Does a 13-year-old who swallowed a quarter require a neck x-ray?

Management of Quarter Ingestion in a 13-Year-Old

A 13-year-old who has swallowed a quarter does not require a neck X-ray if they are asymptomatic and able to swallow normally, as the coin has likely passed into the stomach. Instead, an abdominal X-ray should be obtained to confirm the location of the quarter.

Assessment Algorithm for Coin Ingestion

Initial Evaluation

• Determine presence of symptoms:
  • Dysphagia (difficulty swallowing)
  • Odynophagia (painful swallowing)
  • Drooling
  • Inability to swallow saliva
  • Respiratory symptoms (choking, stridor, dyspnea)
  • Neck pain or tenderness

Imaging Decision Tree

1. If symptomatic (especially with dysphagia, drooling, or respiratory symptoms):

   • Obtain biplanar radiography (AP and lateral) of neck, chest, and abdomen to locate the coin 1
   • CT scan if perforation is suspected or plain films are negative but symptoms persist 1

2. If asymptomatic:

   • Obtain abdominal X-ray to confirm the coin has passed the esophagus 1
   • No neck X-ray is necessary if the patient can swallow normally and has no respiratory symptoms

Rationale and Evidence

Coin ingestion is one of the most common foreign body ingestions in children, accounting for approximately 13% of all choking episodes 1. However, the management approach differs significantly based on the patient's age and symptoms.

At 13 years old, the patient is beyond the high-risk age group for complications from coin ingestion. The Centers for Disease Control and Prevention data shows that choking rates decrease consistently with increasing age, with the highest risk being in infants and children under 3 years 1.

Coins that pass through the esophagus into the stomach typically continue through the gastrointestinal tract without complications 1. According to the World Journal of Emergency Surgery guidelines, approximately 80-90% of ingested foreign bodies pass spontaneously through the gastrointestinal tract 1.

Management Based on Coin Location

• If coin is in esophagus (confirmed by imaging):

  • Endoscopic removal is recommended, especially if the patient is symptomatic 1
  • Timing of removal depends on symptoms and location within the esophagus

• If coin is in stomach or beyond:

  • Conservative management with monitoring for passage in stool
  • Follow-up X-ray in 1-2 weeks if the coin is not observed in stool
  • Surgical intervention is rarely needed unless complications develop 2

Important Considerations

• Unlike button batteries, which require urgent removal due to risk of pressure necrosis and chemical burns 3, coins are generally less dangerous
• Quarters are large enough to be easily tracked radiographically but small enough to pass through the GI tract in most teenagers
• If the patient develops new symptoms after initial assessment, immediate reevaluation is warranted

Common Pitfalls to Avoid

• Assuming all foreign body ingestions require the same management approach
• Failing to distinguish between high-risk objects (button batteries, sharp objects, magnets) and lower-risk objects like coins
• Unnecessary radiation exposure from multiple X-rays when clinical assessment suggests the coin has passed the esophagus
• Delaying endoscopic intervention when a patient is symptomatic with an esophageal foreign body

In conclusion, while foreign body ingestion requires careful assessment, a 13-year-old with an asymptomatic quarter ingestion can be managed with an abdominal X-ray to confirm passage beyond the esophagus, followed by conservative management and monitoring.