Foreign Bodies of Aero-Digestive Tract

Dr. Krishna KoiralaMBBS, MS ( ENT-HNS)Associate Professor

MCOMS, Pokhara2016-05-24

Introduction• Foreign Body in Aero-digestive tract

is a common clinical occurrence

• It is an ENT Emergency

• Foreign Body enters the body by either

– Ingestion: “F.B. Esophagus”

–Aspiration: “F.B. Bronchus”

Foreign Body ingestion• Epidemiology

– Children >>> Adults

– Boys > Girls

– No Racial / Geographical Predisposition

Etiology• More common in children

– Lack Molar teeth, poor mastication

– Natural tendency to put objects in mouth

– Play with objects inside mouth

– Easy Distractibility

• Types of F.B

– Coins: Commonest in children

– Household items, Pen cap, Small Toys

– Meat Bone: Commonest in Adults

Pathogenesis• Foreign Body lodges in esophagus at

– Just below Crico-pharynx ; Commonest ; ??

–Above Crico-pharynx

–Above Aortic constriction

–Above Left Bronchial constriction

–Above Gastro-esophageal junction

Symptoms• Odynophagia /Dysphagia

• Drooling of Saliva

• Refusal to take oral feeds

• Fever + Prostration

• Difficulty breathing

• Chest / Back Pain

• Collapsing Child

• Hematemesis

Signs• Usually no clinically elicitable signs

• Drooling saliva

• Fever

• Tachypnea

• Tachycardia

• Hamman’s Sign– Seen in esophageal Perforation with

pneumomediastinum

– Quashing sound over precordium with each heartbeat

Investigations• X-ray Neck and Chest – Always get both AP and Lateral views

– Radio-opaque foreign body easily seen

– Radio-lucent F.B. evidenced by Air in the Esophagus

• Barium Swallow– Radio-lucent F.B well visualized

• Esophagoscopy– Diagnostic as well as Therapeutic

Radio - Opaque F.B Esophagus

Double Lumen Sign: Disc Battery

Radio-Lucent F.B Esophagus

Treatment• Observation

• Balloon Catheter Removal

• Rigid Esophagoscopy and removal with forceps

• Thoracotomy

1. Observation– Usually for 24 hours

• Immediate presentation

•Blunt foreign body below the cricopharynx

•Child Stable

– Spontaneous passage of foreign body into the stomach is expected

– If it doesn’t pass into stomach, Esophagoscopy is done

– C/I: Disc Battery Ingestion: emergency (Risk of liquifactive / coagulation necrosis)

2. Balloon Catheter Removal–Performed in centers where there is no

access to esophagoscopy

–90 % efficacy

–Advantages: No GA, Cost effective

–Complications: Emesis, Tracheal placement

–Esophagoscopy needed in case of failure

3. Rigid Esophagoscopy and foreign body removal with forceps

– Gold Standard Modality

– GA Needed

– Complications

•Iatrogenic Perforation, Oro-dental injury

4. Thoracotomy– Migrated F.B, unsuccessful rigid

esophagoscopy

• Epidemiology

– More common in children than adults

– Boys > girls

– No racial / geographical

predisposition

Foreign Body Aspiration

Etiology• Commonly seen in children

– Poor airway reflexes– Lack Molar teeth ,poor mastication

– Natural tendency to put objects in mouth

– Play with objects inside mouth– Easy distractability

• Type of F.B

– Vegetable Matter: Peanuts Commonest

– Pen cap, whistles, safety Pin

Pathogenesis• Foreign Body lodges in

– Bronchi

•Right Main Bronchus Commonest

•Sitting / Standing Position

–Rt. Lower Lobe- Lower portion •Supine Position

–Rt. Lower Lobe- Upper portion– Trachea– Larynx

Right main Bronchus- Straighter and Wider

Symptoms• Choking

• Gagging

• Violent Coughing

• Dyspnea

• Stridor

• Wheezing

• Cyanosis

• Hoarseness

Signs

• Inspiratory Stridor

• Bi-phasic Stridor

• Expiratory Stridor

• Unilateral Wheezing

• Decreased Breath Sounds

Investigations• X-ray Neck and Chest

– PA and Lateral Views– Inspiratory and expiratory films – air

trapping– Atelectasis– Pneumonitis– Consolidation

• Airway Fluoroscopy– Radio-lucent F.B

• Bronchoscopy – Diagnostic as well as therapeutic

Radio - Opaque F.B Rt. Main Bronchus

Radio-Lucent F.B. Rt. Lung ( Hyperinflation)

Radio-Lucent F.B Lt. Bronchus (Atelectasis)

Radiolucent F.B seen on Fluoroscopy

Treatment• Rigid Bronchoscopy and foreign body

removal

– Gold Standard

• Fiber-optic Bronchoscopy

– F.B in distal bronchus

• Tracheostomy & F.B Removal

– Large F.B in Sub-glottis

• Thoracotomy: Migrated F.B

F.B . Trachea

Bronchoscopes

Optical forceps

Net F.B retrieval system

First aid ‘choking’

• Back blows

• Abdominal thrusts /Heimlich maneuver

• Chest thrusts

Back Blows

Five rapid blows given by heel of hand between shoulder blades

Abdominal thrusts

5 rapid thrusts given between umbillicus and xiphisternum

Chest thrusts

5 rapid thrusts given in middle of sternum

Errors to avoid in suspected foreign body cases

• Do not reach for the foreign body with the fingers

• Do not blindly pass an esophageal bougie or other instruments

• Do not hold up the patient by the heels

• Do not fail to have an X-ray done

• Do not fail to search endoscopically for a foreign body in all cases of doubt

• Do not tell the patient he has no

foreign body until after X-Ray

examination, physical

examination, indirect examination

and endoscopy all have proven

negative