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International Journal of Medicine and Medical SciencesTable of Contents:Volume 5Number 6June 2013ARTICLESCase ReportMultiple oesophageal coin-like foreign bodies appearing like one:A caution for otorhinolaryngologistSegun-Busari Segun, Afolabi Olushola Abdulrahman, Alabi Biodun Sulyman,Adebola Stephen Oluwatosin247Research ArticlesThe effect of clofibrate in near term newborns with non hemolytic jaundiceSedigheh Hossein pour Sakha, Manizheh Mostafa Gharehbaghi andMohammad Ebrahim RahbaniThe comparison of intradermal versus intramuscular vaccination ofhepatitis B in healthcare workers who fail to respond to previous repeatedintramuscular vaccinesMasoud Mardani and Amir RoudgariAntibacterial activity of Schiff base ligands containing pyridine anddisulphide moieties against some chosen human bacterial pathogensSabina Jhaumeer Laulloo, M. G. Bhowon, S. Ravikumar, A.Kalaiarasi, M. Raja and V. VijayakumarPatterns of antibiotic use among childrenHala Abdullah Hussien Abu Romman251255260264

International Journal of Medicine and Medical SciencesTable of Contents:Volume 5Number 6 June 2013ARTICLESResearch ArticlesHealth care seeking among pulmonary tuberculosis suspects in Wuhan:A community-based studyQiong-hong Duan, Peng Wang , Jing Lv , Rong Zhong, Wei-hua Wangand Qing-zhi ZengPerception of the public on the common zoonotic diseases in Jimma,Southwestern EthiopiaDawit Tesfaye, Daryos Fekede, Worku Tigre Alemayahu Regassaand Amene Fekadu273279Profile and outcome of diabetic admissions at the University of UyoTeaching Hospital, UyoB. C. Unadike, I. Essien, N. A. Akpan, E. J. Peters and O. E. Essien286Awareness and attitudes to voluntary counseling and testing (VCT) forhuman immunodeficiency virus/acquired immune deficiency syndromeS. U. Mbamara, N. J. A. Obiechina and J. C. Akabuike290Seroprevalence of Toxoplasma gondii between couples in Ramadi cityusing enzyme linked immunosorbent assay (ELISA)Mohanad Mohammad, Shehab Ahmed and Abudalla Hussain295Impact of lymphatic filariasis elimination programme by study ofadvances and challenges using mathematical modelVaibhav Changediya and Subhash Devdhe300

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Vol. 5(6), pp. 247-250, June 2013DOI: 10.5897/IJMMS09.395ISSN 2006-9723 2013 Academic national Journal of Medicineand Medical SciencesCase ReportMultiple oesophageal coin-like foreign bodiesappearing like one: A caution for otorhinolaryngologistSegun-Busari Segun, Afolabi Olushola Abdulrahman*, Alabi Biodun Sulyman, AdebolaStephen OluwatosinDepartment of Otorhinolaryngology,University of Ilorin Teaching Hospital,P. O. Box 2400, Ilorin,Kwara State, Nigeria.Accepted 2 May, 2013Ingestion of foreign bodies is a common pediatric problem. Majority of ingested foreign bodies passfreely without causing any injury. Ingestion of multiple foreign objects and recurrent episodes areuncommon. Thus we present a case of multiple foreign body ingestion to cautionotorhinolaryngologist. We present a six year old boy admitted eight hours following ingestion of amultiple roundish metallic object. There is associated dysphagia to solids and liquid feeds withdrooling of saliva. He has had two episodes of induced non-projectile vomiting which contains recentlyingested feeds prior to admission. There is no cough or difficulty in breathing. Examination of the neckrevealed a positive pointing sign. Plain radiograph of the soft tissues neck revealed a spherical radioopaque object of metallic density within the oesophagus at the level of C5 to C7. Patient had rigidoesophagoscopy under general anaesthesia with extraction of the multiple metallic foreign bodies. Itwas uneventful both post operatively and on follow up. The study thus revealed though multipleoesophageal foreign body is rare, there is need for caution among the otorhinolaryngologist whenextracting the oesophageal foreign bodies and also stressed the need to double check again followingextraction, that is, to repeat endoscopy.Key words: Multiple, oesophageal, foreign bodies, endoscopy, otorhinolaryngologist.INTRODUCTIONIngestion of foreign body is relatively common in theaero-digestive tract among the paediatric populationworld wide. However some of them get impactedbecause of either their large size or shapes (Amadasun1995; Hawkins 1990; Crysdal et al., 1991; Davey andBurkitt 1989; Jackler and Kaplan 1989), while some maypass through the gastrointestinal tract freely uneventful(MacManus 1941). Aerodigestive foreign body ingestionamong the paediatric population is a preventable problem(Afolabi et al., 2009). Management of foreign body ingestions varies and it depends upon the object ingested,its location, the patient's age and past history. Once a foreign body is impacted in the throat, it become associatedwith dramatic presentation of dysphagia and or droolingof saliva which may be a source of apprehension to thepatient, to the care giver and the healthcare providers.Ingestion of multiple foreign objects and repeatedepisodes are uncommon. Thus we present our case tocaution otorhinolaryngologist who is providing the rescueservices to have a second and third look.CASE REPORTPatient I.A. is six year old school boy who was admitted through theemergency Paediatric Unit eight hours post foreign body ingestion.The patient was said to have swallowed a roundish metallic object,*Corresponding author. E-mail: droaafolabi@yahoo.com. Tel: 2348035727069.

248Int. J. Med. Med. Sci.Figure 1. Plain radiographs of the soft tissues of theneck (anterior-posterior view).joint.The patient has good oro-dental hygiene but with pooling ofsaliva in the oral cavity; dentition was intact with no use of dentures,no foreign body visualised in the oropharynx. He has a granularposterior pharyngeal wall.Otologic and anterior rhinoscopy was essentially normal. Therewas tenderness at the front of the neck on palpation andscarification marks were noticed at these points.A diagnosis of impacted pharyngo-oesophageal foreign bodyingestion was made. Plain radiographs of the soft tissues of theneck (AP and lateral view) revealed a spherical radio-opaque objectof metallic density within the oesophagus at the level of C5 to C7,with air-oesophagogram in which the lower limit cannot bedelineated (Figures 1 and 2).The patient’s heamogram and blood biochemistry were all withinnormal limits. Patient had rigid oesophagoscopy using paediatricKarl Storz oesophagoscope with gentle extraction of foreign bodyunder general anaesthesia with small size 3.0 endotracheal tubeintubation. The surgical findings were multiple, silver colouredspherical metallic objects of the same size were extracted at about12 to 14 cm from the upper incisor, at the level of the cricopharyngeus. These objects were superimposed on one another.Repeat endoscopy was done to ensure no other foreign bodieswere left out.Post operatively, patient was uneventful. Patient commenced oralintake, 48 h post-operatively with no evidence of oesophageal perforation. The patient was discharged home 72 h post operatively.Follow up revealed he has remained well for six months now.DISCUSSIONFigure 2. Plain radiographs of the soft tissues of theneck (lateral view).while he was playing. There is associated odynophagia, dysphagiato solids and liquid diet and there is drooling of saliva. He has hadtwo episodes of induced non-projectile vomiting of which containsrecently ingested food prior to admission. There was no cough anddifficulty in breathing. There was no abnormal neck swelling. Therewere no otologic or nasal symptoms. The patient was not a knownpsychiatric or asthmatic patient. He is from a monogamous familyand the first child of the family. There was noticed failed attempt atremoval using bolus of meal.Clinical examination revealed a boy not in any obvious cardiorespiratory distress, not pale, afebrile, but with drooling of salivaand a positive pointing sign at the level of cricothyroid cartilageThe majority of foreign body ingestions occur in thepaediatric population with a peak incidence betweenages six months and six years (Afolabi et al., 2009; Webb1995; Cheng and Tam 1999; Hachimi-Idrissi et al.,1998).The age group which our index case presentedfalls into, may be associated with peer group influence. Inchildren, the true duration of the foreign body in theoesophagus may be unknown until it is discomforting;however in the index case the duration was said to beabout eight hours when the attention of the care giverwas drawn to it. Nevertheless, the exact timing ofinsertion may be difficult. Male are at risk of foreign bodyinsertion or ingestion as in the index case reported, thismay be associated with the increased risk of explorationof all cavities and high level of inquisitiveness among themale children than the female children similar to previousreports (Afolabi et al., 2009).In adults, true foreign object ingestion occurs morecommonly among those with psychiatric disorders,mental retardation or impairment caused by alcohol, andthose seeking some secondary gain with access to amedical facility (Webb 1995; Blaho et al., 1998; Kamal etal., 1999). Edentulous adults are also at greater risk forforeign body ingestion, including their dental prosthesis(Blaho et al., 1998; Abdullah et al., 1998).The most common site of foreign body impaction in theoesophagus is the cervical oesophagus at the level of thecricopharyngeus which is similar to our finding; in thereport presented, the foreign body lodged was lodged at

Segun et al.Figure 3. Multiple metallic foreign body.Figure 4. Diameter of multiple metallic foreign body.about 12 to 14 cm from the upper incisors. The nextcommonest site is the thoracic oesophagus at the level ofthe aortic arch (Nandi and Ong 1978). This radiographicinvestigation done in our index case if combined with theclinical findings of his pointing sign as it corresponded tothe location of the foreign body increases the specificity.(Lue et al., 2000) reported a sensitivity and specificity of39 and 72%, respectively while a recent study quoted24954.8 and 100% (Akazawa et al., 2004), for their plainradiographs. The present report does not report a certainpercentage as it was a single case report.Two radiological views as is customarily done in ourcentre was buttressed by Whelan-Johnson S, Hall CE,who equally stated that two radiological views arerecommended in the assessment of oesophageal foreignbodies (Whelan-Johnson and Hall 2009).Oesophageal foreign bodies are commonly encountered in otolaryngology practice. Such circumstances areoften compounded by pre-existing psychiatric problemssuch as bulimia and/or anorexia nervosa (Sastry et al.,2008). Patients with bulimia may often present with avery similar pattern of multiple episodes of ingestion oflarge foreign bodies. Identification of this eating disorder(especially when there is a recurrent history of large,accidentally ingested foreign bodies) and promptpsychiatric referral is essential for efficient long-termmanagement of this condition (Sastry et al., 2008). Ourpatient has no psychiatric illness.Management of the patient is influenced by thepatient’s age and clinical condition; the size, position ofthe coin if vertical or horizontal, shape, and classificationof the ingested material; the anatomic location in whichthe object is lodged; and the technical abilities of theendoscopist (Ginsberg 1995;Faigel et al., 1997; Michaudet al., 2009). The index patient presented had the multiple foreign body that is metallic, silver coloured with adiameter of about 4 cm (Figures 3 and 4) which is equivalent to the oesophageal diameter in vertical positionrelative to the oesophageal lumen; thus there was nosign of airway compression and allows minimal swallowing, thus no total dysphagia. The timing of endoscopicintervention in foreign body ingestion is dictated by theperceived risks of aspiration and/or perforation base onthe position/placement. In this situation, the interventionwas after 12 h of injury due to investigative procedureand sourcing for finance. This extraction was done undergeneral anaesthesia with a Karlstorz rigid oesophagoscope and foreign body removed. Further delay in theremoval may predispose the patient to corrosion of themetallic object with increased risk of perforation andmucosal reaction.ConclusionMultiple oesophageal foreign body though rare, is anemergency with need for caution among theotorhinolaryngologists/endoscopist. As it is commonamong the paediatric population, all patients with foreignbodies in the aero-digestive tract should have adequatehistory, ear, nose and throat examination along with thepointing sign (if the child is old enough) which should becombined with the radiological investigation. Patientsshould be assumed to have multiple foreign bodies thusthe need to scope the aero-digestive tract and re-scope

250Int. J. Med. Med. Sci.after extraction to look for a remnant if there are and toascertain the integrity of the site of impaction of the FB, inthis case the mucosa.REFERENCESAbdullah BJJ, Teong LK, Mahadevan J, Jalaludin A (1998). Dentalprosthesis ingested and impacted in the esophagus andorolaryngopharynx. J. Otolaryngol. 27:190-4.Afolabi OA, Okhakhu AL, Adeosun AA (2009). Re-Emergence Of CoinIn Nigerian Currency: Implication In Medical Practice. Intern. J.Otorhinolaryngol. 9(1):4.Akazawa Y, Watanabe S, Nobukiyo S, Iwatake H, Seki Y, UmeharaT, Tsutsumi K, Koizuka I (2004).The management of possiblefishbone ingestion. Auris Nasus Larynx 31(4):413-416.Amadasun EO (1995). Coin as oesophageal foreign

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