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A 4 year old boy was referred to hospital with suspected meningitis. There was a four day history of neck stiffness and anorexia but also of drooling and dysphonia. Examination revealed him to be significantly dehydrated but alert and afebrile. There was no stridor. Serum urea and electrolytes were consistent with hypernatraemic dehydration: sodium 161 mM/l; urea 16.9 mM/l; creatinine 74 µM/l. A lateral radiograph of the neck showed a large foreign body in the proximal oesophagus at the level of cricopharyngeus (see fig). After appropriate fluid resuscitation, the foreign body was removed under general anaesthesia revealing a significant ulceration in the posterior superior pharynx and minor oedema of the arytenoids corresponding with P and A on the figure respectively. The child’s parents identified the foreign body as a bolt recently noted to be absent from its hole in a bed-head. The postoperative recovery was swift and complete. The discharge weight was almost 15% greater than the weight on presentation. This case illustrates how cricopharyngeus (“the upper oesophageal sphincter”) is one of the three sites where oesophageal foreign bodies may lodge—the other two sites being where the aortic arch descends anterior to the mid oesophagus and at the level of the cardiac sphincter. The case also serves as a reminder that young children can conceal a potential life threatening condition for several days.
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