Foreign Bodies of the Airway, Esophagus and Ear

Foreign Bodies of the Airway,
Esophagus and Ear
Presented by
Nannaphat pradutdecha
Lauren DH, Sheri AP. Foreign bodies of te
airway and esophagus. Cummings
otolayngology Head & neck surgery. 5th
ed. Philadelphia : Elsevier, 2010 : 2935-43
 Nancy Sculerati. Foreign body of the nose.
Pediatric otolaryngology. 4th ed.
Philadelphia : WB Saunders Co, 2002 :
FB result in approximately 150 deaths per
year in children secondary to
 Most deaths occur before hospital
 Most aerodigestive foreign bodies are
 The highest incidence occurs between 1
and 3 years of age
◦ 25% of patients are younger than 1 year.
Lack posterior dentition (molars - necessary for
proper grinding of food)
Less-controlled coordination of swallowing,
and immaturity in laryngeal elevation and
glottic closure
Oral exploration (age-related tendency to explore the
environment by placing objects in the mouth)
Easy distractibility (often running or playing at the time
of ingestion)
The most common esophageal FB are coins ,75%
Round objects, trinkets, disk batteries, and sharp
objects constitute less than 20% of impacted
esophageal FB
Multiple esophageal FB impactions, 80% have an
esophageal anomaly
Recurrent esophageal FB, 19% have esophageal
anomalies that previously required surgical repair
Vegetable matter is seen in 70-80% of
airway FB ingestions
the most common
◦ peanuts in the United States
◦ watermelon seeds in Egypt
◦ pumpkin seeds in Greece
Plastic pieces constitute approximately 515% of airway FB -tend to remain longer
because they are inert and radiolucent.
Most airway FB lodged in bronchi
 common in the right main
bronchus in adults
◦ position of the carina to the left of
the midline
◦ lesser angle of divergence from the
tracheal axis
children : right = left main bronchi
(no clear explanation)
Most esophageal FB impact in
cervical esophagus just below
cricopharyngeus muscle
 Another 4% to 5% of
esophageal foreign bodies
become lodged at
◦ midesophagus
◦ distal esophagus
often caused by extraluminal
compression --aortic arch or
left main bronchus
Figure 72-1. Schematic view of the esophagus and its relationship to neighboring structures. LES, Lower
esophageal sphincter; UES, upper esophageal sphincter.
(Reprinted with the permission of the Cleveland Clinic Foundation.)
Management of choking victims
rescue breaths and chest
Children > 1 year
require gentle abdominal
thrusts while supine
Older children and adults
Heimlich maneuver
(standing, sitting, or recumbent)
Note : Back blows or abdominal thrusts in individuals
with only partial obstructions could lead to complete
obstruction and are not recommended.
Three clinical phases of FB aspiration
 Initial phase occur at the moment of during
aspiration--choking, gagging, and paroxysms of
coughing or airway obstruction
 Asymptomatic phase when FB becomes lodged,
and the reflexes fatigue --choking, gagging, and
coughing are subside, can last hours to weeks
 Third phase--complications from obstruction,
erosion, or infection causes hemoptysis,
pneumonia, atelectasis, abscess, or fever
Site of the
•Irregular FB or orientation in sagittal plane may
produce only partial obstruction, allow air flow but
laryngeal edema can lead to complete obstruction.
•Typical: symptoms of obstruction and hoarseness,
some mimic croup
•Typically do not have hoarseness
•Three signs associated with tracheal FB: asthmatoid
wheeze, audible slap and palpable thud
Triad of cough, wheezing, and decreased breath sounds. One large series
reported that 65% have the classic triad but 95% have at least one
airway foreign bodies,
80-90% are found in the
•vomiting, odynophagia, dysphagia, ptyalism
•A large FB may cause symptoms of airway
obstruction and cough (compression or irritation of
upper airway)
•In long-standing impaction, fever and other symptoms
Daksheh H. pahrik. Paediatic thoracic surgery. P 359
Laryngotracheal Foreign Bodies
A 17 month old male presents to the ED in the evening with a one-hour history of noisy and abnormal breathing after a
choking episode while he was eating a chocolate and almond bar. He was able to speak and drink fluids without difficulty
VS T36.8, P200 (crying), R28 (crying), oxygen saturation 99% in room air. He appeared alert, with no signs of respiratory
distress. He was able to speak, had no cyanosis, no drooling, and no dyspnea. His lung sounds showed mild wheezing with
possible mild inspiratory stridor. An albuterol aerosol was administered but no improvement was noted. A chest
radiograph was ordered
Bronchial Foreign Bodies
check-valve effect : expiration ,resulting in hyperinflation of
the affected side and mediastinal shift to the opposite side
Bronchial Foreign Bodies
ball-valve effect is produced later when FB obstruct on inspiration and
open on expiration, producing atelectasis on the affected side and a
mediastinal shift toward the affected side
Esophageal Foreign Bodies
Food or true foreign bodies
◦ Chicken bones (opaque), fish bones (non-opaque)
◦ Coins, toy trucks
Most often they impact just below cricopharyngeous (70%)
◦ Another 20% impact at the level of the aortic arch
◦ Another 10% at EG junction
 History taking
 standard radiographic : posteroanterior
and lateral airway and chest films
 NPO for 6 hours, and adequately
 Age-appropriate equipment for
endoscopic foreign body removal
Guidelines for Selection of Bronchoscope,
Esophagoscope, and Laryngoscope for
Diagnostic Endoscopy by Age
under GA : provide optimal airway control
and patient comfort
 method of evaluation and removal of FB
should be communicate with anesthesiologist
 Patients are placed supine for mask induction
using volatile inhalational agents
 Eye protection prevents corneal abrasions
 Topically anesthetized with 1% to 4% lidocaine
to inhibit laryngeal reflexes and to reduce the
incidence of laryngospasm.
Laryngeal FB
◦ Preoxygenated then mask induction
◦ anesthesia is maintained with an insufflation
catheter through the nares into the hypopharynx
Tracheobronchial FB removal
◦ laryngoscope tip is placed in the vallecula to
expose the larynx for passage of the bronchoscope
◦ breathes through bronchoscope until finish
Esophageal FB
◦ patient undergoes ETT
◦ ETT prevents inadvertent aspiration of FB into the
airway during attempted removal
◦ minimizes any tracheal compression caused by a
rigid esophagoscope
Bronchial FB
Healthy bronchus is examined first
Bronchoscope is positioned above the foreign body,
and secretions are gently suctioned to expose the
object fully
 Preoxygenated before the attempt at removal
 Bronchoscope, forceps, FB are removed as a unit
 Bronchoscope is returned immediately to the airway
for ventilation and assessment for other FB
simultaneous biplane fluoroscopy can be used for
extraction of radiopaque foreign bodies in the lung
esophageal FB
Esophagoscope is passed through right side of mouth
and directed toward pyriform sinus, angled toward
sternal notch
 Esophageal lumen is kept in view at all times while
gently advanced until FB is visualized
 FB is engaged with the forceps; esophagoscope is
advanced toward the object and removed as a single
 Esophagoscope is reinserted to assess esophageal
mucosa and to identify additional FB below the
primary one. (Multiple foreign bodies are found in 5%
of pt.)
Removal of Sharp Objects
Tip of a pointed object engages mucosa, causing
point trailing
Safety pins : Two methods of removal are suggested
1) sheathing the point within the endoscope while
locking the forceps closed to hold the keeper against
the outside of the tube particularly during extraction
through the larynx
2) gastric version (under fluoroscopic guidance) of
esophageal safety pins, using rotation forceps to flip
the safety pin point down within the stomach
Kenny H. Chan, et al.Endoscopy of the Aerodigestive Tract. In : Bluesone CD.
Surgical Atlas of Pediatric otolaryngology. 2002 :581
Removal of Sharp Objects
Severely impacted or embedded sharp object ,
open surgical approach may be the safest method
of FB removal
 Long or large objects in children younger than 2
years may not pass through the duodenum,
remove these objects from the stomach
endoscopically before they migrate further or
perforate a bowel wall
Disk batteries
are commonly used in hearing aids, calculators,
watches, and other portable electronic devices
Peak incidence of ingestion occurs at age 1 to 2
33% of cases, the ingested battery is from the
child's hearing aid
Mercuric oxide–containing batteries can cause
systemic mercury poisoning if they open in the
gastrointestinal tract
Disk batteries
In 1 hour, esophageal mucosa damaged
 In 4 hours, leakage of caustic battery
contents cause erosion muscular wall of
 Within 6 or more hours, esophageal
perforation leading to mediastinitis,
tracheoesophageal fistula, or death may occur
From: Foreign body of the pharynx and esophagus. Pediatric otolaryngology. 4th ed. Philadelphia : WB Saunders Co, 2002 : 1327
Esophageal Perforation
Caused by the object itself, length of time that
lodged, attempts to retrieve object
 Preoperatively esophageal perforation may be
diagnosed on preoperative radiographic, cervical
subcutaneous emphysema, retroesophageal
abscess or obvious extraluminal portion of the
esophageal FB
 Early signs of a perforation: fever + tachycardia,
tachypnea, increased pain
Esophageal Perforation
Early recognition and management, decreased
mortality rate for esophageal perforation has
from 60% to 9%
 NPO and broad-spectrum ATB,necessary in
pharyngoesophageal perforations (the most
common area injured in endoscopic removal of
esophageal FB)
 In more severe injuries, drainage, closure, or
more complex surgical repairs may be necessary
Postoperative Management
After esophagoscopy
NPO for 4 hours
 monitored signs of perforation: fever,
tachycardia, and tachypnea
 ATB are not routinely given unless significant
esophageal injury
Postoperative Management
After bronchoscopy
When appropriate-sized bronchoscopes are
used for brief procedures, epinephrine or
corticosteroids are not given.
 Chest physiotherapy may help to clear
inspissated secretions
 Routine postoperative radiograph is
unnecessary unless the patient's symptoms
persist or progress.
Postoperative Management
After bronchoscopy
Fail extraction or incomplete, patients are
rested for several days, and then returned to
the OR for repeat endoscopy
 Recovery time of more than 1 week was
associated with preoperative inflammatory
findings by radiologic study, procedure time
greater than 50 minutes, and worsening
postoperative radiologic findings
Pneumonia and atelectasis are the most common
complications after bronchial FB removal.
◦ Pt. usually respond to intravenous ATB and chest
◦ Bleeding can occur because of granulation tissue or
erosion into a major vessel
◦ Pneumothorax and pneumomediastinum can result
from an airway tear.
◦ Laryngeal inflammation and edema have decreased
significantly with the use of appropriate-sized
Long-term complications : granulation tissue,
stricture formation occur at site of lodged
 During esophagoscopy, ETT may be dislodged,
and the patient may have cricopharyngeal spasm,
esophageal mucosal injury, or perforation
 After esophagoscopy, vomiting, aspiration, a
second missed FB and fever are the most
common complications
 Esophageal perforation, retroesophageal abscess,
mediastinitis, and death are rare
Controversies in Management
Flexible bronchoscopic removal is not
recommended,especially in small children-poor control airway and FB
 Impacted esophageal FB, nasogastric tube
has been proposed to push FB into
stomach,blind technique may cause
esophageal injury (not universally
Controversies in Management
Foley catheter removal with fluoroscopic control of blunt
radiopaque esophageal FB, recommended for a single object
lodged below cricopharyngeus for a short duration
◦ Advantages : reduced cost and avoidance of general anesthesia.
◦ Disadvatage: not allow a postretrieval assessment of esophageal
mucosa or identification of a nonradiopaque second FB
◦ coin is not grasped using this technique, loss of control of coin
at the level of posterior pharynx can result in an airway
◦ risk of vomiting and aspiration with an unprotected airway,
emotional traumaand (awake and restrained in a steep headdown position)
Controversies in Management
Papain (meat tenderizer) has been used in
impacted esophageal meat boluses
◦ Papain was given as a 5% solution to adult
patients, with the meat passing in most
◦ at least two cases of mediastinitis and death in
these patients caused by necrosis of the
esophagus and perforation.
Controversies in Management
Flexible esophagoscopy has been used for
removal of blunt objects or meat
impaction. Sharp objects pose a greater
risk because of inability to sheath the
object as with a rigid esophagoscope
Foreign body of the nose
◦ Persistent rhinitis, unilateral purulent
◦ Adenoiditis
◦ sinusitis
◦ Adult witness child putting something in nose
Foreign body of the nose
◦ Seeds swell when moisted by nasal secretion ,
Increase impact overtime
◦ Foam rubber increase irritation with oxidation
and breakdown material
◦ Plastic or other inert material gradual formation
of granulation obscure FB cause pressure erosion
of surrounding bone
◦ Button batterries rapidly cause severe mucosal
burn  septal perforation , saddle nose
Foreign body of the nose
 Decongestant
 Anterior rhinoscope : nasal speculum,
 Frazier suction tube
 เตรี ยมRight angle hook, flexible cerumen
curette and alligator forceps
 Restrain or sedate or under brief GA
Foreign body of the nose
ใส่guazeชุบadrenaline or antibiotic oinment
 ให้ ATB
 ให้ ยาแก้ ปวด
Formed from intranasal
FB that encrusted with
mineral salt ( Calcium,
 Treatment : remove
 ถ้ าช่องหูบวม ทาให้ ยบ
ุ บวมก่อน
 ส่องดูในหูวา่ มีสงิ่ แปลกปลอมหรื อไม
 เลือกวิธีนาสิง่ แปลกปลอมออก : ดูดออก, ฉีดน ้า, ear hook,
alligator forceps
 ให้ ATBหยอดหู หรื อกิน
 ให้ ยาแก้ ปวด

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