From Beer Pong to the OR: Management of Metallic Bottlecap Foreign Body Ingestion

From Beer Pong to the OR: Management of Metallic Bottlecap Foreign Body Ingestion | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 30 July 2025 V1 Latest version Share on From Beer Pong to the OR: Management of Metallic Bottlecap Foreign Body Ingestion Authors : Richa Nathan 0009-0003-1883-6957 [email protected] , Luke Mammen , and Melissa Mortensen 0000-0002-6743-9726 Authors Info & Affiliations https://doi.org/10.22541/au.175388282.21312757/v1 309 views 170 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Foreign body (FB) ingestion is a common presentation seen by otolaryngologists ranging from mild discomfort to life-threatening airway compromise. Vegetative matter is the most common airway FB, but inorganic items such as coins and plastic toys are also commonly ingested. Current literature describes the best approaches for management of FB ingestion, From Beer Pong to the OR: Management of Metallic Bottlecap Foreign Body Ingestion Richa S. Nathan, B.S. 1,2 , Luke Mammen, M.D. 1 , Melissa Mortensen-Welch, M.D. 1 Department of Otolaryngology, Albany Medical Center, Albany, New York, USA Albany Medical College Running Title: Management of Metallic Bottlecap Ingestion Funding: N/A Conflict of Interest: None to disclose. Corresponding Author: Richa S. Nathan, [email protected] , 865-604-4042, 50 New Scotland Avenue, Albany NY, 12208 This report is being presented as an oral presentation at the Combined Otolaryngology Spring Meeting (COSM) on behalf of the American of Broncho-Esophagological Association (ABEA) in New Orleans, Louisiana on May 15 th , 2025. Keywords: Foreign body ingestion, Esophageal inlet, Metallic bottlecap, Rigid esophagoscopy, Airway management Introduction: Foreign body (FB) ingestion is a common presentation seen by otolaryngologists with presentations ranging from mild discomfort to life-threatening airway compromise. FBs account for 11% of the cases seen in otolaryngologic emergencies and carry potential for significant morbidity. 1 FB aspiration results in approximately 3,000 deaths in the US every year. 2 FB ingestion is most common in patients under the age of 15, with the highest incidence between 1 and 3 years of age. 2 Vegetative matter is the most common, but inorganic items such as coins and plastic toys are also commonly ingested. 2 Currently there is a paucity of literature describing the safe extraction of rare FBs, such as metallic bottlecaps. While many ingested FBs are benign and pass spontaneously, sharp, serrated or irregularly, disc-shaped objects such as metallic bottle caps pose a significant risk of mucosal injury, perforation, pressure necrosis or obstruction, making them hazardous. Though infrequent, ingestion of such objects may be underrecognized in certain populations. 3 Young adult males who engage in high-risk drinking behaviors, including binge drinking and social drinking games, may be especially vulnerable. 3 Alcohol intoxication impairs protective reflexes, increases impulsivity, and may contribute to accidental ingestion of dangerous objects during social activities. 3 Given this trend, it is important that otolaryngologists maintain a high index of suspicion when evaluating young, inebriated patients with FB ingestion. This case highlights the successful management of a metallic beer bottlecap lodged in the esophageal inlet and discusses key clinical considerations for atypical FB ingestions. The purpose is to share clinical pearls for identifying, imaging, and managing unusual FB ingestion. Case History/Examination: This case describes a 19-year-old male who presented to the emergency room with acute onset of throat pain, odynophagia, dysphagia and globus sensation secondary to the accidental ingestion of a metallic beer bottlecap during a party game. The cap had unknowingly fallen into his cup during beer pong approximately one hour prior to arrival. He denied shortness of breath, dysphonia, or hematemesis. His vital signs were stable. Physical examination showed posterior oropharyngeal erythema without visible FB, pooling of secretions or evidence of respiratory distress. A bedside flexible fiberoptic nasopharyngolaryngoscopy (FFNPL) showed a patent airway with atraumatic laryngeal structures, no pooling of secretions, and no FB visible at the level of the oropharynx or larynx. A lateral and anteroposterior neck X-ray revealed a radiopaque, disc-shaped object consistent with a metallic bottlecap lodged at the proximal esophageal inlet (Figure 1). The patient was taken urgently for rigid esophagoscopy. After induction of general anesthesia and endotracheal intubation, a Dedo laryngoscope was inserted into the oral cavity and advanced to the esophageal inlet (Figure 2). The bottlecap was visualized and successfully removed using upward-angled cupped forceps without resistance (Figure 3). After removal, examination revealed a small superficial posterior mucosal tear and anterior pressure necrosis, without bleeding or perforation. The patient was extubated without complication and transferred to the post-anesthesia care unit in stable condition. He tolerated the procedure well and was discharged later that day on a soft diet with no immediate complications. Written informed consent was obtained from the patient for the publication of this case report in accordance with the journal’s patient consent policy. Differential Diagnosis: • Esophageal foreign body ingestion (metallic vs. food bolus) • Esophageal perforation • Globus pharyngeus • Acute pharyngitis • Cervical spine pathology Conclusion and Results: This case illustrates the successful removal of a metallic bottlecap from the esophageal inlet in a young male following accidental ingestion during recreational drinking. Metallic bottlecaps pose significant risks including airway obstruction, mucosal injury, pressure necrosis, and esophageal perforation. Successful removal of the bottlecap underscores the importance of prompt airway assessment and imaging followed by surgical intervention. Raising awareness about atypical FB ingestions and developing standardized protocols for their evaluation and treatment may improve patient outcomes and prevent life-threatening complications. Key Clinical Message: Metallic bottlecap ingestion in intoxicated young adults is an underrecognized but potentially dangerous phenomenon. Early identification, airway assessment, and prompt surgical intervention are critical to preventing serious complications such as esophageal mucosal injury or perforation. Discussion: Adult FB ingestion is uncommon and often involves food-related bolus impaction or intentional ingestion. 4 In these cases of FB ingestion, FFNPL is often normal but may show pooling in the pyriform fossae. 2 The initial management of esophageal FB obstruction, especially in the setting of food bolus impaction, is conservative. Higher risk ingestion such as button batteries require immediate removal due to the risk of severe injury to esophageal mucosa from liquefactive necrosis potentially resulting in perforation and mediastinitis. 4 If conservative management fails, an esophagoscope is passed under general anesthesia and advanced into the esophageal lumen until the foreign body is visualized or pushed through to the stomach prior to removal. 4 With the rise of high-risk drinking behaviors, it is important to remain vigilant when obtaining a history and evaluating young adults. Inebriated patients may have increased impulsivity and impaired protective reflexes which puts them at higher risk for accidental foreign body ingestion. Accidental ingestion of atypical FB, particularly those with sharp, rigid, or serrated features such as metallic bottlecaps, present unique challenges in management. While most ingested FBs are radiolucent or pass spontaneously, sharp and metallic objects pose a significantly higher risk of mucosal injury, pressure necrosis, or perforation, particularly when lodged at high-risk anatomical narrowing such as the esophageal inlet. In this case, the patient presented with symptoms of globus sensation, pain, and mild respiratory difficulty, all nonspecific but common in esophageal impactions. 5 Radiographic imaging was instrumental in confirming the diagnosis, with the bottlecap clearly visible on plain X-ray. Importantly, flexible nasopharyngolaryngoscopy ruled out airway compromise, supporting early surgical removal rather than emergent airway intervention. While the case described here was managed successfully, it is important to recognize that metallic bottlecap ingestion is not an isolated phenomenon. A recent German case series similarly reported 14 cases of bottlecap ingestion over a 10-year period in a single university town, suggesting an underrecognized public health issue in high-risk populations. 3 Their findings revealed that while bottlecaps are inherently sharp and serrated, the resulting injuries were generally limited to mild mucosal erosions and erythema, similar to this case. This relative lack of severe complications was attributed to early presentation and the population of young, otherwise healthy men. 3 The events were strongly associated with rapid consumption of large quantities of beer from open bottles in poorly lit environments, increasing the risk of accidental ingestion. 3 Based on this data, clinicians should counsel at-risk patients to avoid beverages with serrated bottlecaps and to consider alternative packaging or drinking practices to prevent future occurrences. Author Contributions: Richa S. Nathan, B.S. : Conceptualization, Data Collection, Writing –Original Draft Luke Mammen, M.D. : Conceptualization, Supervision, Methodology–Review & Editing Melissa Mortensen-Welch, M.D. : Conceptualization, Supervision, Methodology–Review References: 1. Awad AH, ElTaher M. ENT Foreign Bodies: An Experience. Int Arch Otorhinolaryngology. 2018 Apr;22(2):146-151. doi: 10.1055/s-0037-1603922. Epub 2017 Jul 14. PMID: 29619103; PMCID: PMC5882369. 2. Kullar P, Yates PD. Infections and foreign bodies in ENT. Surgery. 2012 Oct 30;30(11):590-596. doi: 10.1016/j.mpsur.2012.09.005. PMID: 27057069; PMCID: PMC4821371. 3. Bertlich M, Ihler F, Sommerlath Sohns JM, Canis M, Weiss BG. From the Bottlecap to the Bottleneck: Frequent Esophageal Impaction of Bottlecaps Among Young Males in a Small University Town. Dysphagia. 2022 Feb;37(1):192-197. doi: 10.1007/s00455-021-10263-x. Epub 2021 Feb 13. PMID: 33580816; PMCID: PMC8843902. 4. Ambe P, Weber SA, Schauer M, Knoefel WT. Swallowed foreign bodies in adults. Dtsch Arztebl Int. 2012 Dec;109(50):869-75. doi: 10.3238/arztebl.2012.0869. Epub 2012 Dec 14. PMID: 23293675; PMCID: PMC3536040. 5. Chirica M, Kelly MD, Siboni S, Aiolfi A, Riva CG, Asti E, Ferrari D, Leppäniemi A, Ten Broek RPG, Brichon PY, Kluger Y, Fraga GP, Frey G, Andreollo NA, Coccolini F, Frattini C, Moore EE, Chiara O, Di Saverio S, Sartelli M, Weber D, Ansaloni L, Biffl W, Corte H, Wani I, Baiocchi G, Cattan P, Catena F, Bonavina L. Esophageal emergencies: WSES guidelines. World J Emerg Surg. 2019 May 31;14:26. doi: 10.1186/s13017-019-0245-2. PMID: 31164915; PMCID: PMC6544956. Supplementary Material File (abea figure 1.docx) Download 302.75 KB Information & Authors Information Version history V1 Version 1 30 July 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords adolescent health and throat ear emergency medicine nose otolaryngology public health Authors Affiliations Richa Nathan 0009-0003-1883-6957 [email protected] Albany Medical College View all articles by this author Luke Mammen Albany Medical Center View all articles by this author Melissa Mortensen 0000-0002-6743-9726 Albany Medical Center View all articles by this author Metrics & Citations Metrics Article Usage 309 views 170 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Richa Nathan, Luke Mammen, Melissa Mortensen. From Beer Pong to the OR: Management of Metallic Bottlecap Foreign Body Ingestion. Authorea . 30 July 2025. DOI: https://doi.org/10.22541/au.175388282.21312757/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. 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