Case Report
Swallowing dynamics status post caustic ingestion in a pediatric patient: A multidisciplinary case report

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Abstract

A case report of a 10 year old male illustrates the effect of damage to the tongue base, hypopharynx, cricopharyngeus, and esophagus on the sensory and motor components of the swallowing mechanism. The characteristics of the dysphagia were manifested clinically, radiographically, and endoscopically. A myectomy was required to restore functional swallowing as scar tissue formation in the cricopharyngeus severely interfered with the dynamic components of swallowing. A collaborative approach facilitated communication and effective treatment planning; the multidisciplinary components in the management of this case are discussed.

Introduction

The incidence of caustic ingestion in children has become less common in recent years given the public health interventions for prevention, yet it remains a significant cause of pediatric morbidity in the Unites States and world-wide [1], [2]. Data from the American Association of Poison Control Centers Toxic Exposure Surveillance System show that in the United States, more than 2.1 million toxic exposures to caustic agents were reported in 2014; of those, 47.7% occurred in children less than five years of age [3]. The injuries that are incurred secondary to ingestion depend upon the type, amount, and concentration of the material consumed, as well as the contact time and chemical reaction with the tissue site. Thus, the potential respiratory, gastrointestinal, and upper airway injuries result in varying degrees of physiologic impairment [3], [4], [5], [6], [7], [8], [9]. Individual evaluation is required as the evolution of the injury and the subsequent clinical picture can be changeable [3], [10].

In the pediatric population, caustic ingestion occurs most commonly as an accidental event as opposed to an intentional act [11]. The pattern of tissue injury differs depending on whether the product is alkaline or acid in nature; types and examples of caustic agents are summarized in Table 1. Materials frequently ingested by children include alkaline substances (drain cleaners, bleaches, oven cleaners, liquid dishwasher products, disk batteries, hair relaxers, household cleaners with ammonia) [3], [5], [11]. Alkaline products have been shown to cause esophageal injury if the pH is greater than 11.5–12.5 by liquefaction necrosis, leading to early disintegration of mucosa, facilitating deep penetration and subsequent perforation [9]. Acid ingestions (toilet bowl cleaners, rust removers, swimming pool cleaners) are reported as less common in children [3]. Acid agents tend to have a noxious taste, leading to spitting, choking, and gagging, and potential facial burns and airway compromise [5], [12]. Acids tend to cause significant esophageal injury if the pH is less than two as a result of coagulation necrosis. The pathophysiology of the corrosive injury and the evolving nature of injury require ongoing assessment and management, both acutely and in the future.

The effects of caustic ingestion on the esophagus account for most of the serious injuries and long-term complications in both children and adults [11]. The short term esophageal complications in include perforation and death; the long term complications include the development of persistent esophageal strictures and the increased risk for esophageal carcinoma. However, as in the aforementioned, injuries may also occur in the oral, oropharyngeal, hypopharyngeal, and upper esophageal sphincter regions [11], [13]. Such injuries have potentially serious implications for oropharyngeal and esophageal phase swallowing dynamics [4]. We describe a case report of a ten year old male that depicts the progressive nature of caustic ingestion injury on the sensory and motor components of the swallowing mechanism. The chronology of events is summarized in Appendix 1. The multidisciplinary components in the management of this case are discussed.

Section snippets

Case description

A ten year old boy sustained a severe caustic ingestion injury during an afternoon science experiment demonstration, after ingesting a chemical mixture that was intended to be benign but turned out to be sodium hydroxide. After eating what he understood to be dry ice with salt on it, he immediately experienced a burning sensation in his mouth, throat, and chest. He was taken to an urgent care center, and after relating the events surrounding the ingestion, he was immediately transferred to an

Conclusion

The patient described in this case study underscores the efficacy and necessity of a collaborative multidisciplinary approach in the management of pediatric caustic ingestion injuries. In this circumstance, multidisciplinary assessment and management facilitated evaluation and ultimately the effective treatment of severe pharyngeal swallowing deficits that evolved as a result of sodium hydroxide ingestion. The fibrotic changes to the tissue in the cricopharyngeal region as a result of the

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