Purpose or Case Report: Esophageal foreign bodies (FBs) are common in children and can lead to serious complications if undetected. Fluoroscopic esophagram has been standard for radiolucent FBs but involves giving oral contrast and possible poor patient tolerance. Low-dose chest CT offers further advantages of a faster workflow and possibility of remote interpretation.

We hypothesized that low-dose CT is sensitive and specific for radiolucent esophageal FBs in children. We correlated these results with the gold standard, esophagogastroduodenoscopy (EGD) when available and clinical resolution when no EGD was performed.
Methods & Materials: The retrospective study was performed at a large Children’s Healthcare System. The study included 69 patients (mean age 8.6 ±5.4 years; 58% male) with suspected radiolucent esophageal FBs who underwent low-dose chest CT from 2022-2025. For negative CTs, EGD was performed selectively in patients with continued high clinical suspicion. The unverified negatives (no EGD was performed following negative CT) were also included in analysis if patients tolerated oral intake at discharge, had no complications, and symptoms resolved at discharge (chart review). Sensitivity, specificity, positive/negative predictive values (PPV/NPV), and accuracy were calculated with 95% confidence intervals (CIs).
Results: Of 69 cases, CT was negative in 44 with 1 false negative (EGD positive). There were 43 true negatives based on negative EGD (n=4) and clinical resolution (n=39). CT positives (n=25) yielded 21 true positives and 4 false positives based on subsequent EGD.

Performance: Sensitivity of 95.5% (95% CI: 77.2-99.9%), specificity of 91.5% (79.6-97.6%), PPV of 84.0% (63.9-95.5%), NPV of 97.7% (88.0-99.9%), and accuracy of 92.8% (83.9-97.6%). Mean ordered-to-completed examination time was 38.8 ± 24.8 minutes. The median with IQR radiation dose for the exam was 0.62 [0.34 – 1.91] mSv.

Limitations include retrospective design, small single-center sample and partial verification bias from selective EGD.
Conclusions: Low-dose CT demonstrates high accuracy for radiolucent esophageal FBs in children, with excellent sensitivity (95.5%) and NPV (97.7%) supporting its role in safely ruling out FBs and reducing unnecessary EGDs. Given its advantages over esophagram- faster workflow, remote interpretability and no contrast, low-dose CT could potentially replace esophagram as the standard imaging modality in pediatric esophageal FB emergencies. Prospective multi-center validation is warranted to confirm our findings.