------------------------------------------------------------------------------ TITLE: Foreign Bodies in the Aerodigestive Tract SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds DATE: 30 October 1991 RESIDENT PHYSICIAN: Eric Bridges, M.D. FACULTY: Byron J. Bailey, M.D. DATABASE ADMINISTRATOR: Melinda McCracken, M.S. -------------------------------------------------------------------------------- "This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." I. Introduction A. History - Techniques of endoscopy for foreign bodies codified by Jackson and Jackson in 1936. - Use of a Foley catheter for removal of foreign bodies from the esophagus reported by Bilger in 1966. - Mohammed and Hededus reported the use of carbonated beverages in dislodgement of impacted esophageal foreign bodies in 1986. B. Epidemiology - Foreign body ingestion and aspiration has been a recognized problem since ancient times and reported in the medical literature since the early 1800's. - The U.S. National Safety Council reports that there are approximately 1000 deaths per year due to foreign body ingestion or aspiration. - Suffocation from aspiration or ingestion of foreign bodies is the third leading cause of accidental death in children younger than 1 year of age and the fourth leading cause in children 1 to 6 years. - Foreign body ingestions outnumber aspiration about 2 to 1. - Seventy percent of all foreign bodies ingested into the food and air passages occur in children younger than 14 years of age. - Age is a significant factor in the incidence of foreign body ingestion as 55% of patients are children younger than 4. - Laryngeal foreign bodies are more common in children younger than 1 year of age. - A small percentage of esophageal foreign penetrate the esophagus (31 of 2902 in one series and 25 of 2394 in another) and there have been only 321 cases reported in the world literature from 1818 to 1983. II. Evaluation A. Signs and symptoms 1. Esophageal foreign bodies - Foreign body ingestion should be considered in the differential diagnosis of any child with a history of a choking, gagging, coughing, or vomiting episode who is subsequently undergoing evaluation for dysphagia, weight loss, fever, or airway symptoms. - Children and adults with known structural or functional abnormalities of the esophagus (e.g., repaired T-E fistula, achalasia, previous esophageal injury) are at increased risk for retained foreign bodies including foodstuffs. - Foreign bodies which have perforated the esophagus may present as neck abscesses, mediastinitis, peritonitis, persistent infection of the respiratory tract, or aorto-esophageal fistula. - Fistulas between the blood vessels of the neck or chest and alimentary tract are often signaled by a sentinel bleed. 2. Laryngeal foreign bodies - Frequently cause complete airway obstruction and sudden death. - Partial obstruction may cause hoarseness, croupy cough, aphonia, odynophagia, hemoptysis, wheezing, and varying degrees of dyspnea. - Laryngeal symptoms and signs may be due to a foreign body initially lodged in the larynx which then migrated to the trachea or bronchus. 3. Tracheal foreign bodies - An audible slap heard at the open mouth during cough. - Palpatory thud with respirations. - Asthmatoid wheeze heard with the ear at the patient's mouth. 4. Bronchial foreign bodies - Three distinct stages of a foreign body accident: a. violent paroxysms of coughing, choking, gagging, and airway obstruction that occur immediately when the foreign body is swallowed or aspirated. b. an asymptomatic interval when the foreign body becomes lodged and reflexes are fatigued with subsidence of symptoms. c. symptoms of complications such as obstruction (atelectasis), emphysema, lung abscess, fever, hemoptysis. - The relatively asymptomatic second stage of foreign body presentation accounts for the fact that over 25% of foreign bodies are undetected for more than a week. B. Imaging - Routine studies include plain radiographs of the neck and chest. - In foreign body ingestion, lack of a foreign body in the neck or chest on X-ray examination should include abdominal imaging. - A lateral chest radiograph with the neck flexed, head extended, and arms behind the back allows visualization of the entire airway from the mouth to carina. - Inspiratory and expiratory films can show differential expansion of each lung suggesting partial obstruction, but may be difficult to obtain. - Videofluoroscopy allows a dynamic examination of the airway without excessive radiation exposure. - Contrast esophagrams may be helpful in visualizing radiolucent foreign bodies which are not completely obstructing. - CT or MRI scan can show the location of foreign bodies which may have become extraluminal and are not found at endoscopy. - Arteriography may be indicated in penetrating foreign bodies which are causing vascular complications such as carotid artery aneurysm or pseudoaneurysm of the aorta. - Bronchograms may occasionally be useful in outlining a radiolucent foreign body that is too peripheral for endoscopic visualization. III. Management A. General considerations - Most foreign bodies which present to the otolaryngologist have passed the acute the stage and should not be considered emergencies. - A careful, complete history and physical examination of the patient along with appropriate radiographic studies should be completed before attempted endoscopic removal of any foreign body which is not acutely or imminently likely to occlude the airway. - The parents of children should be counseled on the complications of foreign body ingestion, including smooth, blunt foreign bodies, which if present for an extended period of time prior to removal may be as risky if not more risky to remove than sharp objects. - Parents should never be promised removal of foreign bodies on the first attempt as circumstances may dictate that endoscopic removal is more risky than leaving the object and pursuing alternate methods of removal. - The anesthesiologist should be considered a part of the endoscopic team and intimately associated with the findings in the patient and planned course of action. - With the possible exception of common esophageal foreign bodies (e.g., coins), it is highly desirable to practice extraction on a duplicate foreign body, to determine problems with forceps purchase, object rotation, and insecure fit. Parents may be sent home to retrieve a duplicate foreign body for practice. - Two hours spent in preparation for a procedure may allow endoscopic removal in two minutes, while two minutes spent in preparation may result in attempting makeshift, ineffective procedures for two hours. - The Heimlich maneuver is the only non-endoscopic procedure that should be used to remove foreign bodies, and the indications for performing this procedure must be closely followed. B. Anesthesia - Topical anesthesia may suffice for foreign body removal in cooperative adult patients, particularly when using flexible endoscopes. - Most children require general anesthesia for safest removal of foreign bodies. - In the presence of airway obstruction, sedation is contraindicated and the patient should be breathing spontaneously at all times. - After a 6 to 10 minute breathe down of inhalation agent, the endoscopist should expose the larynx in case the foreign body is in the larynx or hypopharynx, and spray lidocaine in the larynx prior to intubation with the rigid ventilating bronchoscope. - Positive pressure ventilation is avoided, since this tends to drive tracheo-bronchial foreign bodies further distally. C. Instrumentation - In general, rigid bronchscopes and esophagoscopes are more useful in foreign body extraction than flexible endoscopes. - A complete armamentarium of instruments is essential, all in good working order. Lack in proper instruments is never a valid excuse for failure to remove a foreign body or lose a patient. - Occasionally flexible endoscopes may be used in concert with rigid instruments, particularly in peripheral bronchial objects in adults. - Suggested endoscope sizes for infants and children are listed in Table 80-4, but the actual bronchoscope used should easily pass through the subglottic cricoid ring. - At least 60 variations of four basic types of forceps exist, these being forward-grasping, rotation, ball-bearing, and hollow object. D. Techniques of laryngeal, tracheal, and bronchial FB extraction - The position and presentation of the FB must be noted prior to extraction and any sharp points buried in the mucosa freed. This can be accomplished bye using the tip of the scope or as shown in Figure 22. - The foreign body is rotated to the largest diameter of the lumen for extraction; the esophagus, this is the coronal plane, in the larynx the sagittal plane. - Pointed objects must be sheathed within the endoscope or rotated and removed with the point trailing. - Fluoroscopy may be required to remove objects in the lung periphery. It must be kept in mind that the fluoroscope does not visualize the tissues between the forceps blades and the foreign body. - Try to avoid driving a FB further down; get around it and pull it back with the forceps. The FB should be anchored against the mouth of the scope and scope, forceps, and FB removed as a unit. - The tracheobronchial tree should be inspected completely to rule out the presence of multiple foreign bodies. The anticipated normal lung is observed first, suctioned of secretions to obtain optimal function for inspection of the pathologic side. - Forcep spaces may be obliterated by granulations or edematous mucosa. The scope may be pushed past granulations or they may be removed with suction. Bleeding can be controlled with topical epinephrine 1:30,000 on a sponge-carrier. - Vegetable foreign bodies such as peanuts and carrots are grasped lightly with peanut forceps to avoid fragmentation. 1. Causes of "stripping off" - Factors which cause the FB to be stripped from the grasp of the forceps include three related to the forceps and three related to the FB: (1) faulty application of the forceps, (2) wrong forceps for the problem, and (3) mechanically imperfect forceps; (a) poor orientation of the FB (solution: rotate the object 90 degrees at the vocal cords), (b) failure to anchor the FB against the tube mouth, and (c) a FB that is too large for the lumen (solution: fragment the FB or remove it through a tracheotomy). E. Techniques of esophageal foreign body removal - Foley catheter removal of foreign bodies has been advocated by various non-endoscopic specialists when endoscopic facilities are unavailable or distant. This procedure is generally discouraged by endoscopists, but if it is to be utilized must follow certain guidelines: a smooth, radiopaque object, cooperative patient, lodgement less than 48 to 72 hours, barium esophagram negative for complete obstruction, multiple foreign bodies, or underlying esophageal disease, and an endoscopist standing by to management the airway. - The failure rate of foley catheter extraction of FBs is reported at 15% with no airway complications. - The use of gas-forming agents or carbonated beverages has been reported by Rice et al. and Mohammed and Hegedus. The failure rate is 20% with these methods and was without complications. - Proteolytic enzymes should not be used to dissolve foodstuffs impacted in the esophagus as they can also digest an inflamed, ulcerated esophageal wall. - Most common location for lodgement of esophageal foreign bodies is at the cricopharyngeus level followed by the midthoracic level and the G-E junction. This corresponds to the anatomic narrowings shown in Figure 2. - Sharp objects should have their points sheathed in the scope prior to removal or if that is not possible, advanced into the stomach, reversed in direction and be removed with the points trailing. - Gastric version of sharp objects requires insufflation of air into the stomach. To insufflate the stomach may require use of the flexible endoscope. - Razor blades should be sheathed within the esophagoscope or a flexible overhood prior to removal. A simple gastrotomy may be required to remove razor blades in the stomach. - Jackstones are a fairly common pediatric foreign body and frequently present with some form of airway compromise due to compression of the party wall. These should be removed by grasping the point with the ball on the end. - There are 5 parts to an open safety pin: point, point shaft, spring, keeper shaft, and keeper. In open safety pin problems the point is invariably "up" with the keeper being the presenting part. If the point cannot be delivered into the scope, ring rotation forceps are used to advance the pin into the stomach and gastric version attempted. - Following removal of a foreign body, the esophagus should be reinspected by other foreign bodies. IV. Post-operative care and complications. A. Airway foreign bodies - Antibiotics or steroids are not given. Chest physiotherapy is used in patients with long-standing pneumonia, purulent bronchitis, and atelectasis. - The exception to steroid use is in the patient who develops laryngeal or subglottic edema due to the endoscopic procedure who has undergone attempted removal elsewhere prior to referral. This is treated with head elevation, racemic epinephrine, and high-dose dexamethasone (1 to 1.5 mg/kg up to a 30 mg bolus). - Complications include perforation of a bronchus on endoscopic removal with pneumothorax, pneumomediastinum, or vascular perforation. Long-standing foreign bodies can cause bronchial stenosis, bronchiectasis. B. Esophageal foreign bodies - Patient should be closely monitored for signs of perforation with developing suppurative symptoms in the neck, chest, or abdomen. - Long-standing foreign bodies can present with vascular or suppurative complications prior to removal. - There are documented cases of rapid exsanguination after acute perforation of the esophagus and carotid artery by sharp objects. - Disc battery ingestion can lead to rapid necrosis of the esophageal wall and should be removed emergently when discovered in the esophagus. The mechanism for this injury seems to be contact of the concentrated electrolyte solution in the battery with the esophagus. These batteries are most likely to lodge in the esophagus of children when the battery is greater than 23 mm in diameter. - False aneurysm of the aorta has been reported as complication of long-standing esophageal foreign body. - Perforation of the esophagus is almost invariably accompanied by pain, with cervical perforations causing neck or chest pain and thoracic perforations causing chest or abdominal pain. Fever, tenderness, subcutaneous or mediastinal emphysema also accompany perforation. - Management of esophageal perforations is not standardized with various authors recommending conservative therapy vs. drainage vs. repair. The mortality from esophageal perforation of all types is in the range of 20%, increasing with delay in diagnosis. ---------------------------------END------------------------------------- TEST QUESTIONS - The following test questions are intended to provide proof to accrediting agencies that you have read and understood the entire Grand Rounds element. Your answers should be based on the text of the Grand Rounds element. Answers should be sent by e-mail addressed to fbquinn@utmb.edu. Answers can be sent by U.S Postal Service mail, using a plain sheet of paper on which the Grand Rounds element and the subscriber are fully identified. Correct answers will be transmitted to the subscriber via e-mail. Comments and alternative points of view should be expressed at the end of the list of the subscriber's answers. The University of Texas Medical Branch (UTMB) is accredited by the Accreditation Council For Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. UTME designates this continuing medical education activity for 1 credit hour in Category 1 of the Physicians's Recognition Award of the American Medical Association. 1. An audible slap heard at the open mouth during cough most likely represents a. a tracheal foreign body b. a bronchial foreign body c. an esophageal foreign body d. atelectasis 2. Routine imaging studies in the evaluation of a patient with an aerodigestive tract foreign body should include: a. videofluoroscopy of the upper airway b. CT or MRI of the neck and chest c. plain radiographs of the neck and chest d. all of the above 3. A four year old patient is know to have ingested a sharp foreign body which was not seen on endoscopy. Which of the following would most likely help to localize an extraluminal foreign body? a. plain radiograph of the abdomen b. arteriography c. videofluoroscopy d. CT or MRI of the neck and chest 4. The only non-endoscopic procedure that should not be used to remove foreign bodies in the aerodigestive tract is a. having the patient swallow a tethered ferromagnet b. indirect laryngoscopic instrumental removal c. Heimlich maneuver d. blind instrumental removal 5. A two year old boy has a foreign body in the esophagus. The safest method of removal is via a. I.V. sedation b. physical restraint without anesthesia c. general anesthesia d. rectal sedation 6. A thirtyfive year old man has a laryngeal foreign body. Your first choice of anesthesia should be a. topical b. general endotracheal c. I.V. sedation d. rectal sedation 7. The most common location for lodgement of esophageal foreign bodies is a. mid-thoracic level b. cricopharyngeal level c. gastro-esophageal junction d. lodgement is equally likely at all levels 8. In the postoperative care of a patient with an airway foreign body, use of steroids is indicated a. routinely b. in the patient who develops atelectasis c. in the patient who develops pneumonia d. in the patient who develops laryngeal edema 9. A three year old girl is seen in the emergency room after ingesting a watch (disc) battery. Radiographs show the battery to be localized at the level of the cricopharyngeal sphincter. The most appropriate management of this patient is a. emergency endoscopic removal b. Heimlich maneuver c. administration of antibiotics and steroids d. monitoring for signs of perforation of the esophagus 10. Foley catheter removal of esophageal foreign bodies may be useful in certain instances, especially if endoscopic facilities are not readily available. Which of the following patients would be the best candidate for foley catheter removal? a. a combative drunk who ingested the cork from his wine bottle b. a toddler who ingested a safety pin c. a young adult who ingested a single buckshot pellet the night before coming to the emergency room d. a child who ingested a marble a week previously In order for the sponsors of this CME activity to monitor its usefulness and appropriateness to subscribers, we ask that your supply answers to the following questions concerning the accompanying Grand Rounds Online CME segment: 1. Was the presentation organized in an acceptable manner? yes no opinion no 2. Was the material adequate to your continuing education needs with respect to content? yes no opinion no 3. Was the material appropriate to your clinical practice needs? yes no opinion no 4. Did you feel that the discussants' remarks were responsive to the issues presented in the body of the Grand Rounds segment? yes no opinion no 5. Do you consider the presentation to be timely with regard to current information available in both the lay press and the professional literature? yes no opinion no 6. Are the questions submitted with the Grand Rounds element meaningful in that they stimulate thought and perhaps further inquiry? yes no opinion no 7. Is the method of submitting the subscriber's answers to these questions expeditious and convenient? yes no opinion no 8. Would you recommend this method of completing the general requirment for Continuing Education Activity to your colleagues? yes no opinion no 10. 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