Esophageal foreign body (EFB) is one of the emergency conditions frequently encountered today; however, with early diagnosis and/or treatment, patients can recover without any problems.[1] Since the esophagus is the narrowest place of the upper gastrointestinal system, EFBs constitute a major part of all gastrointestinal system foreign bodies. As a special group, intellectually disabled patients have a tendency to put every object they get hold of into their mouth and they usually lack proper chewing coordination. Therefore, when symptoms such as dysphagia, odynophagia or hyper-salivation are seen in intellectually disabled patients, EFBs should be suspected. The treatment is based on extraction of the foreign body with esophagoscopy or in rare cases with surgery, when necessary.[2]

A 19-year-old, intellectually disabled male patient was referred to our clinic with complaints of suddenonset dysphagia and shortness of breath. His physical examination showed increased secretions in his mouth. As his posteroanterior chest roentgenogram revealed a round lesion with smooth contours in the right superior mediastinum, thoracic computed tomography was performed which showed two spherical foreign bodies with smooth contours in the esophagus, one exerting pressure to the right side of the trachea and the other localized under the first one (Figures 1a and b).

Figure 1: (a) A round-shaped lesion in the right superior mediastinum is visible on posteroanterior chest roentgenogram. (b) Two spherical foreign bodies, one above the other, in the esophagus are detected in the coronal plane of thoracic computed tomography.

A rigid esophagoscopy was administered to the patient. A whole walnut, approximately 3.5 cm in diameter, was stuck in the second constriction of the esophagus and the patient"s identification wristband just above it. First, the patient's identification wristband was extracted. Then, holding it from a broken part on its shell with forceps, the walnut was pulled up, but it was not possible to bring it through the first constriction. Subsequently, an effort was made to push it to the stomach, but it also failed. During the same session, cervical esophagotomy was administered, the esophagus was set free and the foreign body was extracted (Figures 2a, b and c). Through the same incision, an esophagoscope was inserted and the other walnut was seen to have fallen into the stomach. The mucosal and muscular layers of the esophagus were repaired primarily. While the patient was being monitored in the clinic on postoperative Day 2, his relatives reported that he swallowed the oxygen saturation probe. This foreign body was also extracted using esophagoscopy (Figure 2d). With no additional problems in the postoperative period, the patient was discharged on Day 6. A written informed consent was obtained from the parents and/or legal guardians of the patient.

Figure 2: (a) A foreign body is visible in the esophagotomy incision. (b) Whole walnut extracted from the same incision. (c) Image of the patient identification wristband and walnut extracted. (d) Oxygen saturation probe extracted by way of esophagoscopy.

In conclusion, it should be borne in mind that esophageal foreign bodies in large amounts and in different structures can be encountered simultaneously in intellectually disabled patients. Such patients should be kept under strict surveillance in the postoperative period and their family members should be informed about the issue to prevent any recurrences of esophageal foreign bodies.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The authors received no financial support for the research and/or authorship of this article.

References

1) Taş A, Kara B, Yalcin MS, Sarıtaş B. Extraction of esophageal foreign body with traction technique via endoscopic retrograde cholangiopancreatography balloon. Acta Gastroenterol Belg 2017;80:432-3.

2) Orji FT, Akpeh JO, Okolugbo NE. Management of esophageal foreign bodies: Experience in a developing country. World J Surg 2012;36:1083-8.