Esophageal perforation and neck abscess from ingested foreign bodies: treatment and outcomes

Ear, Nose & Throat Journal, Oct, 2003 by Henry Chuen Kwong Lam, John Kong Sang Woo, Charles Andrew van Hasselt

Abstract

Over a 6.5-year period, 5,848 patients who had ingested a foreign body were admitted to the ENT unit at the Prince of Wales Hospital in Hong Kong. Potentially serious complications developed in 12 patients (0.21%). Eight patients had an esophageal perforation; three had clinical evidence that their injury had been caused by the foreign body itself and five were deemed to have been injured iatrogenically during esophagoscopy. One of the latter group eventually developed an abscess. Four patients originally presented with an abscess. Three of these patients and the patient who later developed an abscess were treated with neck exploration and surgical drainage. One of the patients who initially presented with an abscess refused surgical treatment and was treated conservatively. Conservative treatment was also initiated for all patients who had a perforation. Patients on the conservative regimen were administered intravenous broad-spectrum antibiotics and were not permitted to take any food or liquids by mouth; they received their nutrition via either enteral feeding or total parenteral nutrition. Conservative treatment was successful in all seven patients with a perforation and no abscess and in the one patient with an abscess who refused surgery. Moreover, all four patients who underwent surgical treatment recovered. Our experience demonstrates that esophageal perforation related to an ingested foreign body can be safely treated by conservative means if the diagnosis is made before significant contamination occurs. Conversely, abscesses (cervical or mediastinal) related to an ingested foreign body should be explored and surgically drained.

Introduction

Ingested foreign body is a common clinical problem in Hong Kong, primarily because it is a consequence of long-standing local cooking and eating habits. Major complications--including esophageal perforation, deep neck abscess, and (in rare cases) esophagoaortic fistula--have been reported in 0.5 to 1.0% of such patients in Hong Kong. (1,2) Esophageal perforation is associated with significant morbidity and mortality, and its treatment (surgical vs conservative) is controversial. Most authors suggest early surgical closure of the perforation and drainage of the contaminated area. (3-5) Nevertheless, satisfactory results have also been reported with conservative approaches. (6-8) The development of abscesses in the deep neck spaces and the mediastinum following foreign-body ingestion can occur in the absence of any clinical evidence of esophageal perforation.

We reviewed a large number of cases of ingested foreign bodies. In this article, we describe our findings with respect to the diagnosis, management, and outcomes of those patients who experienced potentially serious complications of foreign-body ingestion.

Patients and methods

We audited the hospital records of 5,848 patients who had been admitted to the ENT unit at the Prince of Wales Hospital in Hong Kong between July 1, 1987, and Dec. 31, 1993, with a complaint of an ingested foreign body. We reviewed the case notes of all patients who had stayed in the hospital at least 4 days, all patients who were readmitted within 1 month, and all patients who required esophagoscopy.

More than 600 patients fulfilled at least one of these criteria. A total of 169 had been hospitalized for 4 days or longer because of social or concurrent medical problems. Two patients, both Vietnamese refugees, had been readmitted within 1 month; both declined esophagoscopy and were discharged after 2 days of uneventful observation. Either diagnostic or therapeutic esophagoscopy had been performed on 519 patients (8.9%); 441 underwent rigid esophagoscopy and 78 flexible esophagoscopy.

Results

Among the 5,848 patients, major complications developed in 12 (0.21%)--five males and seven females, aged 8 to 79 years (mean: 44). Eight patients (0.14%) had an esophageal perforation (table 1) and four (0.09%) presented with a retropharyngeal abscess (table 2). All 12 patients had undergone rigid rather than flexible esophagoscopy.

Esophageal perforation. We classified the perforation patients into three groups according to the timing of their diagnosis:

Group 1. Patients 2, 5, and 6 were diagnosed with an esophageal perforation at presentation on the basis of obvious radiologic signs. All had sought treatment within 24 hours of foreign-body ingestion. These perforations were at or above the level of the cervical esophagus.

Group 2. Patients 1 and 7 had iatrogenic perforation of the cervical esophagus diagnosed during esophagoscopy.

Group 3. Patients 3, 4, and 8 had iatrogenic perforations that were not noticed during rigid esophagoscopy. Perforation did not become evident until afterward, when they developed persistent pain, fever, and/or leukocytosis. In addition, patient 4 later developed both a retropharyngeal and a mediastinal abscess.

Treatment. Initially, all eight patients were managed conservatively. They received broad-spectrum antibiotics intravenously and they were prohibited from taking any food or liquids by mouth; they received their nutrition via either enteral feeding or total parenteral nutrition.