What is the treatment for a 23-month-old child with a coin (foreign body) lodged in their esophagus?

Management of Esophageal Coin in a 23-Month-Old Child

A coin lodged in the esophagus of a 23-month-old requires urgent flexible endoscopic removal within 24 hours if the child is asymptomatic, or emergent removal within 2-6 hours if symptomatic (drooling, respiratory distress, inability to swallow, or pain). 1, 2, 3

Immediate Assessment and Diagnostic Workup

• Obtain biplanar radiographs (AP and lateral views) to confirm the coin's presence, distinguish esophageal from tracheal location, and identify the exact anatomical level of impaction 2
• At 23 months of age, this child falls within the highest-risk group, as children aged 3 years or younger account for 77.1% of choking episodes 2, 3
• Common impaction sites in young children include the upper esophageal sphincter (cricopharyngeus muscle) and the thoracic esophagus at the aortic arch level 2, 3
• Do NOT perform contrast swallow studies as they increase aspiration risk and impair subsequent endoscopic visualization 1

Clinical Decision Algorithm

If the Child is Symptomatic (drooling, respiratory distress, stridor, inability to swallow, pain):

• Arrange emergent flexible endoscopy within 2-6 hours 1, 2, 3, 4
• This represents complete or near-complete obstruction requiring immediate intervention to prevent aspiration and perforation 1, 3

If the Child is Asymptomatic:

• Arrange urgent flexible endoscopy within 24 hours 1, 3, 4
• While some evidence suggests observation for 8-16 hours may allow spontaneous passage in 25-30% of cases 5, this applies primarily to distal esophageal coins 6
• Proximal and middle esophageal coins should be promptly removed as they rarely pass spontaneously 6
• The observation approach increases hospital length of stay (19.4 vs 10.7 hours) without reducing the overall need for endoscopy in most cases 5

Endoscopic Approach

• Flexible endoscopy is the first-line approach for most esophageal foreign bodies 7, 1, 3
• Rigid endoscopy should be considered as second-line if flexible endoscopy fails, particularly for coins in the upper esophagus 7, 1, 2
• During endoscopy, first attempt gentle pushing of the coin into the stomach using air insufflation and instrumental pushing 1
• If pushing fails, use retrieval techniques with baskets, snares, or grasping forceps 1
• Obtain diagnostic biopsies during the index endoscopy to assess for underlying esophageal disorders, which are found in up to 25% of pediatric patients with foreign body impaction 7, 1

Post-Procedure Monitoring

• Keep the patient nil by mouth if there are concerns about laryngeal competence 1
• Monitor for warning signs of complications including stridor, obstructed breathing, agitation, fever, and deep cervical or chest pain 1
• Watch for signs of mediastinitis (severe sore throat, deep cervical pain, chest pain, dysphagia, fever, crepitus), which can occur after esophageal perforation 1

Important Caveats

• Coins measuring 23.45-26.00 mm in diameter are most commonly retained in the esophagus and account for 73% of cases 8
• The smaller esophageal diameter in a 23-month-old makes impaction more likely and increases complication risk compared to older children 3
• Prolonged retention leads to pressure necrosis, perforation, and mediastinitis 2, 3
• Surgical intervention is required in only 1-3% of cases for complications such as irretrievable foreign body, perforation, or mediastinitis 7