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Radiological Findings

When suspicion for an ingested foreign body is high, frontal and lateral radiographs should be obtained from the nasopharynx to the abdomen. Radiology reveals 100% of metal objects, 86% of glass and 26% of fish bones (Cheng and Tam 1999). Commonly ingested foreign bodies such as medications, small plastic toys and organic material are not seen on plain radiography. These radiolucent foreign bodies may show on the barium esophagram as filling defects in the barium. A contrast examination must not be performed with a high grade obstruction because of the aspiration risk. Chronically lodged foreign bodies cause inflammation, edema of the esophageal wall and narrowing of the lumen (Fig. 2.25).

Fluoroscopic Foley catheter removal has a high (91%) success rate with coins that have been in place for less than 3 days. The rate of successful removal is lower with coins that have been lodged for a longer time period (Schunk et al. 1994). The success rate is b a

Fig. 2.25a,b. Chronically impacted coin. Frontal (a) and lateral (b) chest radiographs with an impacted coin and inflammatory narrowing of the adjacent airway. The space between the trachea and the esophagus is thickened, evidence of chronic inflammatory change

also lower (83%) in cases with underlying esopha-geal pathology (Schunk et al. 1994). An underlying stricture will not permit passage of the Foley catheter, and may be a cause for failure. Foley catheter removal is limited to objects without sharp edges. This technique must not be attempted in children with clinical or radiological airway compromise and should not be attempted in the presence of esopha-geal edema (Schunk et al. 1994).

Patients for fluoroscopic removal should not be sedated in order to maintain their airway. However, patients must be restrained and placed in the prone oblique position. A Foley catheter size 8-12 is placed through the nose or mouth under fluoroscopy to below the foreign body. The balloon is then inflated with 3-5 ml of contrast medium, taking care not to over distend the esophagus. The catheter is gently withdrawn, and the foreign body is delivered into the hypopharynx from where it can either be spontaneously expectorated, or manually removed by the radiologist whose fingers are in the child's mouth. A useful tip is to don two pairs of rubber gloves as these offer protection from being bitten by the patient. Occasionally, the Foley catheter will push the foreign body distally into the stomach. Complications are minor, and may include epistaxis and vomiting, but esophageal laceration may occur (Schunk et al. 1994). Although effective, this procedure is not widely performed and many pediatric radiologists defer to endoscopic extraction.

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