Hrev_master Abstract Foreign Body (FB) swallowing is one of the most common medical emergencies in the world. This injury can cause mortality and morbidity in all age groups. This study aimed to evaluate the paraclinical methods in diagnosis of foreign body and its compli- cations compared to operating room findings in patients with oral, pharyngeal and esophageal symptoms. This was a retrospective study. All patients referred to the ENT (Ear, Nose, Throat) depart- ment of Amir A’lam hospital with complaints of foreign body swallowing admitted in the operating room were studied. The patients’ information including demographic information, type of swallowed body, paraclinical information and operating room find- ings were extracted from the patients’ records. This study was per- formed on 219 patients admitted to ENT clinic. The mean age of the patients was 45.10±20.61 years. The highest and the lowest fre- quencies for foreign body type were chicken bone in 61 cases (28.31%) and disk battery in 1 case (0.5%). The most and the least frequency of complaints after foreign body type were dysphagia in 129 cases (58.9%) and neck tenderness in 7 cases (3.19%). Computerized Tomography (CT) scan findings and operative find- ings were almost same except in two cases. Kappa agreement for lateral neck and observation in the operating room was 50.5% (P <0.001) and WBC count was significantly higher in patients with complications (P=0.010). According to the results, foreign bodies diagnosed with lateral neck can be reliable to make a decision based on it in patients with foreign bodies. High WBC count implicated in complicated for- eign body cases. Introduction Foreign body swallowing is one of the most common medical emergencies in the world that can occur intentionally or accidentally.1 Foreign body swallowing can affect all ages, but it is more common in children under the age of 5 years and in toothless people.2.3 This injury can cause mortality and morbidity in all age groups, of which the most frequent victims are children aged 1 to 3 years old.4,5 Some diseases such as esophageal stenosis and neuro- muscular and mechanical problems have been implicated as predis- posing factors for foreign body in adults.6 The type of swallowed foreign body has a wide range including metallic and nonmetallic objects, sharp objects such as glass and locks pins, fish bone, as well as circle objects such as coins and toys in infants.7,8 The most com- mon locations for foreign bodies are age-varying, and overall, the highest manifestation of 5-year-olds is similar to that of adults.9 Vomiting, odynophagia, dysphagia, and drooling are common symp- toms of foreign body ingestion, and if the foreign body is large, may cause airway obstruction. Delay in diagnosis and removal may cause obstruction, deep neck abscesses, esophageal perforation and medi- astinitis.10,11 Rapid removal of the foreign body reduces the risk of perforation. Therefore, the foreign body should be removed as soon as possible by the most common method of removal of the foreign body through esophagoscopy.12-14 One of the important diagnostic methods for the foreign body is to perform radiological imaging and these methods can be used in cases where the foreign body is absent from taking patients to the operating room and potentially performing rigid esophagoscopy.15 In this study, record of patients with suspected foreign body that had been gone the operating room of Amir A’lam analyzed and all of the relevant imaging including simple X-rays and Computerized Tomography (CT) scans were reviewed. We were also considering potential and fatal complications of foreign bodies to test the ability of pre-clinical studies to detect these com- plications in accordance with the findings of the operating room. Materials and Methods Study design and setting This was a retrospective study. All patients admitted to the Ear, Nose, Throat (ENT) department of Amir A’lam hospital with com- plaints of swallowed foreign body how had been gone operating Emergency Care Journal 2020; volume 16:8726 Correspondece: Ebrahim Karimi, Otolaryngology Research Center, Tehran University of Medical Sciences, Tehran, Iran. E-mail: karimiebrahim2019@gmail.com Key words: Foreign body; operating room; CT scan. Conflict of interest: No one. This work was not supported by any grant. Ethics approval and consent to participate: The manuscript does not contain any individual person's data in any form. Received for publication: 12 February 2020. Accepted for publication: 28 February 2020. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2020 Licensee PAGEPress, Italy Emergency Care Journal 2020; 16:8726 doi:10.4081/ecj.2020.8726 [Emergency Care Journal 2020; 16:8726] [page 31] Evaluation of Paraclinical Methods in diagnosis of Foreign Body and its complications compared to operating room findings in patients with oral, pharyngeal and esophageal symptoms in Amir A’lam Hospital Reza Erfanian, Ardavan Tajadini, Saeed Sohrabpour, Keyvan Aghazadeh, Abdolhossein Mehdinezhad, Ebrahim Karimi Otorhinolaryngology Research Center, Tehran University of Medical Sciences, Tehran, Iran Non -co mmerc ial us e o nly room were selected in 2018. The patients’ information including demographic characteristics, type of swallowed object, presenta- tion time after swallowing foreign body, symptoms, visibility of foreign body by esophagoscopy, laceration, perforation, abscess and external approach, radiologic findings lateral graph and com- puted tomography reports, leukocytosis and length of hospitaliza- tion were extracted from the records of hospitalized patients. Inclusion criteria were all patients admitted with foreign body swallowing and exclusion criteria were lack of hospitalization, incomplete records and patient dissatisfaction. Statistical analysis Qualitative data were reported as percentage and frequency. Quantitative data were reported as mean ± SD. Chi-square test was used to investigate the relationship between the qualitative vari- ables. Kappa statistic was used to assess the degree of agreement between different diagnostic methods. P value <0.05 was consid- ered significant. The data were analyzed using SPSS version 21 software. Results This study was carried out on 219 patients admitted to the ENT department of Amir A’lam hospital. The mean age of the patients was 45.10 ± 20.61 years (ranging from 1.5 years with swallowed coin to 84 years with swallowed fish bone). There were 114 males (52.1%) and 105 females (47.9%). The mean number of days past foreign body ingestion at the time of hospital admission was 1.62±1.30 days (ranging from 1 to 7 days). The most common cause of foreign body was chicken bone (28.31%) and the least common cause was disk battery (0.5%). The distribution of foreign body frequency by type is shown in Table 1. The highest frequency of foreign body complaints was related to dysphagia in 129 patents (58.9%) and the lowest was tenderness of the neck in 7 patents (3.19%) (Table 2). Of the 198 cases performed using lateral neck, 185 cases were observed in the operating room and 13 cases were not observed (Table 3). Kappa agreement for lateral neck and observation in operating room was 50.5% (P<0.001). Correlation of foreign body observation in CT scan with oper- ating room findings was investigated. In 50 cases CT scan was per- formed, foreign body was observed but in the two cases it was not observed in the operating room. One of them has had garlic and the other fish bone beneath the mucosa (Figure 1). Complications of the operating room were evaluated and observed for 16 patients (7.3%) including two perforations and 14 abscesses. The mean heart rate, body temperature, length of hospi- talization, drooling and WBC were evaluated in the two groups with/without complications. The results showed that white blood cell count was significantly higher in patients with complications (P=0.010). Table 4 shows that the other variables were not signifi- cantly different. The results also showed that there was a signifi- cant relationship between leukocytosis and drooling (P<0.05). The study showed that CT scans were consistent with intraop- erative findings in the diagnosis of foreign body complications (P<0.001). Table 5 shows the number of matching CT scans with intraoperative findings in the diagnosis of foreign body complica- tions. The relationship between foreign body and morbidity was investigated. The results showed that the most common type of for- eign body that caused abscess was fish bone but was not statistical- ly significant (P>0.05). In addition, there was no statistically sig- nificant relationship between the ingested body and the observed complications (P>0.05) (Table 6). Article Table 1. The distribution of foreign body frequency by type. Type Frequency Percent Battery 1 0.5 Metal object 7 3.19 Denture 9 4.1 Coin 15 6.8 Unknown object 31 14.15 Fish bone 46 21 Meat bone 49 22.83 Chicken bone 61 28.31 Total 219 100 Table 2. The distribution of foreign body complaints. Type Frequency Percent Dysphagia 129 58.9 Odynophagia 121 55.2 Throat foreign body feeling 81 36.9 Vomiting 57 26 Respiratory distress 23 10.5 Retrosternal chest pain 22 10.4 Drooling 12 5.4 Tenderness at the touch of the neck 7 3.19 Table 3. Distribution of cases using lateral neck and observation in operating room. Lateral FB Operation room FB observation Total No Yes Yes 1 197 198 No 8 13 21 Total 9 210 219 Figure 1. Axial CT scan image of patient with submucosal bone foreign body in retropharyngeal space: During rigid endoscopic evaluation in operation room we did not find foreign body prob- ably due to deep submucusal location. [page 32] [Emergency Care Journal 2020; 16:8726] Non -co mmerc ial us e o nly [Emergency Care Journal 2020; 16:8726] [page 33] Discussion In the present study, the paraclinical methods in diagnosis of foreign body and its complications compared to operating room findings in patients with oral, pharyngeal and esophageal symp- toms were evaluated. Swallowed disk battery was the least com- mon cause of foreign body. Regarding symptoms, the highest fre- quency of foreign body complaints was dysphagia in about 60% of the patients and the lowest was tenderness of the neck in 3 % of the patients. Approximately 93 % of diagnosed cases with lateral neck was observed in the operating room with 50.5 kappa agreement. Regarding complications, there were two perforations and 14 abscesses, and high white blood cell count and drooling were sig- nificantly higher in patients with complications. In a study by Sharafi et al., the most common complaint of for- eign body ingestion was dysphagia and the most common cause of Article Table 4. The mean heart rate, body temperature, length of hospitalization, drooling and WBC in the two groups of patients with/with- out complications. Complication N Mean SD t P value Temperature No 203 36.97 0.324 -1.656 0.118 Yes 16 37.26 0.713 Heart Rate No 203 86.42 3.95 -0.947 0.345 Yes 16 87.38 2.91 Blood Pressure No 203 1.01 0.09 0.397 0.692 Yes 16 1.00 0.00 Time of Hospitalization No 203 1.87 0.70 -0.721 0.471 Yes 16 2.00 0.73 White blood cell No 203 6204.93 1772.47 -2.923 0.010 Yes 16 9556.25 4558.79 Drooling No 203 1.08 0.27 -1.465 0.162 Yes 16 1.25 0.44 Figure 2. Axial CT scan image of patient with severe odynophagia which occurrd after garlic ingestion: During rigid endoscopic evaluation we did not find foreign body probably due to move- ment of object toward stomach because of decreasing upper esophageal sphincter tone by anesthetic paralyzing agent. Table 5. Compatibility of CT scans with intraoperative findings in the diagnosis of foreign body complications. Variable Operation room complication P value Perforation Abscess No CT No 0 0 39 <0.001 Complication Perforation 2 0 0 Cervical abscess 0 9 0 Total 2 9 39 Table 6. Type of foreign body by operating room complication. Type of Foreign Body Operating room complication Total No Abscess Perforation Fish 32 4 0 36 Chicken 59 3 1 63 Meat 32 3 0 35 Teeth 8 1 0 9 Coin 15 0 0 15 Battery 1 0 0 1 Seed 1 0 0 1 Metal 6 0 1 7 Other 49 3 0 52 Total 203 14 2 219 Non -co mmerc ial us e o nly [page 34] [Emergency Care Journal 2020; 16:8726] foreign body was chicken bone. In the under 15 years age group, the most common foreign body was coin as in our study. Also, the complications of foreign body swallowing were erosion, ulcer, mucosal rupture, re-admission, esophageal rupture and abscess, respectively.16 According to the endoscopic results, the most com- mon location of the foreign body was found in the upper third of the esophagus. The results of this study were in consistent with our study and study of Karimaneh and Najafi, that is, the most com- mon cause of foreign body was chicken bone. Like our study, coin was responsible to the most common cause of foreign body in chil- dren.17 In a study by Pirzadeh et al., the most common and the least common cause of foreign body was chicken bone and coin, respec- tively, in such a way that was consistent with our results.18 Regarding the diagnostic method, 41.4% were diagnosed with sim- ple radiography and the rest were diagnosed with endoscopy and only one case of swallow wing was diagnostic with barium.16 It should be noted that a higher diagnosis with lateral X-ray may be due to the use of digital radiography that gives the operator con- trast shift ability and may also be due to the higher experience of radiologists at the center. In a study by Karimaneh and Najafi, 84% could be diagnosed by radiographic evaluation.17 Our study showed that of 198 cases, 185 cases were diagnosed by lateral X ray radiologic observation, which it was appropriate method. Pourrashidi et al., revealed that half of patients with foreign body diagnosed with X-rays. Ultrasound results were positive in 96.4% of cases. The correlation coefficient of radiographic results with sonography was significant in patients with foreign body complaints and had good agreement coefficient of 0.896. The high coefficient of correlation between the results of ultrasound and radiography indicates that these imag- ing systems can be used interchangeably depending on the patient’s condition and the patient’s history. In fact, kappa coeffi- cient in this study was higher than our study. The reason of this dif- ference can be close methods of sonography and chest-x ray because both was based on radiography not observation. In our study, no association was found between the time of swallowing and the complications. While in the study of Sung et al.,19 this rela- tionship was observed. Also, in our study, the most common cause of abscess was related to fish bone, but it was not statistically sig- nificant, which could be due to lower sample size. Sung et al. revealed that the risk of complications can be increased with a longer duration of impaction, large bone and its type. In our study, high WHC was associated with high compilations, but high WBC did not necessarily indicate an abscess. In clinical traumas that were severe, we had an increase in WHC independent of infectious complications. Therefore, high WBC can indicate a complica- tion.20 Another clinical point is this that CT scans shows very well the complications and it is recommended for people with drooling or high WBC. Conclusions According to the results, foreign bodies diagnosed with lateral neck can be reliable to take a decision based on it in patients with foreign bodies. The CT scan have a valuable role for diagnosis of complications in foreign body ingestion scenarios. Leukocytosis may be a sign of esophageal injury. In the end, we suggest per- forming further study in this regard comparative study with large sample is needed to conclude crucial results. References 1. Guirgis M, Nguyen R, Pokorny C. Accidental ingestion of plastic from takeaway containers-food for thought. Med J Aust 201;194: 245-6. 2. Okhakhu AL, Ogisi FO. An unusual foreign body in human oesophagus – case report. Benin J Postgr Med 2007;9:41-3. 3. Baraka A, Bikhazi G. Oesophageal foreign bodies. Br Med J 1975;1:561-3. 4. Baral BK, Joshi RR, Bhattarai BK, Sewal RB. Removal of coin from upper esophageal tract in children with Magill’s forceps under propofol sedation. Nepal Med Coll J 2010;12:38-41. 5. 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