Journal of Education and Teaching in Emergency Medicine

ABSTRACT: History of present illness: A 64-year-old female presented to the emergency department feeling like she had “pills stuck in [her] throat,” specifically calcium and a multivitamin, which she tried to relieve with drinking, eating and sticking two fingers down her throat. She was sitting upright, speaking in full sentences but had a hoarse voice. She was tolerating her secretions but had frothy sputum in the posterior oropharynx.

Significant findings: Soft tissue lateral X-ray of neck was performed. The lateral soft tissue X-ray of the neck showed a metallic foreign body at the level cricoid.

Discussion: Most swallowed foreign bodies enter the esophagus. Larger foreign bodies tend to obstruct proximally and may cause airway compromise in addition to esophageal trauma.1 Foreign bodies tend to lodge at areas of anatomic narrowing, most commonly the upper and lower esophageal sphincters, physiologic angulation, and areas of pathologic stricture.2,3 Ensuring airway patency and ability to manage secretions is paramount and any concern for compromise should prompt emergent consultation with otolaryngology and/or gastrointestinal. Determination of which service to consult should be made based on the suspected location of obstruction and associated symptoms. In addition to obtaining a complete history of the ingestion including type of foreign body, size, and shape, it is prudent to ask what measures, if any, the patient has already taken to remove the object.

In this case, flexible fiberoptic laryngoscopy revealed swollen arytenoids and some small abrasions proximal to the vocal cords, which themselves appeared normal. She had copious secretions with no foreign bodies seen. On endoscopy, a metallic finger ring was found at the cricopharyngeus muscle along with non- obstructing laryngeal edema. The ring was removed with rat-toothed forceps. No pills were found. The patient had no recollection of swallowing the ring, but presumably, it slipped off her finger in the process of attempting to make herself vomit. After brief observation, she passed a bedside swallow assessment and was discharged in good condition. Repeat upper endoscopy 8 days later revealed a tortuous esophagus but was otherwise unremarkable.

Topics: Foreign body, laryngoscopy, endoscopy, airway management.