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Introduction: More than 100,000 cases of foreign body (FB) ingestion are reported each year in the United States and 80% of cases occur in children. Patients may be asymptomatic or have only transient symptoms at the time of ingestion. We report the case of a 1 year old female with longstanding esophageal FB after roughly 2 months of ongoing stridor that was misdiagnosed as croup. Case: 1 year old healthy female presented to the ED for intermittent stridor with crying. On initial evaluation by PCP 2 months prior, patient had concomitant upper respiratory infectious symptoms and was diagnosed with croup. She improved with steroids and humidified oxygen. Five weeks from the initial diagnosis, parents returned to the PCP with ongoing concern though patient was asymptomatic on evaluation. A soft tissue neck X-ray was obtained and interpreted as normal and routine follow up with ENT was planned. Three days later, parents present to the ED complaining of worsening stridor over the past 48 hours and have not yet been evaluated by ENT. Exam in the ED is notably for biphasic audible stridor that is loudest with inspiration. Decadron and nebulized epinephrine were administered. A two view chest X-ray was obtained and interpreted as normal. However, ED team was concerned for narrowing of the mediastinal trachea on lateral view chest X-ray; the pediatric service was consulted recommending CT chest with IV contrast that showed edema in the superior mediastinum centered around the esophagus and tracheal flattening above the carina with 2 mm AP diameter. She was started on IV Zosyn and flexible bronchoscopy and esophagoscopy were performed. Visualization of the esophagus demonstrated a plastic piece with jagged edges seen at the upper esophagus with mucosal folds surrounding it. The trachea had only mild inflammatory changes but was otherwise without injury. The FB was removed and the patient recovered completely. Discussion: Esophageal FBs occur most commonly in children aged 6 months to 3 years and tend to lodge in areas of physiologic narrowing, including the upper esophageal sphincter, level of the aortic arch, and the lower esophageal sphincter. Patients may be asymptomatic, or may present with dysphagia, refusal to eat, wheezing, choking or stridor. Longstanding esophageal FBs may lead to recurrent aspiration pneumonias and can damage the esophageal mucosa leading to strictures. They may also erode through the esophageal wall creating a fistula with the trachea or other nearby structures.



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