Nailed it! Endoscopic retrieval of ingested nail in a toddler. We have nothing to disclose. The objectives are to demonstrate the feasibility of safely removing nail and foreign body from a toddler endoscopically, understand the angle of approach to make the retrieval more feasible, learn to utilize multiple endoscopic procedural skill sets to achieve removal of foreign body, and appreciate the different types of accessories necessary to remove the foreign body. Foreign body ingestion is common from 6 months to up to 6 years of age. The most common cause of foreign body ingestion in children are coins, bone, sharp objects, and batteries. The most common area of foreign body in children are usually the esophagus, pelvic, stomach, and duodenum. In the esophagus, upper esophagus is the most common area. Children are usually presented with adenophagia, drooling, cough, irritable crying, nausea, and vomiting. Depending on the foreign body, the endoscopist or ENT will be consulted. Button batteries or sharp objects in the upper esophagus can lead to edema and possible perforation and have to be removed promptly. A 13-month-old was presented with fevers with a TMAX 100.4. The reported patient swallowed a rock and had some choking initially, which resolved. The child has been vomiting and drooling saliva ever since that episode and has been fussy ever since. A physical exam demonstrated pharynx with erythema, but no x-rays or lesions. An x-ray was performed to assess any retained foreign body. As you can see from the AP view, you can see a U-curved nail that is present in the upper esophagus, and on the lateral view, a multi-angulated nail that is present. ENT was consulted and took the patient to OR, and using a direct laryngoscope, attempted to remove the nail, but was unsuccessful. They were able to push the nail forward down into the esophagus. Therefore, GI was consulted to remove the nail. As you can see, the defect in the posterior portion of the upper esophagus and anteriorly is the esophagus. Using a pediatric gastroscope and a pediatric forceps, we were able to splay open the defect, which demonstrates muscle injury in the upper esophagus. We later proceeded down into the esophagus, and in the mid-esophagus, saw the foreign body. The nail was grasped by the pediatric biopsy forceps and was slowly pulled up into the upper esophagus. At the time we reached the upper esophageal sphincter, the nail was embedded in the defect and was unable to be removed. Techniques were utilized to grasp that nail and pull up into the side, but this was causing more trauma in that area. A foreign body retrieval hood was placed on the pediatric gastroscope and was challenging to get it past the upper esophageal sphincter, as it was very tight in this toddler. Even with the hood, we were unable to grasp the nail and get the hood over it to try to safely remove it from the upper esophagus. After studying the nail more carefully, we realized by trying to get the U-portion of the nail towards us, we would be able to safely remove the nail and prevent it from getting embedded. We therefore went in the inferior portion of the nail, grasping it and lifting it up so as to get the U-portion towards us so that the nail doesn't get impinged anywhere and we're able to remove it into the mouth. Since the nail was dislodged in the mouth, an ENT forceps was used to grasp the nail and bring it out. As you can see, the nail has a U-shaped pattern and we were able to grasp it at the U-portion to prevent it from getting hinged in the esophagus. Fluoroscopy images were performed afterwards, which showed no leak. Contrast was accumulating in the defect area, but again, no leak. It is important to review the images carefully to understand the curvature of the foreign body. A foreign body retrieval hood may not be possible to cross the UES depending on the size of the patient. Care should be taken not to force the hood if resistance occurs at the UES. Try to move the foreign body in different directions due to the curvature to assess the best path for endoscopic removal. Always coordinate with anesthesia and ENT as they can be very helpful in these situations.

endoscopic retrieval

ingested nail

toddler

foreign body ingestion

angle of approach