A Coin in the Airway

Victor Bor-Chang Hsue, Vijay Patel

N Engl J Med 2024; 390: e33

DOI: 10.1056/NEJMicm2312266

A healthy 14-year-old boy presented to the emergency department with a 6-hour history of hoarseness and difficulty swallowing after having accidentally swallowed a coin. On physical examination, the patient was breathing comfortably without stridor or drooling. Radiographs of the chest (Panel A, posteroanterior view) and neck (Panel B, lateral view) showed a rounded, radiopaque foreign object situated vertically within the subglottis (the region between the vocal cords and the trachea). A diagnosis of foreign-body aspiration was made. Accidentally ingested foreign bodies usually end up in the esophagus. When aspirated into the airway by older children, foreign bodies typically lodge more distally than in this case (in the trachea or a mainstem bronchus), owing to gravity and the larger airway size. Airway foreign bodies — especially those in the trachea and larynx — necessitate immediate removal to reduce the risk of respiratory compromise. Rigid bronchoscopy was performed while the patient was under general anesthesia, and a U.S. quarter was visualized within the subglottis and removed with optical forceps (Panel C and Video 1). On reinspection of the airway, mild subglottic mucosal ulceration due to the mass effect of the coin was seen (Panel D, asterisks, and Video 2). After the procedure, the patient’s symptoms abated and he was discharged home.

一名14岁健康男孩因意外吞食硬币而出现声音嘶哑和吞咽困难6小时后前往急诊科就诊。体格检查：患者呼吸顺畅，没有喘息或垂涎。胸部X线片（图A，后前位）和颈部X线片（图B，侧位）显示声门下（声带和气管之间）可见一个圆形的、不透射线的异物。患者诊断为异物吸入。一般而言，意外吞入的异物会进入食道。如果异物被较大年龄的儿童吸入气道，由于重力作用和气道较大，异物通常会停留在比本例更深的位置（如气管或主支气管）。对于气道异物，尤其是气管和喉部的异物，必须立即取出，以减少呼吸道阻塞风险。患者在全身麻醉下接受了硬质支气管镜检查，声门下可见一枚25美分硬币，医生用镊子将其取出（图C和视频1）。重新检查气道时发现，由于硬币的肿块效应，声门下黏膜出现轻度溃疡（图D，星号和视频2）。手术后，患者症状减轻，出院回家。