Abstract
Introduction: intra-tracheal migration of esophageal foreign body is very uncommon and dangerous. It is most often caused by a vulnerable foreign body accidentally swallowed. We report the first observation of intra-tracheal migration of corrosive battery in our practice, with review of the literature. Observation: It was a three-years-old girl received in ENT with dyspnea occurred on a chronic dysphagia. The chest x-ray revealed an endotracheal opacity. This proved to be a button battery that migrated into the trachea through an eso-tracheal perforation. Due to this situation, an emergency medico-surgical care was stored, with a favorable evolution at the cost of a laborious management of the residual fistula. Conclusion: Classically innocuous, esophageal foreign body can be unnoticed and became extra-esophageal through esophageal migration in general and tracheal in particular, thus transforming a chronic digestive problem into an expressive respiratory emergency.
Keywords: Button battery, Eso-tracheal, Migration, Fistula
Introduction
Intra-tracheal migration of esophageal foreign body is an uncommon respiratory emergence in ENT practice. It is more often caused by vulnerable foreign bodies, accidentally swallowed and remained unknown for a long time [1]. It occurs especially in children and transforms a firstly chronic digestive problem into a secondary respiratory emergency that requires radiographic and endoscopic investigations. The treatment is faced to the problem of extraction of the causal foreign body and the difficulties of the management of the caused eso-tracheal fistula that can be often spontaneously resolved under a medical care without surgical closure [1, 2].
Observation
A girl child of three-years-old, was brought to ENT service of our academic hospital for dyspnea that begun about twowelve days ago. There was an medical history of chronic dysphagia that has been evolving for 06 weeks. Clinical examination revealed a tracheal dyspnea, without any notion of inhallation of foreign object in the days before. X-ray of chest realized revealed a metal-like radio-opacity in the tracheal light. (Fig. 1).
Fig. 1.
Entrance images: Patient photography (a), with his initial chest X-ray (b)
An endoscopy under general anesthesia with rigid paediatric bronchoscope was also performed and revealed a tracheal foreign body. An attempt to remove it by tracheal route has led to blockage and subglottic release due to the large size of the foreign body that could not pass through the glottis. However, due to these reasons an emergency tracheotomy was performed to remove the foreign body. It was a button of battery of 20 milimeters in diameter (Fig. 2).
Fig. 2.
Per-operative images: Patient after tracheotomy (a) and the extracted battery (b)
Panendoscopy exploration revealed an eso-tracheal fistula at about 12 Centimeters from the upper dental arch with perilesional granulation tissues. Post-operative treatment was made of antibiotic therapy based on amoxicillin and clavulanat and feeding througt nasogastric tube. A X-ray of esogastric transit performed at 45 days post-surgical act revealed a tight stenosis with an image of eso-tracheal fistula. Due to this situation, we decided to keep the nasogastric feeding.The control at 06 months after operative act was favorable with good clinical evolution and normal x-ray images (Fig. 3).
Fig. 3.
Post-operative images: Patient at 06 months ago (a) and his normal X-ray of esogastric transit control (b)
Discussion
Esophageal foreign bodies are common in childwood especially at the oral phase of psychological development [1, 2]. It generally manifests by difficulty of eating, vomiting, neck and chest pain, etc. Sometime they can be without obvious symptoms and evolving silently to any complications as reported in the case of our young patient who has been received for acute dyspnea occurred on more than 06 weeks of uncompleted dysphagia. Mostly, complications are digestive or mediastinal like hematemesis, esophageal stenosis or mediastinitis [2, 3]. Intra-tracheal migration is an unusual complication which transforms esophageal foreign body into low respirator’s one and then transforming a simple chronic digestive problem into a severe respiratory emergency that requires chest radiographic investigations [1, 3]. This exploration is essential for the beginning of the diagnosis. In our case it revealed an intra-tracheal obstacle by a coin like opacity. Definitive diagnosis remains endoscopic which constitutes in the same time, the first step for the management of these cases. It confirms the diagnosis, allows the removal of the foreign body and makes possible injuries checkup [2, 3]. In this observation, endoscopic was performed under general anesthesia and allowed to localize the foreign body and to make an exhaustive injury assessment. Extraction of the foreign body was performed by tracheal opening because of its relative large size compared to that of glottis diameter. That was possible by the fact of endoscopic accessibility of the foreign body. In case of intrathoracic migration, extraction would be by thoracotomy which is a heavy surgical act with any risk of post-operative morbidity [4]. Evolution in our case was favorable after a long period of medical care. The eso-tracheal fistula was spontaneously resolved under prophylactic antibiotic therapy with a long nasogastric tract feeding. For some authors, esophageal perforation requires endoscopic or thoracotomy surgical closure [4, 5]. In contrast, we think that surgery must remain an alternative act for the case of failure situations of medical cares in an under-medicalized context like ours.
Conclusion
Button cells batteries as intra-esophageal foreign body are very dangerous. One of their serious complications is the esophageal perforation and then, their extra-esophageal migration which can be a therapeutic defy as it was the case in our context with any difficulties of management of the residual eso-tracheal fistula. So we must keep these things away from the children and watch them for preventing theses domestic accidents.
Funding Sources
This research did not receive any specific grant from funding institutions in the public, commercial, or not-for-profit sector.
Declaration
Conflict of Interest Statement
The authors declare that they have no competing interest. They all approved the final manuscript.
Statement of Ethics
In this study, all procedures performed were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments. Informed consent was obtained from the patient’s father for publication of this case report and any accompanying images.
Footnotes
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