Foreign Body Aspiration

Esophageal Foreign Body: Another Cause of Stridor in Infants

Children’s Hospital of Michigan

Dr Zaghloul is a pediatric gastroenterology fellow, Dr Kamat is pediatric residency program director, and Dr Al-Ansari is pediatric gastroenterology attending in the department of pediatrics at Children’s Hospital of Michigan and Wayne State University in Detroit.

Stridor in infants is mostly caused by abnormalities of the airway. Foreign body ingestion is an uncommon cause of stridor in infants, and this diagnosis may be challenging in the absence of a clear history or radiological findings. Here, we describe a unique case in which an extensive evaluation of an infant’s stridor finally led to a surprising discovery and potentially overlooked cause of stridor in infants.

A Case of Recurrent Stridor. The parents of a 1-year-old girl first noticed a change in their infant’s breathing at age 10 months. At that time, she was evaluated by her primary care physician at a local hospital. A magnified airway study revealed tracheomalacia of the mid-trachea just below the thoracic inlet, and the parents were reassured of the benign course of the condition. The infant was later brought to another hospital for evaluation. Direct laryngobronchoscopy was performed and results were reported to be normal.

After 2 months of persistent stridor, the 1-year-old was brought to our emergency department because of worsening symptoms. Radiographs of both the neck soft tissues and chest were normal. The infant was admitted to the hospital.

Direct laryngobronchoscopy showed collapse of the mid-trachea with external compression anteriorly from right side, minimal soft tissue edema, and ulceration at the site of compression. Although the swelling was nonpulsatile, concern for a possible vascular ring led to a cardiothoracic and cardiology consult. Results of MRI with an angiogram of the chest and echocardiogram were normal. Gastroenterology was consulted to evaluate for gastroesophageal reflux. Esophagogastroduodenoscopy revealed a foreign body, a piece of plastic, in the proximal esophagus.

The foreign body was successfully retrieved with forceps. The patient had remarkable improvement and her stridor resolved.

Patient Age May Be a Clue. The differential diagnosis of conditions that cause recurrent stridor in infants is large and includes congenital anomalies of the larynx, subglottic stenosis (eg, from prolonged intubation), neurological abnormalities, vocal cord paralysis, metabolic abnormalities (such as hypocalcemia), and foreign body ingestion (see page 379 of this issue for a discussion of the evaluation and treatment of underlying causes).1 A congenital anomaly of the airway, such as tracheomalacia, usually presents with stridor shortly after birth. This was an unlikely cause of stridor in our patient because of her age at presentation.

The peak incidence of foreign body ingestion occurs in children between 6 months and 3 years of age. Up to 40% of these cases are unwitnessed by caregivers, and about half of them are asymptomatic and have no complications. Most ingested foreign bodies pass spontaneously; however, 10% to 20% require endoscopic intervention, and 1% or less require surgical intervention.2,3

Why the Diagnosis May Be Missed. A foreign body most commonly becomes lodged in the esophagus in locations of natural anatomic narrowing: the upper esophageal sphincter (cricopharyngeus), where the left main-stem bronchus or aortic arch crosses the esophagus, and the gastroesophageal junction.4 Foreign bodies in the esophagus can be asymptomatic but more commonly present with GI or respiratory symptoms. GI symptoms include dysphagia, odynophagia, blood in the saliva, food refusal, gagging, and foreign body sensation in the throat. Respiratory symptoms are rare and include wheezing, stridor, tachypnea, and dyspnea.2

Mohiuddin and colleagues5 reported on 3 patients with esophageal foreign body ingestion who were treated for asthma or upper respiratory tract infection 1 to 2 months before the correct diagnosis was made. An esophageal foreign body that presents with respiratory symptoms can be difficult to diagnose because, as stated above, a significant percentage of ingestions are unwitnessed, also the foreign body may be radiolucent (pieces of wood or plastic). These factors greatly contribute to the delay in diagnosis and management, which can increase the risk of complications.4 Typically, the longer the duration of impaction, the higher the complication rate.

Early Diagnosis Is Essential. Esophageal foreign bodies can cause serious morbidity and mortality.4 Thus, early diagnosis and management is crucial to prevent complications, including perforation with mediastinitis or abscess formation, tracheoesphageal fistula, hemorrhage secondary to erosion into the aorta, and stricture formation.1,4