Double coin ingestion in a child: a rare occurrence

INTRODUCTION

Swallowing foreign objects is a common occurrence, particularly among children, frequently leading to cases in emergency departments. While this can happen at any age, it is more prevalent in young children between six months and five years, driven by their natural inclination to explore their surroundings by putting objects into their mouths. Coins rank as the most common swallowed foreign bodies, often lodging in the upper oesophagus.^1,2

Children with lodged coins in the upper oesophageal region typically exhibit symptoms like drooling, dysphagia, pain, or a sensation of a foreign body. Interestingly, a minority may remain asymptomatic, posing a risk of complications if left unidentified.³ Radiographic imaging, particularly X-rays, is essential to confirm the presence of an ingested object. This not only aids in identification but also helps rule out more serious concerns like the ingestion of button batteries, a potentially life-threatening situation.⁴

This report highlights a rare case involving a three-year-old child with an oesophageal foreign body. The X-ray findings were intriguing, suggesting the ingestion of a button battery. However, urgent esophagoscopy revealed an unexpected twist-a perfectly aligned pair of coins in the same location, positioned opposite each other. This case underscores the importance of thorough examination and the potential for unexpected findings in the assessment and management of oesophageal foreign bodies, emphasizing the need for careful and precise diagnostic approaches in such situations.

CASE REPORT

We report a case of a 3-year-old male child who presented to the ENT emergency with chief complaints of vomiting and decreased oral acceptance. There was no history of respiratory distress. As per patient’s father child was apparently alright and playing at home. Then suddenly she started vomiting and was quite frightened with pale look. She had three episodes of vomiting further which consisted of food particles mainly. On further enquiry and assurance to patient she revealed that she kept coins in her mouth while playing. She also complained of foreign body sensation, and she hid the truth due to fear of scolding. The patient presented in ENT emergency for diagnosis and management. On careful examination, there was no abnormality in mouth and throat. Respiratory rate was normal. On auscultation air entry was bilaterally equal with no signs of cyanosis or adventitious sound. The radiograph of neck and chest in anteroposterior view revealed the disc shaped circular foreign body as suspected. But to our surprise the soft tissue radiograph of neck lateral view revealed foreign bodies which appeared to be double and superimposed because of irregularity of border of coin (Figure 1).

Later under general anesthesia rigid esophagoscope was inserted and foreign body coin was visible. The foreign body was held with forceps and then both coins removed carefully avoiding damage to surrounding structures. No intra-operative complications were seen. As suspected from radiographs two coins i.e., one rupee and two-rupee coins stick with mucus were retrieved (Figure 2). The esophagus was inspected again. The patient was then kept under observation under antibiotic and analgesic cover. Postoperative event was uneventful. The patient was stable and discharged with adequate medical advice.

DISCUSSION

Foreign bodies lodged in the throat often escalate into medical emergencies, potentially requiring surgical intervention. Among children, coins are the most commonly ingested foreign objects, constituting up to 60% of such cases. Typically, coins get stuck in the upper oesophagus near the cricopharynx, and prompt removal within 24-48 hours is advisable.⁵ However, the ingestion of multiple coins is a rare occurrence, adding complexity to the situation.

Clinical studies recommend two radiological views for assessing oesophageal foreign bodies: anteroposterior and lateral view soft tissue neck radiographs. In cases where foreign bodies remain unremoved, the risk of infection or perforation increases. Notably, these objects may adhere to each other, making it challenging for double-dimensional projections to indicate their presence. Therefore, a comprehensive history and meticulous evaluation of both anteroposterior and lateral X-ray views are crucial for diagnosis.^6,7

In a unique case presented here, two coins appeared as a circular disc overlapping in the anteroposterior view, making it difficult to differentiate them. Even on the lateral view, the distinction of a double thick line, indicative of two coins, was challenging. Distinguishing between the potentially harmful button battery and the comparatively less threatening double coins becomes challenging. Our recommendation is that urgent endoscopy should be the preferred approach in such cases to eliminate the possibility of an impacted button battery. Nevertheless, when dealing with lodged coins in the upper oesophagus, prompt removal is crucial and should be undertaken as an emergency measure, typically within a 24-hour window. This urgency is essential to prevent complications such as oesophageal constriction or erosion of the mediastinum.⁸

CONCLUSION

Otolaryngologists play a crucial role in managing emergency cases involving lodged foreign bodies, particularly within their daily practice. The nature of the lodged item, especially in paediatric cases, demands heightened attention, as obtaining a clear history from parents or caregivers can be challenging. The rarity of certain cases, such as the alignment of two coins in the oesophagus, highlights the diagnostic challenges, especially when a detailed history is lacking. This underscores the significance of meticulous evaluation and heightened awareness of potential complications associated with oesophageal foreign bodies.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Dereci S, Koca T, Serdaroğlu F, Akçam M. Foreign body ingestion in children. Turk Pediatri Ars. 2015;50(4):234-40.
2. 2. Conners GP. Management of asymptomatic coin ingestion. Pediatrics. 2005;116(3):752-3.
3. 3. Upadhyaya EV, Srivastava P, Upadhyaya VD. Double coin in esophagus at same location and same alignment-a rare occurrence: a case report. Cases J. 2009;2(1):7758.
4. 4. Kramer RE, Lerner DG, Lin T, Michael M, Manoj S, Thomas CS et al. Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. J Pediatr Gastroenterol Nutr. 2015;60(4):562-74.
5. 5. Amin MR, Buchinsky FJ, Gaughan JP, Szeremeta W. Predicting outcome in pediatric coin ingestion. Int J Pediatr Otorhinolaryngol. 2001;59(3):201-6.
6. 6. McGahren ED. Esophageal foreign bodies. Pediatrics Rev. 1999; 20(4):129-33.
7. 7. Mahafza TM. Extracting coins from the upper end of the esophagus using a Magill forceps technique. Int J Pediatr Otorhinolaryngol. 2002;62(1):37-9.
8. 8. Thomson M, Tringali A, Dumonceau JM, Marta T, Merit MT, Raoul F et al. Paediatric Gastrointestinal Endoscopy: European Society for Paediatric Gastroenterology Hepatology and Nutrition and European Society of Gastrointestinal Endoscopy Guidelines. J Pediatr Gastroenterol Nutr. 2017;64(1):133-53.