Throat Pain
Article Outline
An 85-year-old woman presented, complaining of pain and foreign body sensation at the throat immediately after taking her medicines about 40 minutes before arrival. The patient's medical history was significant for dementia only. Her vital signs were normal. On physical examination, the oropharynx appeared normal. A soft tissue neck plain radiograph was obtained, which revealed a radiopaque density (arrow) over prevertebral region at the C6-7 level, suggestive of a swallowed foreign body retained in the cervical esophagus (Figure 1). Subsequent emergency upper gastrointestinal endoscopy was performed (Figure 2).
Figure 1.
Neck soft tissue lateral view, demonstrating foreign body retained in the cervical esophagus.
Figure 2.
Endoscopic examination. Used with permission of Chung-Pang Wang, MD, Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan.
Diagnosis
Press-through package mis-swallowing. The press-through package measured about 1.8×1.5 cm, containing a tablet lodged in the esophagus, and was removed in an uncomplicated fashion endoscopically. The patient was doing well at outpatient follow-up.
The press-through package, which consists of a polyvinylchloride/aluminium blister-wrapped pack, is commonly used to protect freeze-dried tablets from moisture exposure. Accidental ingestion of a press-through package has been seen increasingly in cases of gastrointestinal tract foreign body in the emergency department. The press-through package is usually prepared for use by cutting single-tablet allotments from the blister packs. Small press-through package pieces are square, often with sharp corners. They can become lodged in the gastrointestinal tract and pose a risk for bowel perforation when inadvertently swallowed. Intestinal or esophageal perforation by blister-wrapped tablet has previously been reported.1, 2, 3 Press-through package ingestion is frequently seen in older patients, among the mentally impaired, or in patients with visual impairment.2, 3 Obstructive ileus caused by a press-through package is a rare occurrence.4 A case series from the Japanese literature reported 28 cases of perforation of the small intestine by a blister-wrapped tablet in the press-through package. Most of these patients with perforation were elderly (mean age 77 years).5
The press-through package material is often difficult to detect on plain radiograph directly because of its radiolucency. However, air trapped in the press-through package makes the drug tablet visible on the plain radiograph.
References
- Intestinal perforation after ingestion of a blister-wrapped tablet. Lancet. 1995;346:1308
- . Intestinal perforation after ingestion of a blister-wrapped tablet. Lancet. 1996;347:128–129
- Esophageal perforation caused by a press through pack. Dis Esophagus. 2003;16:169–172
- Obstructive ileus caused by a swallowed foreign body (a “press-through” package) and preexisting adhesions. Am J Emerg Med. 1997;15:52–53
- Peritonitis due to perforation of the small intestine by a press-through-package. Jpn J Gastroenterol Surg. 2002;35:317–321
For the diagnosis and teaching points, see page 115.
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PII: S0196-0644(07)01784-2
doi:10.1016/j.annemergmed.2007.11.017
© 2008 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
