Foreign body ingestions are common in children. They can pose a diagnostic problem if the foreign body is embedded in the soft tissues of pharynx. A 4 year old girl presented with halitosis for two years. A pharyngeal foreign body, a metallic ring, was seen on lateral radiographs of the neck. The foreign body was removed under general anaesthesia. A completely embedded pharyngeal foreign body should be considered in cases presenting with halitosis.
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The ingestion of foreign bodies is not uncommon in infants and children. In some instances, this can go undetected, if the foreign body is embedded in the base of the tongue or pharynx.1 We present a rare case with a longstanding foreign body, a metal ring, in the pharynx.
A 4 year old girl presented to our department with a history of halitosis. This complaint had been first noticed two years ago and had a gradual onset. It was noted that she was diagnosed with upper respiratory tract or dental infections for many times and treated with antibiotics without any benefits. The repeated throat cultures were all negative.
Examination of the oropharynx showed no abnormality except for a slightly inflamed posterior pharyngeal wall. The tonsils were normal. There were multiple bilateral microlymphadenopathies in the neck. In the endoscopic examination of the pharynx, it was noted that above the sulcus terminalis, just in the midline, there was a slight reddish, granulated tumefaction with a foul smelling discharge on it. Other clinical examinations were unremarkable. A lateral radiograph of the neck was performed to evaluate the retropharyngeal space. It showed a metallic ring stuck to the posterior pharyngeal wall at the junction of oropharynx and hypopharynx between the C1-C2 cervical vertebrae (fig 1). The parents were asked again for the source of the ring. Then, the parents informed that, at the age of 9 months, the child had swallowed her mother's golden ring while playing with it. At that time, only serial abdominal radiographs were performed and they did not show the foreign body. It was thought that, either the mother failed to detect the excretion of the ring, or that the ring had not been swallowed at all.
The foreign body was removed under general anaesthesia. The outcome of the patient was excellent. No complications were observed.
Foreign body ingestion is a common complaint in paediatric practice. The ingested foreign bodies are usually toy parts, coins, needles, pins, or plugs. They usually pass harmlessly through the gastrointestinal tract but a few become impacted at various levels of pharyngeal soft tissues.2 The diagnosis of a pharyngeal foreign body may pose a problem, particularly when the history is not forthcoming, as in the patient described here. The symptoms of pharyngeal foreign bodies are usually dysphagia, pain, stertor, excessive salivation, upper respiratory tract infection, or refusal to eat and drink.3,4 None of these symptoms were present in our patient and that was uncommon. She only complained of halitosis. The causes of halitosis are stomatitis, pharyngitis, tonsillitis, dental caries, bad oral hygiene, sinusitis, foreign bodies in upper airway, continuous oral breathing, oeosephageal diverticules, gastric bezoar, and rarely bronchiectasy and lung abscess. For the patient presented here, the lateral radiograph of the neck showed the longstanding pharyngeal foreign body as the cause of halitosis.
Undiagnosed pharyngeal foreign bodies can result in retropharyngeal cellulitis or abscess. The history provides a clue to the diagnosis. But if the history is not reliable enough, as in our patient, plain radiographic evaluation of the upper airway may provide information to the diagnostician. If the impacted foreign body is radioluscent, in the presence of positive history, symptoms or clinical suspicion, endoscopic examination is suggested.5 The diagnosis of radio-opaque foreign body ingestion does not pose a major problem. However, it is crucial to take a radiograph from the pharynx, where the foreign body is most likely to become impacted, to the level of pylorus.6 In our case, only serial abdominal radiographs had been performed during the ingestion period in infancy. For that reason, there was a delay in the diagnosis of the foreign body for this patient.
Endoscopic techniques for evaluation and management of airway problems in paediatric patients have improved greatly in the past decade. Careful selection of the most appropriate instrument and technique by well trained medical or surgical endoscopists will result in safe and effective diagnosis and treatment.2 For the patient presented here, the longstanding foreign body could only be removed surgically, because it was completely embedded in pharyngeal soft tissues.
In conclusion, it is important to be aware of the possibility of a pharyngeal foreign body in young children, particularly when the history is unreliable or if the clinical symptoms are atypical.
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