Aerodigestive tract foreign bodies

By Dr. Abhilash Antony

Introduction

• Foreign bodies in upper aerodigestive tract – important cause of morbidity & mortality in young and old

• Management of foreign body can be difficult or routine

FB IN THE NOSE AETIOLOGY:Ant. Nares Post. Nares : vomiting, coughing regurgitation, palatal incompetence Penetrating wounds and nasal surgery Sequestration of bone in situ after trauma Calcification in situ of inspissated mucopus around FB ►Rhinolith

• Location : Anywhere in nasal fossa

• Types of FB: • Inanimate : -vegetable : peas,beans,paper etc -mineral FB : metal parts,plastic toys -post surgical : swabs,packs left behind -sequestra : syphillis• Animate : maggots, round worms.

SYMPTOMS SIGNS

Unilateral foetid discharge, mucopurulent, blood stained

Unilateral nasal block Pain EpistaxisSneezing

• Reddened congested mucosa

• Granulation• Ulceration• Necrosis

MINERAL & VEGETABLE FB

RHINOLITH

• Increasing in size slowly • Initially asymptomatic & later nasal block

• Brown or grey irregular mass near floor of nose

• Feels stony hard & gritty on probing

RHINOLITH

DIAGNOSIS

• Anterior rhinoscopy • Posterior rhinoscopy • DNE • Nasopharyngoscopy • X ray nose & PNS

o U/L purulent nasal discharge in a child must be regarded as d/to FB unless proved otherwise……

INSTRUMENTS

• Suitable size speculum • Probe • Hook • Forceps • Suction

MANAGEMENTINANIMATE FB:If FB is seen : Anterior removal with no anesthesia or with

LA GA in case of : - Uncooperative pt.- In anticipation of severe bleeding - Posteriorly placed FB - Strongly suspected FB but not seen in AR & radiolucent

Cuffed oral endotracheal tube with pharyngeal packFB removal anteriorly or through the NPx.A course of Abx,decongestants & analgesics.

RHINOLITH

• With LA for small rhinolith• Under GA for large rhinolith • Through Lat. Rhinotomy approach for very

large rhinolith • Through Caldwell-Luc approach for extension

into the antrum

Lateral rhinotomy

ANIMATE FB

• Instilling 25% chloroform solution into the nasal cavities TID for 6 wks

• Periodic manual removal of maggots• Ascaris : removal with forceps & systemic

treatment

Anatomy of larynx

• Larynx – – Lies in front of hypopharynx (C3 – C6)– 3 paired and 3 unpaired cartilages– 2 joints – cricoarytenoid & cricothyroid

PHYSIOLOGY OF LARYNX

– PROTECTION OF LOWER AIRWAYS• Sphincteric closure of laryngeal opening

– Laryngeal inlet (AE fold, tubercle of epiglottis, arytenoids)– False cords– True cords

• Cessation of respiration• Cough reflex – important and powerful mechanism

– Phonation– Respiration– Fixation of chest

TRACHEOBRONCHIAL TREE

ANATOMY OF OESOPHAGUS

• Muscular tube extending from the pharynx to the stomach.

• 25 cm long.

• Extends from crico-pharyngeal sphincter (C6 vertebra) to cardiac orifice of stomach (T11 vertebra)

• Constrictions of oesophagus:– Pharyngo-oesophageal junction (C6) – 15 cm from

upper incisors– Crossing of arch of aorta (T4) – 25 cm from upper

incisors– Crossing of left main bronchus (T5) – 28 cm from

upper incisors– Oesophageal hiatus (T10) – 40 cm from upper

incisors

• Other sites for foreign body to lodge in food passage are:

• Tonsils

• Base of tongue/vallecula

• Pyriform fossa

Aetiology

• Age• Loss of protective mechanism• Carelessness• Narrowed lumen• Mental state

Types of foreign bodies

– Non irritant - Plastic, glass, metal, COINS

– Irritant Organic – fish and chicken bones, meat, vegetable matter, beans, seeds

• Sharp objects – safety pin

Clinical features

Symptoms Signs

History – initial choking or gagging Tenderness – lower part of neck on right/left of trachea

Discomfort/pain – just above clavicle to right or left of trachea. Discomfort increases on swallowing attempts.

Pooling of saliva – on I.D.L. Doesn’t disappear on swallowing

Dysphagia - Obstruction to swallowing – partial or total

Sometimes, foreign body may be seen protruding from oesophageal opening in post cricoid region.

Drooling of saliva

Respiratory distress

Substernal/epigastric pain

Clinical features of oesophageal foreign body

Clinical features

• Initial period – choking, gagging, wheezing.• Symptomless interval – respi mucosa adapts

to foreign body.• Later symptoms –

• Laryngeal foreign body • Tracheal foreign body• Bronchial foreign body

Symptoms of laryngeal foreign body

Symptoms of laryngeal foreign body

• Symptoms of obstruction ( partial/complete )

• Hoarseness of voice

• Partial obstruction may lead to complete obstruction as laryngeal oedema increases

TRACHEAL FB SYMPTOMS

• Similar to laryngeal FB without hoarseness• Edema can progress to complete obstruction

• 3 signs : - Asthmatoid wheeze - Audible slap produced from FB contact with the

trachea - Palpable thud over the trachea

BRONCHIAL FB SYMPTOMSTypical triad : (65% of pts)

- Cough- Wheezing- Decreased breath sounds

Sudden onset of wheezing particularly if unilateral Respiratory compromise as a result of swelling of dried vegetable matter or edema around the object leading to complete obstruction & lobar collapse (ATELECTASIS) Respiratory distress due to movement of FB

Diagnosis

• Foreign bodies in airway:– Soft tissue x-ray - PA and lateral view of neck in

extended position– Plain X-ray chest PA and lateral view– X-ray chest at inspiration and expiration– Flouroscopy/videoflouroscopy– CT chest

• Foreign bodies in oesophagus:• Plain X-rays – Soft tissue lateral view neck, PA and

lateral view• Flouroscopy

Management

• Laryngeal foreign bodies – • Heimlich’s maneouvre in children and adult/chest

thrusts, back blows in infant• Cricothyrotomy/emergency tracheostomy

Correcting airway obstruction in an infant

5 Back blows - failure

5 Chest thrusts

Continue this sequence till FB is removed or pt

is ready to be shifted to operation theatre.

Back blows in an infant

• Straddle infant face down,

head lower than trunk, over

your forearm, supported on

your thigh.

• Deliver five rapid back blows,

with heel of other hand b/w

shoulder blades.

Chest thrusts in an infant

Supporting pt’s head, keep

infant supine b/w your

hands, with head lower

than trunk.

Using 2 fingers, deliver 5

rapid backward thrusts on

sternum.

cricothyrotomy

• Tracheal & Bronchial foreign bodies –• Conventional rigid bronchoscopy• Rigid bronchoscopy• Bronchoscopy with C-arm flouroscopy• dormia basket/fogarty’s balloon• Tracheostomy first – bronchoscopy through

trachostoma• Flexible fibre optic bronchoscopy

• Oesophageal foreign body• Oesophagoscopic removal• Cervical oesophagotomy• Transthoracic oesophagotomy

BRONCHIAL FB REMOVAL

• Healthy bronchus examined first • Secretions gently suctioned • 100% oxygen • Forceps are placed through the bronchoscope & FB is engaged • Bronchoscope, Forceps & FB removed as a unit • Bronchoscope is returned to airway immediately for

ventilation & assessment of other FB • Large FB may be broken or tracheotomy performed • If endoscopic retrieval fail, thoracotomy required

ESOPHAGEAL FB REMOVAL• Esophagoscope passed through the right side of mouth &

directed toward PF • Scope angled toward the sternal notch

• Esophagoscope, Forceps & FB removed as a unit

• Esophagoscope is reinserted to assess the condition of mucosa & other FB

SHARP & LONG OBJECTS REMOVAL • Tip of pointed object engages the mucosa • Endoscope is aligned parallel to long axis of airway or

esophagus • Object first moved distally & then removed • Pin-bending forceps may be used for bendable objects

• If severely impacted, open surgical approach may be the safest

• In children < 2yrs , endoscopic removal of long or large ingested objects is preferred

Following removal

• Second look for other / remnant FB

• Aspiration of pus & mucus • Inspection of all major bronchopulmonary segments including

upper lobe orifices

DISK BATTERY INGESTION

• Peak incidence : 1-2 yrs old

• Requires immediate action

• In 1 hr : mucosal damage • In 4 hrs : erosion of muscular wall of esophagus • In ≥ 6hrs : esophageal perforation mediastinitis / ►

tracheoesophageal fistula / death

• Radiography • Check the pts stool in asymptomatic pts

• Return to the hospital if fever or abdominal pain occur

• In children < 6yrs , endoscopic removal of a battery ≥15mm in diameter preferred if not passed out within 48hrs

PILL INGESTION • Pills may lodge in esophagus due to delayed transit, dry

swallow, adherent tablets or supine swallow • Caustic injury to eso. mucosa on prolonged contact

• Symptoms : sudden onset of retrosternal pain, dysphagia, odynophagia, fever, hematemesis & dehydration

• Most resolve within days to weeks

ESOPHAGEAL PERFORATION Caused by : object , length of time the object has been lodged , attempts

to retrieve the object

Radiography : cervical subcutaneous emphysema, retroesophageal abscess, obvious extraluminal portion of FB

Signs : fever, tachycardia, tachypnea, increased pain Esophagography to locate & evaluate extent of injury

Pharyngoesophageal perforation : most common area injured in esophagoscopy

NPO / Broad spectrum antibiotics In more severe cases : drainage, closure, surgical repair

POSTOP MANAGEMENT NPO for 4 hrs

Monitoring for fever, tachycardia, tachypnea, increased pain Antibiotics in significant esophageal injury

Systemic corticosteroids (dexamethasone 0.5 mg/kg) if bronchoscopy prolonged or bronchoscope tight fit in subglottic larynx

When appropriate-sized bronchoscopes used, epinephrine or corticosteroids are not given

Chest physiotherapy Repeat x rays in persistent or progressive symptoms If extraction fail or incomplete, pt. is rested for several days

Complications of Bronchial foreign body removal

• Most complications result from delayed diagnosis & treatment

• Pneumonia & atelectasis are the most common after

bronchial FB removal

• Bleeding • Pneumothorax & Pneumomediastinum • Granulation tissue/ stricture formation

ESOPHAGEAL FB COMPLICATIONS

• Rare • COMPLICATIONS:

– retroesophageal abscess, –mediastinitis, –death

Complications of neglected FB

• Oesophageal ulceration & stricture• Oesophageal perforation mediastinitis• Peri-oesophageal cellulitis• Retro-pharyngeal abscess• Respiratory obstruction due to – tracheal compression – laryngeal oedema

THANK YOU