as instrumentation. We used hypopharyngoscope for retrieval of the cricopharyngeal foreign body. Larger luminal dimensions provided ample space for endoscopic examination as well as instrumentation.
Surgical removal of foreign body is performed only in selected cases.[11],[15] If a foreign body is small, blunt, located distal to gastroduodenal junction, and do not pose a threat of obstruction or perforation, conservative management can be opted for.[7] Objects usually pass through the intestinal tract and get evacuated in feces. This is not preferable for large objects and objects that have a potential of complication.[1],[2] Our decision for surgical removal was based on the fact that the object was large on imaging and an attempt for endoscopic removal might lead to perforation at the level of upper esophagus where sharpener was impacted as mucosal injury was already noted. The procedure was uneventful and the foreign bodies could be retrieved.
This patient did not have complications often seen with delayed presentation. The presence of complications makes the management cumbersome which may require gastric bypass, intensive care unit care, long hospital stay, mediastinitis, and sepsis thereby resulting in morbidity and mortality.[2],[5] Postoperatively, our patient was allowed orally on day 2 and discharge was one on day 4 after 72 h of close observation.
Key points
- Foreign body ingestion should be considered in psychiatric patients with acute dysphagia
- Hypopharyngoscope is safe and effective for removal of a large foreign body in the cricopharynx and upper esophagus
- X-ray chest and abdomen should always be done in patients with foreign body cricopharynx before attempting removal
- Radiology can be misleading when the object has both radiolucent and radiopaque components.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
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