Visual Dx

A two-year-old presents at a clinic with persistent cough and neck discomfort and winds up in the ED and eventually the operating room for endoscopic evaluation. Find out the culprit and the best practices to manage the diagnosis.

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Figure 1a: PA chest radiograph demonstrating the double-ring sign

A 23-month-old female presented to a clinic with persistent cough and neck discomfort for more than one month. Additionally, she had difficulty swallowing solid foods but no trouble with liquids. 

She was seen by her primary care provider over one month prior for the same symptoms. She was then started on albuterol and a five-day course of steroids, presumably for clinical suspicion of asthma. During a follow-up visit with the primary care provider, the patient’s symptoms remained unchanged, so she was given another course of steroids and had an outpatient chest x-ray. After review of the chest x-ray (figures 1a,b) the patient was immediately sent to the emergency department. 

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Figure 1b: Lateral neck radiograph demonstrating step-off between anode and cathode

In the emergency department, examination of the child revealed no acute distress, a pulse of 105, temperature of 97.7, respiratory rate of 24 with pulse oximetry of 97% on room air and a weight of 12.7 kg. Tympanic membranes were clear; oropharynx was clear without plaques or exudates; and the posterior oropharynx was symmetric. The neck was without nuchal rigidity but mild stridor was noted. No palpable masses or anterior cervical lymphadenopathy was appreciated. There was no murmur, rub or gallop. Pulmonary exam demonstrated diffuse rhonchi. Abdomen was soft, non-tender without distention. The skin was without rash, erythema, ecchymosis or wounds. 

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Figure 2: Esophageal tissue necrosis (black arrow) and granulation tissue (white arrow) post battery extraction (A: anterior; P: posterior)

ENT was consulted emergently and elected to take the patient directly to the operating room for endoscopic evaluation and removal of the foreign body. Visualization of the esophageal mucosa demonstrated surrounding granulation tissue and necrosis (figures 4 and 5). Repeat endoscopy on post procedural day three demonstrated esophageal stenosis. The patient was tolerating oral food and fluids and discharged home with plans to perform repeat endoscopy in two weeks. She was subsequently lost to follow up.

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Figure 4: White arrow normal esophageal inlet; black arrow: granulation tissue; A: anterior pharyngeal wall; P: posterior pharyngeal wall

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Figure 5: Extensive esophageal necrosis (white arrow); button battery (black arrow).



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