Case presentation

A previously healthy 5-year-old boy was brought to the emergency department after his family suspected accidental ingestion of a 10-yen coin (23.5 mm in diameter and 1.5 mm thick) that had been left on a table at home. On arrival, he was alert and had no hypoxemia (peripheral capillary oxygen saturation (SpO2) 98% on room air). His respiratory status was stable, with no increased work of breathing or drooling. His vital signs were as follows: body temperature, 36.8 °C; heart rate, 104 beats/min; and blood pressure, 94/64 mmHg. Physical examination revealed no abnormal findings in the oral cavity and no abnormal breath sounds. Mild pharyngeal erythema and pain were noted; however, no obvious foreign body was seen on visual inspection, and there was no cervical tenderness or swelling on palpation. The abdomen was flat and soft without tenderness, and there were no findings suggestive of gastrointestinal perforation due to foreign body ingestion. Chest radiography demonstrated a round foreign body at approximately the level of the sixth cervical vertebra (Figure 1). The radiograph showed a circular, homogeneous radiopaque object measuring 23.4 mm in diameter without a double-rim sign. Given the clinical history and radiographic findings, the object was consistent with a 10-yen coin.

Figure 1: Anteroposterior chest radiograph showing a round coin impacted at the level of the sixth cervical vertebra (C6), corresponding to the cricopharyngeus

Because urgent removal was considered necessary, video laryngoscope-assisted foreign body extraction under general anesthesia was planned. Endoscopic removal may require additional preparation, specialized pediatric endoscopic equipment, and the availability of an experienced pediatric endoscopist or a dedicated endoscopy team, which may delay treatment. In contrast, video laryngoscope-assisted removal can be performed promptly without extensive endoscopic equipment by an anesthesiologist or another appropriately trained physician who is skilled in pediatric video laryngoscopy. We therefore selected the video-laryngoscopic approach because suitably trained physicians were immediately available and the procedure could be performed without mobilizing a specialized pediatric endoscopy team. The procedure was performed by a pediatric intensivist skilled in airway management, in the ninth postgraduate year (PGY-9) and with no prior experience in video laryngoscope-assisted foreign body extraction, under the direct supervision of a pediatric emergency physician with extensive experience in this procedure. Anesthesia was managed by another pediatric intensivist experienced in pediatric anesthesia management. A contingency plan was in place to request assistance from a gastroenterologist if removal proved difficult or unsuccessful, and otolaryngology, gastroenterology, and surgery were not directly involved. Although the urgency of the case allowed only limited time, the reported video-laryngoscopic technique [3] and the use of Magill forceps were briefly reviewed with the supervising physician. The procedure was performed at a standard bed in the emergency department. The operator and the supervising physician conducted a structured briefing before the procedure (Table 1).

GAPS category | Briefing item | Specific example in the present case
Goals | Clarification of the procedural purpose and learning objectives | To remove the coin lodged in the esophagus.
Autonomy | Confirmation of the operator’s experience and level of autonomy | The team confirmed that the operator was experienced in tracheal intubation but had no prior experience in video laryngoscope-assisted foreign body removal, addressed any concerns, and agreed that the supervisor could take over at any time if difficulties arose.
Preparation | Sharing of patient information | The patient’s name, age, body weight, and allergy history were confirmed, and the patient was assessed to have no anticipated difficult airway.
Preparation | Confirmation of equipment and medications to be used | The anesthetic agents to be used, the size of the video laryngoscope, the depth of endotracheal tube fixation, and the equipment to be prepared, including the Magill forceps, as well as their use, were confirmed.
Preparation | Assessment of the risk of complications | The risks of airway and esophageal injury were reviewed.
Strategy | Role assignment | The three physicians were assigned the roles of operator, supervisor, and anesthesia provider.
Strategy | Standardized communication methods | Each physician was encouraged to speak up, and the supervisor paid close attention to how instructions were delivered.
Strategy | Emphasis on safety culture | All team members prioritized the points agreed on during the briefing and carried out the procedure accordingly.

During this discussion, several points differing from routine tracheal intubation were emphasized: the endotracheal tube should be secured to the left side of the mouth, rather than the right as in routine intubation, to preserve working space for the procedure; the video laryngoscope should be inserted more deeply and with a slightly larger blade than usual; the orientation of the foreign body determines the direction in which it can be grasped and removed; and the forceps should be withdrawn together with the laryngoscope when extracting the object, as the narrow pediatric oral cavity increases the risk of contact between the grasped coin and the laryngoscope blade, which may cause the foreign body to become dislodged during withdrawal. Under general anesthesia with standard endotracheal intubation, the endotracheal tube was secured to the left side of the mouth to preserve working space for the procedure. A video laryngoscope was inserted to elevate the base of the tongue and expose the esophageal inlet. Under shared monitor visualization, Magill forceps were gently advanced into the esophageal opening with the jaws opened vertically to grasp the coin. Because the pediatric oral cavity is narrow and the grasped foreign body can easily come into contact with the laryngoscope blade and become dislodged during withdrawal, the coin was removed together with the laryngoscope as a single unit (Video 1, Figure 2). The extraction required approximately 6 minutes, and the total time from induction of anesthesia to extubation was approximately 15 minutes. No mucosal injury was observed after removal. The patient subsequently awoke without complication, was observed for several hours without complications, and was discharged home the same day after confirming that oral fluid intake was possible. A post-procedural debriefing was then conducted with the team members involved in the case.

Video 1: Video laryngoscope-assisted removal of a coin impacted in the esophagus

Video 1: Video laryngoscope-assisted removal of a coin impacted in the esophagus

Figure 2: A 10-yen coin removed under video laryngoscope guidanceThe removal procedure is shown in Video 1.