Introduction

There are many etiological factors for foreign body impaction in the oesophagus.¹ Such impaction could pose a major morbidity^{2, 3} and sometime mortality. We report an unusual table spoon impaction in the lower oesophagus complicating domestic emergency management of convulsion in an epileptic.

Case Report

A forty-five year old trader with a weight of 120kg and a known history of seizure disorder for five years, suddenly started convulsing at home. He stopped his anticonvulsant medications because he had not experienced any convulsion in over 3years period. His wife used an adult metallic table spoon with plastic handle to separate his teeth and keep his mouth open so as to prevent injury to his tongue. In the process of struggling, the plastic handle of the spoon disarticulated and the patient swallowed the metallic blade accidentally. The spoon got impacted at the lower oesophageal sphincter causing severe lower chest pain and distressing dysphagia.

Chest x-ray taken few hours after and repeated 24 hours later demonstrated impaction of the spoon in the lower oesophagus with failure of migration. Emergency laparotomy and gastrotomy was done. The spoon was found astride the gastro-oesophageal sphincter. It was carefully removed from the stomach without thoracotomy. There was no attendant perforation. Post-operative recovery was uneventful and subsequent barium swallow confirmed normal oesophagus.

Figure 1

Lateral chest xray showing the spoon at the lower oesophageal sphincter

Figure 2

The metallic spoon after extraction

Figure 3

Upper abdominal Incision for spoon removal

Figure 4

Barium Swallow showing normal lower oesophagus and cardia after removal of spoon foreign body.

Discussion

The use of spoon at home to prevent biting and injury to the tongue during convulsion is common practice in our environment. This case demonstrates the potential danger of foreign body inhalation or swallowing with attendant complications from this practice. Unguarded use of objects as spatula to protect the tongue should be avoided. The use of articulated spoon is particularly dangerous. Prompt and good control of seizure disorders would serve as a preventive measure. Laparoscopic surgical treatment would have been a good option but has not commenced in our Centre presently. The size of the spoon, the position and the degree of impaction made endoscopic removal dangerous because of the risk of oesophageal perforation.

The weight of the patient may have contributed to the violent impact on the spoon dismantling it due to the strong force of muscle spasms. The weight (120kg) and the muscular build of this patient may have posed as a second risk factor in this case.

More commonly found foreign bodies in the oesophagus include: fish bone, meat bones, dentures, coins, and safety pin, (especially napkin pin by nursing mothers or nannies). ¹Others include meat bolus eaten in a hurry, disc battery etc⁴. Common causes of swallowed foreign bodies include children as they play³, loss of protective mechanism, inadequate mastication, psychotics and oesophageal stricture.¹

To the best of our knowledge we are not aware of similar documentation in literature. Any articulated instrument could be equally dangerous as bite block during convulsion. Counseling of the patients with epilepsy and their relatives on ill-advised discontinuation of medication and the danger of use of articulated objects in the mouth is important.