The case of a teenage girl who presented to a Seattle ER after swallowing a fidget spinner has drawn attention to gaps in the efficacy and accuracy of X-ray imaging, according to a case report published in JAMA Otolaryngology—Head & Neck Surgery. The research team called the images “misleading,” warning other clinicians to be aware that what they see may not be what they find once they try to remove foreign bodies.

The young woman, whose reasons for swallowing the handheld toy were undisclosed in the paper, arrived at the hospital only after experiencing severe neck pain and vomiting, Jeffrey P. Otjen, MD, and colleagues wrote. The authors wrote she had a “complex mental health history” that included depression and an eating disorder. They said she broke the toy into three pieces before ingesting it.

“We see cases of ingested—or aspirated, inserted, et cetera—foreign bodies on a nearly daily basis,” Otjen told Radiology Business. “This is a very frequent problem encountered in the pediatric population.”

This woman’s case was unique, though, he said, owing in large part to the sheer size of the object she swallowed. While ingested foreign objects will typically pass without complications, those greater than 20 or 25 millimeters, sharp or pointed objects and devices with magnets or small batteries should raise red flags. A common fidget spinner spans between two and four inches wide—up to 100 millimeters.

Surgical treatment was required to remove the spinner pieces, which were lodged in the girl’s esophagus. Due to her mental health history, the patient was a high-risk anesthesia candidate, Otjen said, so the medical team leaned toward non-invasive treatment, which seemed feasible after a radiographic image detected three round, metallic objects in the patient’s upper esophagus. When the surgical team pried open the esophagus for an esophagostomy, though, they found something unexpected and invisible in X-ray: plastic.

“Most foreign bodies are uniform in density,” Otjen said. “Either they show up completely or don’t at all. Complex objects like toys that have a combination of metal, plastic, wood, et cetera are problematic as they can give a misleading size, as in this case. The most challenging part of foreign body imaging is finding the object and determining if it poses a risk.”

In this patient’s case, he and co-authors wrote, X-ray images suggested the fidget spinner pieces could be removed via a benign course. In reality, large, jagged pieces of plastic went unrecognized on the x-ray, so doctors were forced to take a more challenging operative course than they had planned for. 

Otjen said the problem could have been solved with a CT scan, which would have been able to shed light on the complexity and exact location of the pieces, but clinicians favor x-rays because CTs are time-consuming, pricey and can expose patients to unnecessary radiation.

This case should be a lesson, the authors wrote, for physicians who deal with foreign body ingestion on a regular basis, especially in a pediatric population. Physicians shouldn’t underestimate a patient’s ability to ingest “seemingly innocuous items such as fidget spinners,” they said, and clinicians shouldn’t assume the patient has told them about every object swallowed or inserted. Commonplace symptoms like vomiting, too, can be indicative of further complications.