OriginalArticle Indian Journalof Anatomy199 Volume7 Number 2, March-April2018 DOI: http://dx.doi.org/10.21088/ija.220.0022.7218.1 ImpactionofForeinBodyinpperDiestiveract nravellin theAnatomicalPerspective JulkaAmeet, Jain andana, SuriSheenu Malik, upta amini Abstract Context:Aforeignbodyisanyobjectinaregionitisnotmeanttobe,whereitcancauseharmbyitsmere presenceandmayrequiremedicalinterventionifnotspontaneouslyexpelledfromthebody.oreignbodiesin theupperGItractareusuallyswallowed,purposefullyoraccidentallywhicharemorelikelytobeimpactedat cricopharynxoresophagus.Presentstudyidentifiesthepediatricpopulationtobeespeciallyatahighriskof foreignbodyingestionandouraimistohighlighttheanatomicalaspectscontributingtothis. Aims:Toidentifythecommonestsiteofimpactionofforeignbodyinupperdigestivetractandthenstudythe causativeanatomicalfactorsleadingtothis MethodsandMaterial:AetrospectivestudyconductedinthedepartmentofOtorhinolaryngologyincluding previousrecordsfrom2014onwardsintertiarycarehospitalofcentralIndia.Atotalof10patientsofdigestive tractforeignbodyweretakenandcategoriedaccordingtoage,sex,siteofimpactionandtypeofforeignbody. Results:TheforemostsiteofforeignbodyimpactionisatUpperesophagealsphincterfollowedbyupper1/rd ofesophagusandcommonestagegroupis1-4years. Conclusions:Swallowingisnotascoordinatedandsuccessfulasinplannedintakeofbolusoffood.Thisclearly affectstheopeningofUESleadingtoimpactionoftheforeignbodyatthiscommonestsitefollowedbyupper 1/rdofesophagusandpiriformfossathereafter. KeywordsUpperEsophagealSphincter(UES)Cricopharynxoreignody()PiriformossaImpaction Pharyngeal Constrictors. Introduction childrenandadultsandtendtoberadiolucent.In adults,denturesorpartsfromdenturescanbe swallowedaccidentally.Psychiatricdisorder,alcohol oreignbodyinear,noseandupperaero-digestive intoxication, developmentaldelayandsecondary tractarecommonoccurencesformingalargeshareof gain seeking behaviourfavour true foreign body theemergenciesdealtbytheotorhinolaryngologists ingestion(i.enon-foodobjects)inadults1. inatertiarycarehospital.Virtuallyanyobjectsmall enoughtopassthroughthepharynxmaybe Themajorityofingestedforeignbodieswillpass swallowed.Itemscommonlyingestedbychildren spontaneouslybutthosethatareretainedneedtobe includecoins,smalltoys,pencils,pensandtheirtops, diagnosedandmanagedaccordingly.Weaimtofirst batteries,safetypins,needles,hairpins(whichare identifythecommonsitesforimpactionorretention mainlyradio-opaque),beads,pebblesandpopcorn- offoreignbodyafteraccidentalingestioninupper kernels.ood-relateditems,suchasfish,meatand digestivetractandsecondlytofindtheanatomical chicken bones, are more often ingested by older reasonsforthesame.Inonestudyshowingthe distributionofaeroesophageal,90ofpatients AuthorsAffiliation 1,AssociateProfessor 2Assistant hadaretained,whileitpassesintheother10 Professor,DepartmentofAnatomy 4AssociateProfessor, 2.Approximately80to90ofingestedsare Department ofENT, MGMMedical College, Indore, Madhya passed spontaneouslywithoutcomplications -. Pradesh 42001, India. adiographicevaluationincludingsofttissuelateral CorrespondinAuthor andana Jain, Assistant Professor, neckradiographandwidechestradiographofneck DepartmentofAnatomy,MGMMedicalCollege,Indore, andchestsuggeststhelevelofimpactionandgives Madhya Pradesh 42001, India. cluesregardingshape,sieandnatureoftheforeign E-mail: [email protected] body. Coin and battery cell are usually oriented Received 27.02.2018, Accepted 0.0.2018 edIndian lowerPublication JournalofAnatomy/Volume7Number2/March-April2018 Pvt.Ltd 200 JulkaAmeet,Jain Vandana,Suri SheenuMalik/ImpactionoforeignodyinUpperDigestive Tract: Unravelling theAnatomical Perspective coronallyin the esophagus mostlyat thelevel of MaterialsandMethods cricopharynx.(UES-upperesophagealsphincter) Thepharynxisamusculo-membranoustube Thisisaretrospectivestudywheredatafrom extendingfromthebaseoftheskulltothelevelofthe January2014onwardstill July2017wasobtained sixthcervicalvertebrawhereitiscontinuouswith fromrecordsof ENT department intertiary care theoesophagus.Theinteriorofthepharynxisdivided hospitalincentralIndia.Weincluded10patients intothreeparts-nasopharynx(epipharynx), withhistoryofaccidentalingestionandimpactionof oropharynx (mesopharynx) and laryngopharynx foreignbodyinupperdigestivetractspecificallyas (hypopharynx).Thepharynxactsasacommon perrecordsininpatient,outpatientandemergency channelforbothdeglutitionandrespiration,because careunitsreferredtoENTdepartment.Thesepatients thefoodandairpassagescrosseachotherinthis werecategoriedaccordingtoage,sex,siteof region. impactionandtypeofforeignbodywhichwasthen relatedtotheanatomicalfactorscontributingtosuch Dimensionsoadultpharynx: occurrences. Length12to14cm Asperrecords,mostoftheforeignbodieswere detectedbyplain-raychestAPandsofttissueneck WidthMaximumofabout.cminthe lateralviewalongwith-raybariumswallowfor nasopharynx radiolucentvegetativeforeignbodies,plasticobjects Minimumofabout1.cmatthePharyngo- andmuttonpiecewithoutbone.Allforeignbodies oesophagealjunction(UES) wereremoved by rigid endoscopyunder general anaesthesiaandpostoperativeperiodwasuneventful Structureofthepharynx:Thewallofthepharynx asperrecords. presentsfromoutsideinwardsthefollowingcoats: areolar (buccopharyngeal fascia), muscular, submucous(pharyngealaponeurosis)andmucous. Results Muscularcoat:Itconsistsofstriatedmuscleswhich arearrangedinoutercircularandinnerlongitudinal layers.Thecircularlayercomprisessuperior,middle Outof10patientsstudied,109weremalesand andinferiorconstrictormusclesthelongitudinallayer 1werefemales.Theagegroupofthepatientsvaried consistsofthreepairedmuscles:stylopharyngeus, from1to0years.Around0ofpatientswerein palatopharyngeusandsalpingopharyngeus7. the agegroup 1-4years owing to highercases of accidentalingestionofforeignbody(Chart1). able Site Cases Percentae Piriformfossa 2 1.2 Postcricoid 1 0.2 Cricopharynx(UES) 18 8.2 Upper1/rdesophagus 18 11.2 Middle1/rdesophagus 1 0.2 Lower1/rdesophagus 0 0.00 able ypeofforeinBody Cases Percentae Age0-20years Metallicobect 127 79.7 on-metallicbect 18 11.2 Age20-40years Metallicobect 02 1.2 on-metallicbect 09 . Age40-0years Meatbone 1.87 Age0years Denture 1 0.2 Indian JournalofAnatomy/Volume7Number2/March-April2018 JulkaAmeet,Jain Vandana,Suri SheenuMalik/ImpactionoforeignodyinUpperDigestive 201 Tract: Unravelling theAnatomical Perspective otalo.ofPatients Total No. of Patients Chart Fi. Imageofspecimenoftongue,pharynxandlarynx showingcottonplacedinvalleculaandextentofpiriformfossa Fi.Imageofsagittalsectionheadandneckshowingcotton markedontheleftside placedin valleculaandupperesophageal sphincterone Accordingtothedataobtainedmostcommonsite whilenon-metallicforeignbodiesincludingplastic ofimpactionwasCricopharynx (UES-upper toys, pencilsand vegetativeseeds were found in oesophagealsphincter)in8.2casesfollowedby 11.2cases. rd upper 1/ ofoesophagusin11.2casesand Withadvancingage,non-metallicforeignbodies piriformfossain1.2cases.Solitarycasesof weremore commonlyfound in. of cases as rd impactioninpost-cricoidregionandmiddle1/ of comparedtometallic foreignbodiesinonly1.2 oesophaguswerealsoreported.(Table1). casesintheagegroupof20-40years.Intheagegroup Intheagegroup1-20years,metallicforeignbodies of40-0years,meatboneswerefoundin1.87cases werefoundmorefrequently(79.7cases)including andasolitarycaseofdentureimpactionwasreported coins,batteries,safetypins,needlesandhairpins intheagegroup0years.(Table2). Indian JournalofAnatomy/Volume7Number2/March-April2018 202 JulkaAmeet,Jain Vandana,Suri SheenuMalik/ImpactionoforeignodyinUpperDigestive Tract: Unravelling theAnatomical Perspective Discussion ofthecricoidcartilagebetweentheattachmentof cricothyroidandthearticularfacetfortheinferior thyroidcornu.Itconsistsofasuperficialupper Sphincters are found in the respiratory, obliqueportion,theparsoblique,andalower,deeper, genitourinaryandespeciallyalimentarytracts transverseportion,theparsfundiformis.Theupper consideringthe complexchanges ofphysical and partattachestothemedianraphewhilethelower chemicalformwhichtakeplaceiningestedmaterials partformsacircularbandthatlacksamedianraphe. duringtheirdelayedpassagefrommouthtoanus.It Theareademarcatedbytheparsobliqueandpars isthisdelaywhichisoneoftheessentialfunctionsof fundiformisofcricopharyngeusistermedillians thealimentarysphincters8.Upperesophageal dehiscence(orillianstriangle).Asecondtriangular sphincter(UES)hasalsobeenreferredtoastheinferior area, Laimers triangle, canbe identified beneath pharyngealsphincterbecauseitislocatedatthelower cricopharyngeusbetweenthelongitudinalfibresof endof pharynx and guardsthe entranceintothe theoesophagusastheypasslaterallyoneitherside esophagus.Itisthenarrowestpartofthealimentary toattachtothecricoidcartilage: only thecircular tract (except forthe vermiform appendix) and is muscleoftheoesophagusformsthewallhere.oth constrictedatthebeginning(1cmfromtheincisor trianglesarepostulatedtobesitesofweaknessinthe teeth),Ithastwomajorfunctions:(1)topreventair wallofthepharynxandoesophagus,andare fromenteringintotheesophagusduringbreathing thereforeareaswherediverticulacouldpotentially and(2)topreventrefluxofesophagealcontentsinto form.othcricopharyngeusandthyropharyngeus thepharynxtoguardairwayaspiration9. spreadposteromediallytojointhecontralateral Anatomically,therearethreewellrecognied muscle.Thyropharyngeusisinsertedintothemedian sphinctermechanismstobeconsideredinthe pharyngealrapheanditsascendingfibressurround pharyngealregionofthegastro-intestinaltract.irst, themiddleconstrictormusclewherethelumenofthe thepalatopharyngealsphincterwhichpreventsthe pharynxiswidesthowever,descendingfromthis