ACEP ID:

Pediatric Emergency Medicine

Pearls & Pitfalls - Swallowed Coins Don't Read Textbooks

Larry Mellick, MD, MS, FAAP, FACEP
Professor of Emergency Medicine
Medical College of Georgia

Pearl: Coins aspirated into the trachea or swallowed down the esophagus traditionally are differentiated by their orientation on x-ray. Coins aspirated through the vocal cords classically are described as having an "end-on" orientation. Those in the esophagus are seen as radiopaque disks on the anteroposterior (A-P) view of the chest radiograph. As demonstrated in this case, that truism is not always true.

Presentation: An 8-year-old male was transferred to our pediatric emergency department from another emergency department with the report of having accidentally swallowed a penny. The child demonstrated no evidence of respiratory distress, but there was concern based on the coin's orientation on x-ray that the coin might be located in the trachea. Sure enough, the coin was oriented as if it had passed through the cords and was only a radiopaque sliver on the anterior posterior radiograph. (See Figure 1)  However, on closer examination of both the lateral and A-P radiographs, it was obvious that the coin was aligned alongside and outside of the tracheal air column (See Figure 2)

The patient was admitted to the pediatric surgery service and was taken the next day to the operating room and placed under general anesthesia. The coin's location was confirmed to be in the mid esophagus, and the penny was removed with an esophagoscope.

Discussion: It is a commonly held belief that coins seen end-on (sagittal plane) in the middle of the chest on A-P radiographs are in the trachea, whereas coins in the esophagus will have a disk appearance on anteroposterior chest radiographs. The radiographs of our patient nicely demonstrate that this is not always the case. Even though unusual, others have reported this variability in radiographic finding,1,2 and it behooves the practitioner not to be fooled when esophageal coins end up in a lie that is contrary to the typical textbook descriptions.

References:  

  1. 1. Conners GP, Hadley JA. Esophageal coin with an unusual radiographic appearance. Pediatric Emerg Car. 2005;21:667-669.
  2. 2. Raney LH, Losek JD. Child with esophageal coin and atypical radiograph. J Emerg Med 2008;34:63-66.

 

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