Introduction
The ingestion of foreign bodies in children is a common problem, with approximately 1000 hospital admissions for pharyngeal or oesophageal objects in England per year.1 Coins are the most frequently swallowed foreign body.Reference Kay and Wyllie2 If the patient is symptomatic, prompt endoscopic removal is advised. Diagnosis requires a careful history and plain X-ray imaging. This case report illustrates the importance of obtaining two radiological views to properly manage such cases.
Case report
A five-year-old boy presented to a local minor injuries unit. He had admitted swallowing a coin to his father after playing with some money. He had vomited once at home and remained tearful. A postero-anterior chest radiograph was performed by the minor injury unit staff, confirming the presence of a single, radiopaque disc at the level of the sternoclavicular joints (Figure 1).
Fig. 1 Initial postero-anterior chest radiograph
The patient was transferred to the Bristol Children's Hospital. On arrival, there was no evidence of respiratory distress; the patient was able to swallow his own saliva and talk in full sentences. His oxygen saturation was 99 per cent on air and his chest was clear on auscultation. Repeat postero-anterior and lateral chest X-rays were ordered to confirm the position of the foreign body, as some time had elapsed during transfer and the patient's symptoms had improved. The lateral soft-tissue neck X-ray demonstrated the presence of four radiopaque discs (Figure 2 & 3).
Fig. 2 Lateral soft-tissue neck radiograph
Fig. 3 Close up of lateral soft tissue neck demonstrating multiple foreign bodies
The patient underwent rigid pharyngoesophagoscopy under general anaesthetic within a few hours. Four coins, totalling 37 pence (one 10 pence, one 20 pence, one 5 pence and one 2 pence coin) were successfully removed. Minor superficial mucosal abrasions in the sub-cricopharyngeal oesophagus were noted.
The patient made an uneventful post-operative recovery and was discharged home the following day.
Discussion
This case highlights the importance of obtaining two radiological views when assessing patients with ingested foreign bodies. In the postero-anterior view, the largest of the coins obscured the smaller coins adjacent to it. In our opinion, a second radiological view is essential in order properly to identify the locationReference Conners and Hadley3 of an ingested foreign body and to prevent the risk of missing multiple objects which may not be apparent in a single view. In some series,Reference Yalçin, Karnak, Ciftci, Senocak, Tanyel and Büyükpamukçu4 12 per cent of foreign bodies were removed in the anaesthetic room with Magill's forceps and an intubating laryngoscope. This procedure has a high potential for missing an unidentified second foreign body, compared with formal endoscopic assessment. The second radiological view enables adequate surgical planning and reduces the risk of error in such cases.
