✓

Answer 3 of 50

Foreign Body & Ingestion

A 3-year-old swallowed a single coin an hour ago. He is playful, drank water without difficulty and is tolerating his own secretions. A chest radiograph shows one round metallic opacity face-on at the thoracic inlet, with a smooth uniform edge and no double-ring shadow. Fluoroscopy and an experienced operator are available.

What is the most appropriate way to retrieve it?

Correct answer: A — Fluoroscopy-guided retrieval with a magnet

A single confirmed smooth coin in the upper oesophagus of a well child, with fluoroscopy and an experienced operator to hand, is the one setting in which magnet retrieval is appropriate.

An oesophageal coin must come out within 24 hours, so observation is not an option while it sits above the diaphragm.
A magnet is a blind technique: it needs a single, confirmed, ferromagnetic object. An uncertain number of coins closes the option immediately.
The absence of a double-ring or halo shadow is what excludes a button battery, which is a caustic emergency needing endoscopic removal within two hours.
Magnet retrieval under fluoroscopy avoids a general anaesthetic; endoscopy needs GA with a protected airway.
Tolerating secretions shows there is no complete obstruction, so there is time to use the fluoroscopy suite.

★ Clinical pearl

An oesophageal coin must be out within 24 hours; a button battery must be out within 2 hours.

Exam note

Recalls disagree on this item and no answer key is published: most answer fluoroscopy-guided retrieval with a magnet and a minority answer oesophagoscopy, so the tally alone cannot settle it. This stem is written with the conditions that make the magnet correct rather than merely permitted - one confirmed smooth coin, no double-ring shadow of a battery, a well child tolerating his secretions, and fluoroscopy with an experienced operator to hand. Take away any one of them, an uncertain number of coins, a battery that cannot be excluded, a symptomatic child or no experienced operator, and removal by flexible endoscopy under direct vision becomes the answer.

Go deeper — why the other options fail, and what candidates recalled

Option	Why not
B	Not wrong - endoscopy under direct vision is the alternative and is preferred in much of current practice. It becomes the answer when the number of coins is uncertain, when a battery cannot be excluded, when the child is symptomatic, or when the magnet is not offered. Here it means a general anaesthetic for a well child with a single confirmed coin.
C	Waiting applies to a blunt object that has already reached the stomach in an asymptomatic child. A coin still in the oesophagus must be removed within 24 hours because of pressure necrosis and the risk of aspiration.
D	Rigid bronchoscopy is the instrument for an inhaled airway foreign body. This opacity lies face-on in the oesophagus, and the child has no stridor or respiratory distress.

What candidates actually recalled: Fluoroscopy with magnet (found in 4 recall sets)

Consistent with ESPGHAN / NASPGHAN foreign body guidance

Case Complete