An Open Safety Pin in an 8-month-old Child: A Rare Delayed and Unusual Presentation of This Dangerous Foreign Body

DISCUSSION

FB ingestion and FB aspiration commonly affect young children between 6 months and 6 years.^1,2 A large number of these events remain unwitnessed and asymptomatic, while the swallowed FB traverses the gastrointestinal tract and is passed in the stool.⁴ However, sharp FBs like open SP pose a unique challenge in that they are rarely passed spontaneously. SPs are ubiquitously used worldwide and pose a challenge especially when an open SP is ingested by children.⁵ The sharp end of the SP can penetrate through the esophageal or tracheal luminal wall and can lead to mediastinitis. Rare complications of the sharp end of the pin penetrating the esophageal luminal wall and then causing fatal carotid injury has also been described.⁶

In most cases, the child often presents with symptoms soon after ingestion and the symptoms can vary from dysphagia, excessive salivation, chest pain to breathing difficulty, and pneumonia.⁷ The child in our case reported unusual presentation as the patient was asymptomatic for 8 weeks since the probable ingestion except for regular neck deviation to the right. As the neck deviation in the child was ignored by the parents due to lack of other serious symptoms, this led to delay in diagnosis. When the child developed dry cough and neck spasms, 8 weeks later which was not responding to antibiotics a chest X-ray ordered to rule out infections revealed the open SP with the sharp end acutely angulated to the left. This probably explains why the child regularly deviated her head to the right as the penetrated sharp end probably resulted in pain on flexion to the left. Flexible endoscopy is often the preferred method to remove an open SP.⁸ In our case, we initially attempted to remove the FB first through flexible endoscopy and later through rigid esophagoscopy and both these attempts were unsuccessful since the sharp end tip was not visible as it was embedded in the mucosa. Extreme mobilization of the FB without visualization of the tip was deemed unsafe, and hence, open neck exploration and esophagostomy were done. The neck was opened on the left side with 3-cm horizontal incision at the anterior end of the sternocleidomastoid muscle. Dissection was done between the carotid sheet and the thyroid with the anterior elevation of the thyroid gland to expose the esophagus. Before making a 2-cm esophagostomy in the lateral wall of the esophagus, the recurrent laryngeal nerve was identified and the position of the SP was confirmed on fluoroscopy again. The SP was visualized inside the lumen of the upper cervical esophagus with areas of mucosal ulceration and granulation tissue surrounds the SP. The sharp end of the pin was embedded inside the luminal muscular layer (Fig. 3). It was carefully mobilized inferiorly grasping the nonsharp upper end of the pin and taken out of the lumen (Fig. 4). The wound was closed in layers with a drain. Child was kept on Ryle’s tube feeding for a week, and barium swallow on day 7 demonstrated no leak. The child was then put on oral diet and is doing fine for the past 2 months with neck posture being normal since then.

This case emphasizes that even a sharp FB like an open SP can be asymptomatic for a while before presenting with symptoms that arise suspicion. Since FBs are common in children aged 6 months and above, atypical symptoms without any obvious diagnosis should arise the suspicion of an occult FB. Chronic FBs can penetrate the luminal wall of the esophagus resulting in granulation tissue, and this further leads to fixation of the FB making it extremely difficult to remove endoscopically. We feel that endoscopic removal of an open SP should be abandoned if the sharp tip is embedded the luminal wall and is not visible endoscopically. Open esophagostomy with extraction of the FB even in small children is safe though it carries more perioperative morbidity than endoscopic removal.