Case

A 5 year old patient is brought into your clinic complaining of a sore throat with pain and difficulty when swallowing. Their parent describes that the child accidentally swallowed a small lego that was later expelled after vomiting one day ago. A CT scan with oral barium contrast which shows extraluminal (i.e. outside the lumen of the esophagus) collection of contrast posterior to the esophagus against the vertebral body of T6 to T7.

Question 2/3 - What is your differential diagnosis?

Click on your selected option(s) below  (correct = 1,  over-thinking = 2+)

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Incorrect. While there might still be bleeding, the contrast is oral so it would not specifically be accumulating due to bleeding. That would be more readily assessed by intravenous contrast to assess bleeding.

Incorrect. While there is a possibility of a second lego piece, since the caregivers indicate the swallowed piece was expelled the day prior, plastic is poorly discernable on a CT scan. So while possible, it would not be of primary concern on the differential diagnosis and a retained piece does not explain the barium distribution.

Incorrect. A pneumothorax is air entering the pleural cavity causing the lung to collapse, which is unlikely from a swallowed object as the esophagus travels in the posterior mediastinum.

Incorrect. While we always have concern with objects in children entering the trachea and depositing into bronchi (the right bronchi being the most common for inhaled objects), the patient history indicates a swallowed object due to the vomiting and an airway obstruction is not consistent with oral contrast in the mediastinum.

Correct!  For the oral contrast barium to enter the posterior mediastinum there must be a perforation (a hole) in the esophagus for it to have leaked out. The location suggests this perforation is near T6 or T7 as that is where the barium is localized on the CT scan.