1. Pediatric Case Conference R2 李軒慶 95/06/27 95/06/27

2. Patient ’ s Profile 5 year-old boy BW: 16.8 kg 5 year-old boy BW: 16.8 kg Chart Number: 3489277 Chart Number: 3489277 T/P/R: 37.1/142/25 BP:? E4V5M6 T/P/R: 37.1/142/25 BP:? E4V5M6 檢傷主訴 : 異物卡在喉嚨 檢傷主訴 : 異物卡在喉嚨 Time of arrival: 95/6/8 11:28 Time of arrival: 95/6/8 11:28 Past History: Nothing significant Past History: Nothing significant

3. Symptoms Mis-swallowing of chicken bone while eating 鹽酥雞 three days ago (6/5) Mis-swallowing of chicken bone while eating 鹽酥雞 three days ago (6/5) Vomiting for 5 times Vomiting for 5 times Neck pain aggravated with extension Neck pain aggravated with extension Dysphasia Dysphasia Not able to eat for 3 days Not able to eat for 3 days No fever No fever Neck lat. View was done in OPD this morning Neck lat. View was done in OPD this morning

4. Physical Examination General appearance: alert General appearance: alert Neck: tender(+) over anterior and bilateral neck area ; no stridor Neck: tender(+) over anterior and bilateral neck area ; no stridor Conjunctiva: not pale Conjunctiva: not pale Sclera: not icteric Sclera: not icteric Heart: regular heart beat without murmur Heart: regular heart beat without murmur Breath sound: clear Breath sound: clear Abdomen: soft and flat; no tenderness Abdomen: soft and flat; no tenderness

5. Initial Impression Foreign body mis-swallowing Foreign body mis-swallowing

6. Initial Order (95/6/8 11:40) Consult ENT Consult ENT

8. Image Report Linear high density at pre-vertebral region of C6-7 level, r/o esophageal foreign body, r/o perforation with adjacent inflammation Linear high density at pre-vertebral region of C6-7 level, r/o esophageal foreign body, r/o perforation with adjacent inflammation

9. ENT Consult Sheet Esophagoscopy is indicated to remove the foreign body Esophagoscopy is indicated to remove the foreign body Pre-OP preparation Pre-OP preparation

10. Laboratory Data WBC: 22100 /μL Hb: 11.1 g/dL Seg: 84.5% Platelet: 496 K/μL Band: 1.5% PT: 12.7/10.9 APTT: 42.8/28.9 APTT: 42.8/28.9 BUN: 8 mg/dL Creatinine: 0.4 mg/dL Na: 133 meq/L K: 3.3 meq/L

11. Rigid Esophagoscopy (6/8 14:15) A chicken bone plate about 2.5 x 1.8 cm was removed smoothly without obvious esophagus laceration lesion; mucosa erosion was seen A chicken bone plate about 2.5 x 1.8 cm was removed smoothly without obvious esophagus laceration lesion; mucosa erosion was seen

12. The Following Hospitalization Course NPO with NG tube decompression for 1 day after the surgery NPO with NG tube decompression for 1 day after the surgery Start oral feeding 2 days after the surgery Start oral feeding 2 days after the surgery Esophagography (6/12): No leakage Esophagography (6/12): No leakage Antibiotic treatment with Aq-PCN Antibiotic treatment with Aq-PCN Discharge on 6/14 Discharge on 6/14

13. Discussion

14. Foreign Body Ingestion in Children Anything could be the ingested foreign body Anything could be the ingested foreign body Most common objects: coin (49%) Most common objects: coin (49%) nonmetallic sharp objects (31%) nonmetallic sharp objects (31%) 3 physiological narrowing of esophagus: 3 physiological narrowing of esophagus: Cricopharyngeus muscle (upper esophageal sphincter) Cricopharyngeus muscle (upper esophageal sphincter) Level of aortic arch Level of aortic arch Lower esophageal sphincter Lower esophageal sphincter Higher risk for obstruction if there ’ s past history of previous gastrointestinal tract surgery or congenital malformation Higher risk for obstruction if there ’ s past history of previous gastrointestinal tract surgery or congenital malformation Foreign-body ingestion in children: experience with 1265 cases. J Pediatr Surg 1999 Oct; 34(10):1472-6 Perforation of the intestine by ingested foreign bodies. JAMA 1941; 53:393 Small bowel obstruction and the Garren-Edwards gastric bubble: an iatrogenic bezoar. Gastrointest Endosc 1988 Nov-Dec; 34(6):463-7

15. Clinical Manifestation Asymptomatic – most often Asymptomatic – most often Dysphagia Dysphagia Odynophagia Odynophagia Drooling Drooling Refusal of feeding Refusal of feeding Respiratory symtoms (stridor, wheezing, respiratory distress) Respiratory symtoms (stridor, wheezing, respiratory distress)

16. Diagnosis Physical examination: Physical examination: 1. Crepitus over neck  esophageal perforation 1. Crepitus over neck  esophageal perforation 2. Inspiratory stridor or expiratory wheezing 2. Inspiratory stridor or expiratory wheezing Radiographic examination: Radiographic examination: For localization and identification and detection of complication For localization and identification and detection of complication Endoscopy: Endoscopy: Suggested despite negative radiographic result, if symptoms are severe Suggested despite negative radiographic result, if symptoms are severe Management of ingested foreign objects and food bolus impactions. Gastrointest Endosc 1995 Jan;41(1):33-8

17. Management Observation for up to 24 hours in asymptomatic cases Observation for up to 24 hours in asymptomatic cases Retaining in the esophagus for more than 24 hours is not allowed Retaining in the esophagus for more than 24 hours is not allowed If duration unknown  Endoscopy If duration unknown  Endoscopy Surgical consultation Surgical consultation Management of foreign bodies of the upper gastrointestinal tract: update. Gastrointest Endosc 1995 Jan;41(1):39-51 Management of ingested foreign bodies in childhood: our experience and review of the literature. Eur J Emerg Med 1998 Sep; 5(3):319-23 Occult liver abcess following clinically unsuspected ingestion of foreign bodies. Can J Gastroenterol 1997 Jul-Aug; 11(5):445-8

18. Indications of Urgent Intervention Sharp object or disk battery lodged in the esophagus Sharp object or disk battery lodged in the esophagus Airway compromise Airway compromise Nearly complete obstruction Nearly complete obstruction

19. Retropharyngeal Abscess in Children Most commonly: 2~4 year-old Most commonly: 2~4 year-old As a predominant focus of infection in young children As a predominant focus of infection in young children Related to the anatomical change: Related to the anatomical change: 1. Two chains of lymph nodes draining the nasopharynx, adenoids, posterior paranasal sinuses, middle ear and Eustachian tube 1. Two chains of lymph nodes draining the nasopharynx, adenoids, posterior paranasal sinuses, middle ear and Eustachian tube 2. Atrophy at puberty of the above structure 2. Atrophy at puberty of the above structure Retropharyngeal abscess in children: clinical presentation, utility of image, and current management. Pediatrics 2003 Jun;111(6 pt 1):1394-8 Retropharyngeal abscess in children. ANZ J Surg 2002 Jun; 72(6):417-20

20. Symptom/Sign Dysphagia/Odynophagia Dysphagia/Odynophagia Drooling Drooling Respiratory distress/Stridor Respiratory distress/Stridor Unwillingness to move the neck Unwillingness to move the neck Trismus Trismus Midline or unilateral swelling of the post. Pharyngeal wall Midline or unilateral swelling of the post. Pharyngeal wall

21. Image Neck lateral view (Neck extension while inspiration) Neck lateral view (Neck extension while inspiration) Thickening of the prevertebral space  7mm (C2) Thickening of the prevertebral space  7mm (C2) 14mm (C6) 14mm (C6) CT  “ complete rim enhancement ” CT  “ complete rim enhancement ”  the differential finding between cellulitis and abscess  the differential finding between cellulitis and abscess Head and neck space infections in infants and children. Otolaryngol Head Neck Sug 1995 Mar;112(3):375-82 Accuracy of computerized tomography in deep neck infections in the pediatric population. Am J Otolaryngol 2003 May-Jun;24(3):143-8

22. Microbiology & Management Most common pathogen: Most common pathogen: Streptococcus (Group A) Streptococcus (Group A) Staphylococcus aureus Staphylococcus aureus Respiratory anaerobes Respiratory anaerobes Suggested antibiotic treatment: Suggested antibiotic treatment: 1. Initial: 1. Initial: Unasyn (50mg/kg per dose IV Q6H) Unasyn (50mg/kg per dose IV Q6H) Clindamycin (13mg/kg per dose IV Q8H) Clindamycin (13mg/kg per dose IV Q8H) 2. Maintaining IV form until afebrile : 2. Maintaining IV form until afebrile : Augmentin (45mg/kg per dose PO Q12H) Augmentin (45mg/kg per dose PO Q12H) Clindamycin (13mg/kg per dose PO Q8H) Clindamycin (13mg/kg per dose PO Q8H) Surgery: If antibiotic treatment fails Surgery: If antibiotic treatment fails