A 65 mm screwdriver in the trachea of a toddler initially suspected to be an oesophageal foreign body: a case report

Background Foreign body aspiration is a common airway emergency in children under three years of age. When the family describes the event as swallowing and a radiopaque object projects close to the midline on a single frontal radiograph, it may be taken for an oesophageal one. We report such a case, in which review of the source images also showed that the radiopaque part of a manufactured object substantially understated its true size. Case presentation A previously healthy 2-year-4-month-old boy was brought to the emergency department after his family saw him put a small screwdriver in his mouth. He vomited once and then had an intermittent dry cough, but was comfortable, with an oxygen saturation of 99–100% in room air. A supine anteroposterior radiograph of the chest and abdomen showed a nearly vertical metallic opacity over the upper mediastinum, close to the midline, reported as approximately 48 mm long; the lung fields were clear. An oesophageal foreign body was suspected and flexible gastroscopy was performed under intravenous anaesthesia. It reached the horizontal duodenum and found no foreign body, and a subsequent upright abdominal radiograph was also negative. Non-contrast chest computed tomography, obtained about five and a half hours after arrival with a paediatric low-dose protocol, showed a linear metallic object within the tracheal lumen, together with right-sided obstructive emphysema and bronchopneumonia that had not been present on the initial film. The radiopaque component measured 43 mm. Rigid bronchoscopy the same day removed a screwdriver 65 mm long intact from the trachea; the additional 22 mm was a radiolucent plastic handle. The child was discharged on the second postoperative day and was asymptomatic at review 12 days later. Conclusions A radiopaque object demonstrated on imaging and then not found at upper gastrointestinal endoscopy should prompt reassessment of the airway rather than a search further down the gastrointestinal tract. A cough that begins with a witnessed choking event and persists retains diagnostic weight even when oxygenation and auscultation are normal. For a composite object the radiopaque component is not the object, and its true length may be considerably greater.