When a child’s esophagus is injured due to caustic ingestion — which is the ingestion or swallowing of a chemical substance — they need expert care to repair injury to the esophagus or mouth. The team in the Esophageal and Airway Treatment Program at Johns Hopkins All Children’s in St. Petersburg, Florida, is experienced in treating this often-complex condition.

Caustic ingestion in children typically occurs when the child accidentally swallows a chemical substance like a household cleaner. The most severe injuries involve alkaline household cleaners such as bleach, oven cleaners, drain cleaner, or many laundry detergents. This can cause scarring of tissue throughout the esophagus, injury to the vocal cords, and in severe cases, extensive scarring throughout the back of the mouth.

Why Choose Johns Hopkins All Children’s

Experienced Team

Our team of pediatric thoracic surgeons is experienced in treating caustic injuries, including in severe cases. Treating these injuries properly can involve removing scar tissue and using tissue from other areas of the body to repair and rebuild the damaged esophagus. Our team has this expertise to treat these cases, including in patients who may be experiencing complications from previous treatment for the injury.

Caustic ingestion can also impact the vocal cords. Monitoring the vocal cord nerves during surgery is uncommon, but it is a routine part of our treatment for esophageal and airway conditions. We are experts in optimally managing the vocal cords to prevent further injury and preserve vocal cord function.

Our team also includes pediatric anesthesiologists with expertise in meeting the unique anesthesia needs of children needing surgery for conditions impacting the esophagus and airway, and we also work closely with pediatric gastroenterology specialists to address esophageal and swallowing function in our patients. The hospital’s radiology specialists, nutrition teams and our specialized nursing team also provide additional expertise in caring for our patients. Learn more about our team.

Advanced Diagnostic Techniques

Understanding the full scope of caustic ingestion is essential to providing our patients with the best treatment. Thorough examination of the mouth, esophagus and stomach is critical to understand the problems and develop a treatment strategy. Our team developed a complete dynamic three-phase airway exam that allows us to perform a full assessment of your child’s airway before surgery.

Using various methods, we examine the structure and function of the vocal cords, larynx (or voice box), trachea, as well as the esophagus and into the stomach if needed, to establish a complete picture of your child’s current condition. This thorough testing allows us to understand the problems and carefully plan your child’s treatment and identify additional issues that may be associated with their injury so that your child receives all the treatment they need.

Our Approach to Treatment

When a child swallows a chemical substance, they should first receive emergency care. Once the patient has been stabilized, they can then be evaluated for esophageal injury and treated appropriately. We typically wait until inflammation has gone down to do surgery, so that the child has one surgery with lasting results, minimizing the need for successive surgeries.

The substance swallowed will burn the esophagus. The damage may appear minimal at first but there are certain spots in the esophagus where the substance is able to collect, causing additional damage as it sits in the same spot for a prolonged period, causing extensive scarring. The scarring makes it difficult for the esophagus to remain open enough to function properly. This can sometimes be treated with steroids and dilation of the injured esophagus.

Caustic ingestion can also sometimes cause injury to the tongue, sides and back of the mouth, causing scarring that can close off the airway.

We treat it by removing all the scar tissue. Depending on how extensive the scarring is, some of the esophagus or pharynx may need to be removed and replaced. We may use a section of the jejunum (the middle part of the small intestine) or part of the colon to reconstruct the damaged areas.

Proper treatment begins with fully understanding their injury. Our goal is to understand the full scope of your child’s condition so we can create a treatment plan to address their individual needs.

Testing includes:

Flexible Esophagoscopy: A small, flexible camera is inserted into the mouth and throat and cautiously down the esophagus to look at the structure and lining of the esophagus and even the stomach if it is safe.

Esophagram: Often we can place contrast into the esophagus during the esophagoscopy and get pictures of the inside of the esophagus and the stomach.

Swallow study: We may get a study of the swallowing function of the mouth and the upper esophagus to evaluate for many issues including swallowing, strictures and aspiration, and fistulas to the airway or tracts into the tissues.

Flexible laryngoscopy: A thin, flexible camera is used to examine the nasal passages, throat, and vocal cords, allowing us to look at the structure of the vocal cords and how they work when your child is breathing normally.

Bronchoscopy: Done with anesthesia under the close care of our expert anesthesia team, a thin tube with a camera is used to examine the trachea, bronchi (the passages between the trachea and the lungs), and smaller airways. We can examine things like the anatomy of the trachea and the shape of the cartilage of the trachea and identify secretions that can be sent to the lab for testing, all of which may indicate the extent of the compression and help uncover related issues.

Positive pressure testing: With the patient under anesthesia, we use positive pressure in the airway to open the posterior membrane. This allows us to see things like holes or fistulas to the esophagus, connections to abnormal lung tissue, strictures and narrowing of the airway, and aids us in identifying any rare anomalies that may be contributing to your child’s airway issues before surgery.

Nasal pharyngoscopy: A thin, flexible camera is guided through the nose to examine the nasal cavity, posterior nasal space, throat and larynx.

Microdirect laryngoscopy: With the patient under anesthesia, we use an operating microscope to examine the larynx (voice box).

CT scan: This is usually done with IV contrast to understand the structures around the esophagus and the airway for treatment planning.

Once we understand the full scope of the patient’s injury, our team works together to create a highly individualized surgical treatment plan that will address all their needs.

Before your child’s surgery is complete, we check that blood is flowing properly through the reconstructed esophagus using a specialized type of imaging that allows us to visualize blood flow. After surgery, part of our focus in your child’s recovery is continuing to monitor that they are receiving adequate blood flow as they heal.

Children typically receive nutrition through a gastrostomy tube (also called a G-tube) after surgery. Swallow studies are done to evaluate their ability to swallow after surgery, and once they are able to swallow and manage their own secretions like saliva, they are slowly transitioned off the G-tube. 

What to Expect

We follow all our patients long-term after surgery. Typically, we’ll have a phone follow up with you about a week after your child’s discharge to home, and then they will have an appointment with us in our clinic about a month after the surgery, and again a year after surgery. At each follow up appointment we will evaluate your child, including their growth, their ability to take food by mouth, and lung function, to monitor their recovery and any changes to their condition.

We understand the challenges faced by our patients from other states and other countries and will work with you and your home physicians. We’ll determine appropriate follow up from there depending on your child’s condition.