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Monopoly Airplane Lands in Esophagus Leading to Difficult Extraction: A Case Report on Anesthesia and Surgical Considerations

Matava, Clyde T. MD, MBChB, MMed*; Echaniz, Gaston MD*; Parkes, William MD; Papsin, Blake C. MD, MSc, FRCSC; Propst, Evan J. MD, MSc, FRCSC; Cushing, Sharon L. MD, MSc, FRCSC

doi: 10.1213/XAA.0000000000000562
Case Reports: Case Report
Open
SDC

A 2-year-old child presented with an airplane game piece from the board game Monopoly lodged in her esophagus. The airplane’s wings, engines, and winglets acted like fish hooks that entered the esophageal mucosa easily but were difficult to extract. Chest radiographs were used to estimate the airplane wingspan dimensions, and a Foley catheter was used to dilate the esophagus to allow foreign body extraction via rigid esophagoscopy with optical forceps. Deliberate deep placement of the endotracheal tube facilitated surgical manipulation. This case report highlights the importance of teamwork, communication, and the involvement of multiple disciplines, each with their unique experience and expertise, to formulate a plan of action for patients during unique surgical emergencies.

From the Departments of *Anesthesia and Pain Medicine and Otolaryngology-Head & Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.

Accepted for publication March 24, 2017.

Funding: None.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.cases-anesthesia-analgesia.org).

Address correspondence to Clyde T. Matava, MD, MBChB, MMed, Department of Anesthesia and Pain Medicine, Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada. Address e-mail to clyde.matava@sickkids.ca.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Foreign body (FB) injury is a severe public health problem in childhood, with a highest prevalence between 0 and 3 years of age. Due to their nonspecific clinical presentation and commonly, delayed recognition, FB injuries can lead to morbidity and mortality. Choking is one of the main causes of death in this age group. The objects most frequently swallowed by children are radiopaque coins, screws, batteries, or toy parts. Esophageal foreign bodies of various shapes and sizes can be extremely difficult to extract. Management of a new object may require a novel method of extraction.

Parental written permission was provided for publication of this report.

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CASE DESCRIPTION

Figure 1.

Figure 1.

A healthy 2-year-old girl (15 kg) presented to the emergency department after swallowing an airplane game piece from the board game Monopoly (Hasbro, Pawtucket, RI). The parent witnessed the child playing with the airplane before bedtime and subsequently found her choking and gagging in her crib. The parent immediately performed the children’s Heimlich maneuver, which relieved the obstruction and allowed the child to breathe and talk. The child presented to the emergency department with normal vital signs and no respiratory distress. Serial chest radiographs revealed the airplane game piece lodged in the upper esophagus (Figure 1). Otolaryngologists-Head & Neck Surgeons (ORL-HNS) were consulted for its extraction. Intravenous (iv) access was obtained in the emergency department, and fasting was commenced overnight for 12 hours before surgery. The patient was maintained on 40 mL/h of 5% dextrose in normal saline delivered through a 24-gauge iv cannula.

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Anesthetic Management

Physical examination revealed a somewhat upset child with oxygen saturation of 100% on room air. There was no stridor or hoarseness and no use of accessory respiratory muscles. Auscultation of lung fields demonstrated bilateral and equal air entry with no wheezing. The rest of the physical examination was normal. Chest radiographs demonstrated the esophageal FB with normally inflated lung fields. Separation anxiety was managed with midazolam 0.05 mg/kg iv to good effect. The patient was transported to the operating room where standard monitors were placed and she was preoxygenated. Before induction of anesthesia, the surgical checklist was completed and a prebriefing was performed. The ORL-HNS surgeons described their plan for extraction. The anesthesia team discussed their plan to facilitate the surgery, which included the use of a smaller endotracheal tube (ETT), deflation of the cuff during the procedure, and the use of long-acting muscle relaxation agents to optimize exposure in anticipation of a difficult retrieval and resultant lengthy procedure.

Following completion of the surgical checklist and prebriefing, a modified rapid-sequence induction was performed with the iv administration of glycopyrrolate 0.01 mg/kg, fentanyl 1.5 μg/kg, lidocaine 1 mg/kg, propofol 3 mg/kg, and rocuronium 1 mg/kg. A 4.0 Microcuff ETT (Halyard; Halyard Health, Inc, Alpharetta, GA) was placed and secured at 14 cm at the lips, and the cuff was inflated with 1 mL of air to stop a cuff leak as assessed by using a stethoscope (3M Litmann Pediatric, Maplewood, MN). The cuff was deflated when the surgeons started manipulation, and no leak was noted. Full muscle relaxation was obtained initially with rocuronium with a repeat dose (0.3 mg/kg) given 100 minutes into the case. The patient was maintained on sevoflurane, oxygen, and air using pressure ventilation mode.

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Visualization and Anesthetic Challenges

The airplane was positioned with its nose facing the stomach. Using the chest radiograph, the wingspan of the airplane was estimated to be 24 mm, the length at 28 mm, and the length of the winglets to be 2 mm. The tail of the airplane was initially visualized in the esophagus by lifting the larynx anteriorly with a size 2.0 Wisconsin blade (Heine USA Ltd, Dover, NH) at the level of the cricopharyngeal inlet. However, pressure applied by the surgeons to the anterior esophageal wall caused complete obstruction of the tracheal lumen distal to the ETT as indicated by peak airway pressures increasing to 35 cm H2O from a baseline 10 to 12 cm H2O and a loss of end-tidal carbon dioxide tracing. The tip of the ETT was then advanced by the anesthesiologists under direct fiberoptic vision to just above the carina (16 cm at the lips). This repositioning allowed anterior pressure to be placed within the esophagus by the surgeons without causing airway obstruction for the remainder of the case.

The ORL-HNS surgeons tried numerous instruments to expose the full expanse of either wing in an effort to free the winglets. These included laryngoscopes with size 2.0 and 3.0 Wisconsin blades, a vocal cord spreader, child and adult Benjamin suspension laryngoscopes (KARL STORZ GmbH & Co KG, Tuttlingen, Germany), a Weerda scope (KARL STORZ GmbH & Co KG) with adjustable opening, and a range of esophagoscopes (KARL STORZ GmbH & Co KG) as large as 50 cm in length with a 12 × 16 mm oval-shaped opening. None of these allowed visualization of the airplane’s wing tips. Various optical graspers were used to dilate the lateral aspects of the esophagus and grab the wings, but none worked because the winglets were embedded in the mucosa. The ORL-HNS surgeons discussed the rationale for choosing each tool and why it failed. The ORL-HNS surgeons also asked the anesthesia team for the “go-ahead” before each attempt at extraction.

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Options for Removal Discussed by the Interprofessional Team

General surgery and gastroenterology were consulted intraoperatively by the ORL-HNS surgeons, and the entire team brainstormed and discussed the following options with their benefits and risks:

  1. Cutting the airplane into pieces. This option was immediately dismissed as the airplane was metal and any attempt to cut the plane would likely lead to severe complications that included esophageal and tracheal perforation.
  2. Surgical removal by ORL-HNS using a transcervical approach. This option would involve an incision and scar, a longer procedure, risks of bleeding, potential damage to one or both recurrent laryngeal nerves, and esophageal stricture. In addition, the anesthesia team added that this option would necessitate changing the ETT to a reinforced one, intra-arterial blood pressure monitoring, and possible requirement of a post-surgical intensive care admission, and prolonged intubation. This option was considered higher risk, likely to succeed, and the last resort.
  3. Pushing the airplane into the stomach with maneuvers by gastroenterologists followed by regrasping with a flexible esophagoscope, turning it around and retrieving it nose first, or waiting for natural passage. If the airplane could pass through the lower esophageal sphincter, it might get stuck in the intestine requiring a laparotomy for extraction by general surgery. This option was ruled out.
  4. Expanding the esophageal lumen with air insufflation by the ORL-HNS surgeon to allow freeing of the winglets. This option was not attempted because the lack of a seal distal to the airplane was unlikely to allow enough expansion of the esophageal lumen. In addition, there was already a possibility of an esophageal tear that could predispose to a pneumomediastinum.
  5. Expanding the esophageal lumen by a tool. Based on the measurements performed by the anesthesia team on the chest radiograph, it was determined that a tool that could widen the esophageal lumen to at least 25 to 26 mm would likely push the mucosa away from the wingtip barbs and allow extraction and delivery of the airplane. This fifth option was considered to have the best balance of success versus risk.
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Retrieval of the Airplane: The Fifth Option

A 50-cm-long Karl Storz esophagoscope (KARL STORZ GmbH & Co KG) with a 12 × 16 mm opening was inserted and a 5.5 mm × 53 cm Karl Storz optical alligator forceps (KARL STORZ GmbH & Co KG) was used to grab the FB by the ORL-HNS surgeons. In a test insufflation using a 14-gauge Foley, the balloon with sterile water reached a maximum diameter of 16 mm, short of the desired 25 to 26 mm. A test insufflation of an 18-gauge Foley catheter resulted in a 28-mm diameter sterile water-filled balloon. This was deemed sufficient for the procedure. The 18-gauge Foley catheter was then inserted into the mouth on the outer surface of the esophagoscope (it was not long enough to pass through the scope and would occupy much of the lumen) and was threaded into the esophagus until the balloon was at the level of the airplane wings. The Foley catheter was inflated with sterile water to 28-mm diameter (as tested outside of the patient before insertion). The airplane, inflated Foley, and esophagoscope were then slowly withdrawn as one unit (Supplemental Digital Content, see Video, http://links.lww.com/AACR/A107). This maneuver successfully delivered the airplane via the mouth (Figure 2). Airway compression and ETT displacement and laceration of the esophageal mucosa or the posterior tracheal wall were the main concerns from the anesthesia point of view during delivery. Throughout the delivery, the patient’s vital signs and end-tidal carbon dioxide remained normal. Immediately after the Foley catheter inflation, a transient and single reading drop in the blood pressure was noted (around 20% from the baseline). The heart rate, end-tidal oxygen, and saturation remained normal. Possible causes for this included a vasovagal response or reduced preload from obstruction of the neck veins. This did not recur throughout the course of the airplane delivery.

An esophagoscopy examination, performed immediately after retrieval, revealed a small area of mucosal erosion without evidence of transmural perforation. A nasogastric tube was placed under direct visualization. The ETT was then retracted back to 14 cm at the lips under direct flexible bronchoscopic visualization to ensure there were no injuries to the trachealis muscle. Muscle relaxation was reversed with neostigmine 0.05 mg/kg and glycopyrrolate 0.01 mg/kg. The patient was extubated awake and transferred to the postanesthesia care unit. A postprocedure debriefing was performed. The patient required 2 doses of morphine (0.05 mg/kg/dose) iv to alleviate odynophagia and was discharged to the ward in stable condition. She was given sucralfate (500 mg of oral sucralfate every 6 hours for 4 days) to swallow around the nasogastric tube to prevent stricture formation. A gastrografin swallow study after 24 hours was negative. Given the mucosal injury, clindamycin was ordered (20 mg/kg/day for 4 days) and the patient remained nil per os until postoperative day 2 when clear fluids were started. Diet was slowly advanced, and the patient was discharged home on postoperative day 4 in stable condition.

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DISCUSSION

Esophageal FBs are a common entity in children. Pediatric anesthesiologists and ORL-HNS surgeons must work as a team when managing extraction of these materials. Ever-changing designs of different materials present in the home such as game pieces that can become FB ingestions continuously present novel challenges to teams extracting them.

Coins and batteries constitute the majority of esophageal foreign bodies that typically get stuck at the level of the thoracic inlet.1–3 The late management of esophageal foreign bodies has been reported as a cause of sudden death.4,5 A thorough presurgical and preanesthesia evaluation is important for the planning for expedited removal of the foreign bodies. The use of imaging is important in planning for such procedures. Using chest radiography, the anesthesiologist may obtain very valuable information necessary for planning the anesthetic management, such as size measurements, shape, location, and presence of lung consolidation. In our patient, a difficult extraction was expected. In fact, initial attempts to pull the airplane proximally likely embedded the winglets further into the esophageal wall. Even the largest adult-sized esophagoscopes were not able to distend the esophageal walls enough to mobilize either wing.

The use of a Foley catheter for removal of blunt esophageal foreign bodies in children was first described in 1972.6,7 However, this is no longer recommended on its own without concurrent esophagoscopy due to the risk of airway obstruction. In 1998, Eliashar et al8 first described using a 12-gauge Foley catheter inflated with 3 mL of normal saline at the level of a 3 × 1.5 cm plastic loop with sharp metal nails to dilate the esophagus and allow extraction using a rigid esophagoscope. To our knowledge, this is the first case report on the ingestion of an airplane game piece from this manufacturer. The company was notified about the incident and the subsequent difficult extraction attributed to the airplane’s shape and dimensions.

The use of a smaller ETT and the deflation of its cuff at esophagoscopy maximized surgical access.9 To our knowledge, the deliberate advancement of the ETT to just above carina to prevent further obstruction of the trachea and to allow uninterrupted ventilation despite surgical manipulation and compression has not been previously described in such cases.

Due to the constant airway manipulation by the surgeons, while performing the FB extraction, a close communication between team members is crucial to understand how the surgical plan impacts the anesthesia plan. Similarly, a thorough knowledge by the anesthesiologist of the ORL-HNS’s plan allows a better understanding of the logistics of the procedure for successful preparation for anticipated challenges and complications. Although many surgical environments benefit from collegial and collaborative relationships, the extraction of the FB from the esophagus or the airway mandates such collaboration for optimal patient outcomes.

Team communication during medical emergencies and crises has been reported to influence outcomes.10,11 Familiarity among team members from working together in previous elective and emergency cases facilitated communication during the management of this case. Furthermore, team members used various tools and techniques to enhance communication and situation awareness. These techniques included a “prebriefing” before induction of anesthesia followed by a “time-out” before surgical start. Mini-timeouts were held each time before each attempt to retrieve the airplane. To keep everyone on the same page, the team used “think out loud,” where the following phrases were used: “here is what I am thinking,” “what if we …,” “what do you think.” Thinking out loud and the mock retrievals facilitated the creation of a “shared mental model,” allowing each team member to anticipate what was happening and contribute accordingly. The use of first names and familiarity of team members with each other facilitated a safe environment so that members could speak up. In addition to first names, the team members used first names as well as role titles such as “what does anesthesia think?” In our context, this “team call” created an inclusive environment for the anesthesia fellow who felt an enhanced level of ownership and participation. The “thinking out loud” and practice retrievals allowed for coordination of tasks and this likely led to good teamwork and minimal complications in our patient. The use of other techniques such as sterile cockpit and advocacy enquiry are known to assist with communication in crisis10–12. However, tools and techniques for team communication during crises may be difficult to implement due to dynamic and rapidly evolving situations. During the postsurgical debriefing, our team discussed that while the balloon insufflation had been suggested earlier in the case, it had been important to consider all options before proceeding.

Figure 2.

Figure 2.

In summary, our case report highlights the importance of teamwork, communication, and the involvement of multiple disciplines, each with their unique experience and expertise to carefully formulate a plan of action for patients during unique surgical emergencies. E

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DISCLOSURES

Name: Clyde T. Matava, MD, MBChB, MMed.

Contribution: This author helped conceive, write, and edit the manuscript.

Name: Gaston Echaniz, MD.

Contribution: This author helped review and edit the manuscript.

Name: William Parkes, MD.

Contribution: This author helped review and edit the manuscript.

Name: Blake C. Papsin, MD, MSc, FRCSC.

Contribution: This author helped review and edit the manuscript.

Name: Evan J. Propst, MD, MSc, FRCSC.

Contribution: This author helped review and edit the manuscript.

Name: Sharon L. Cushing MD, MSc, FRCSC.

Contribution: This author helped review and edit the manuscript.

This manuscript was handled by: Raymond C. Roy, MD.

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REFERENCES

1. Peters NJ, Mahajan JK, Bawa M, Chabbra A, Garg R, Rao KL. Esophageal perforations due to foreign body impaction in children. J Pediatr Surg. 2015;50:12601263.
2. Darrow DH, Holinger LD. Aerodigestive tract foreign bodies in the older child and adolescent. Ann Otol Rhinol Laryngol. 1996;105:267271.
3. Gilchrist BF, Valerie EP, Nguyen M, Coren C, Klotz D, Ramenofsky ML. Pearls and perils in the management of prolonged, peculiar, penetrating esophageal foreign bodies in children. J Pediatr Surg. 1997;32:14291431.
4. Byard RW, Moore L, Bourne AJ. Sudden and unexpected death – a late effect of occult intraesophageal foreign body. Pediatr Pathol. 1990;10:837841.
5. Dahiya M, Denton JS. Esophagoaortic perforation by foreign body (coin) causing sudden death in a 3-year-old child. Am J Forensic Med Pathol. 1999;20:184188.
6. Carlson DH. Removal of coins in the esophagus using a foley catheter. Pediatrics. 1972;50:475476.
7. Shackelford GD, McAlister WH, Robertson CL. The use of a Foley catheter for removal of blunt esophageal foreign bodies from children. Radiology. 1972;105:455456.
8. Eliashar R, Sichel JY, Dano I, Braverman I. Removal of a sharp esophageal foreign body using a rigid esophagoscope and a Foley catheter. J Otolaryngol. 1998;27:307308.
9. Kain ZN, O’Connor TZ, Berde CB. Management of tracheobronchial and esophageal foreign bodies in children: a survey study. J Clin Anesth. 1994;6:2832.
10. Brindley PG, Reynolds SF. Improving verbal communication in critical care medicine. J Crit Care. 2011;26:155159.
11. Brindley PG. Patient safety and acute care medicine: lessons for the future, insights from the past. Crit Care. 2010;14:217.
12. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13(suppl 1):i85i90.

Supplemental Digital Content

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Copyright © 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Anesthesia Research Society.