Title: Foreign Bodies of the Upper Aerodigestive Tract
Source: Department of Otolaryngology, UTMB, Grand
Rounds
Date: October 22, 1997
Resident Physician: Robert H. Stroud, M.D.
Faculty Physician: Ronald W. Deskin, M.D.
Series Editor: Francis B. Quinn, Jr., M.D.
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The problem of foreign body ingestion and aspiration is not new, but significant dilemmas in the diagnosis and treatment of this problem remain despite major advances. Since Chevalier Jackson described endoscopic techniques for the removal of foreign bodies in 1936, this has remained the safest and most trusted method of treatment. Techniques for foreign body removal employing fiberoptic endoscopes have been described, and the use of Foley catheters or carbonated beverages for the removal of esophageal foreign bodies have typified the continued interest in treating this often troubling and all too common problem.
Foreign body ingestion and aspiration can affect persons of any age, but the vast majority of these accidents occur in children under the age of five. It is estimated that 1500 deaths occur annually related to the ingestion of foreign materials and 3000 deaths occur annually due to complications of foreign material aspiration. Suffocation resulting from foreign body ingestion and aspiration is the third leading cause of accidental death in children under one year of age, and the fourth leading cause of death in children from ages 1 to 6.
There are many reasons for these impressive statistics. Young children explore their environments with their mouths and are thus at risk for the ingestion and aspiration of non-food items. In the past, safety pins were a frequently implicated object, but since the introduction of the disposable diaper, these events most commonly involve coins. In addition, the lack of posterior dentition and immaturity of the swallowing mechanism make lodgment of food in the esophagus common, and foods such as nuts and seeds the most common airway foreign bodies in children.
In adults, food is by far the most common foreign body of the aerodigestive tract. Due to the decreased sensation of food in the oral cavity in denture wearers, small foreign bodies such as fish bones are commonly found lodged in the oropharynx. In addition, hurried eating can lead to large boluses of meat lodging in the esophagus. A prior history of esophageal pathology such as tracheo-esophageal fistula increases the risk for impaction of food stuffs in the esophagus, and esophageal strictures or obstructing masses may present as an esophageal foreign body. A thorough inspection of the food passage is thus warranted when evaluating these problems.
The signs and symptoms of foreign body ingestion or aspiration are quite diverse and often very non-specific. In most instances, patients are able to relate a history of a foreign body accident, but many are unable to give such information due to their young age. When any patient does give a history of having ingested a foreign body, investigation is warranted regardless of their age or apparent absence of signs and symptoms.
Foreign body accidents usually involve three distinct stages. The first of these is the initial event characterized by an episode of coughing, gagging, choking and occasionally airway obstruction. In most patients, a history of such an event can be elicited. It is not uncommon however, for young children or elderly adults with mental status changes who are prone to such accidents to be incapable of giving a history and the initial event having gone unnoticed by family or caretakers. Older children often are reluctant to divulge the details of the accident due to embarrassment or the fear of punishment. In addition, it is not infrequent for parents of a toddler to minimize a distant episode of coughing and gagging and not include it in the history, making it imperative that the physician specifically inquire as to such an event.
Following the initial event, the patient typically experiences an asymptomatic interval. During this period, the reflexes accounting for the symptoms of the initial event are fatiqued. It is this stage that leads to the frequent delay in diagnosis of several days to months. Physicians are inclined to minimize the possibility of a foreign body accident and misdiagnose the patient's symptoms during this stage. The final stage in foreign body accidents is characterized by complications of the event due to obstruction, erosion or infection. These may be as non-specific as failure to thrive, wheezing, fever, malaise or dysphagia. It is unfortunate, however, that serious complications such as recurrent pneumonia, atelectasis, lung or mediastinal abscess, or massive hemorrhage due to a vascular fistula may occur before a thorough investigation is launched revealing the presence of a foreign body.
Airway foreign bodies are most commonly located in one of the main bronchi and often are not diagnosed until complications occur if the initial event is not recognized. Symptoms may be mild such as wheezing or cough and may improve temporarily with bronchodilators and anti-tussives which support more common diagnoses such as upper respiratory infection and asthma. Complications such as recurrent pneumonias and lung abscess may result from long-standing undiagnosed bronchial foreign bodies. The right main bronchus is the most common location for an airway foreign body. This is due to its greater diameter and smaller angle of branching from the carina when compared to the left main bronchus. Also, there is greater air flow to the right lung and the carina is positioned slightly to the left of the midline.
Laryngeal foreign bodies usually cause complete or partial airway obstruction that has the potential to cause asphyxiation if not relieved promptly with the Heimlich maneuver or tracheotomy. Partial obstruction at the level of the larynx is usually caused by flat, thin objects that lodge between the vocal folds in the sagittal plane. Symptoms include croup, stridor, cough, hoarseness, dyspnea and odynophagia. Tracheal foreign bodies are rare but are slightly more common than laryngeal foreign bodies. Three features described by Jackson and Jackson which can be noticed on examination are the audible slap which is best heard at the open mouth during a cough, the palpatory thud, and the asthmatoid wheeze heard with the ear at the patient's open mouth.
Esophageal foreign bodies can cause a myriad of symptoms ranging from complete esophageal obstruction with overflow of secretions and aspiration, to mild odynophagia or dysphagia. Often forgotten is the potential diagnosis of esophageal foreign body in children who present with respiratory complaints and symptoms including stridor, croup, and pneumonia. These symptoms are caused by the compression of the tracheal wall by large objects lodged in the esophagus. Esophageal foreign bodies are most frequently located at the narrowest portion of the esophagus, the level of the cricopharyngeus muscle.
In patients suspected of having ingested or aspirated a foreign object, plain radiographs of the neck and chest taken in two dimensions are paramount to the diagnosis and pre-operative evaluation. Often, a radiopaque foreign body is obvious. In this case, a radiograph taken in the greatest diameter of the object should be attained as this helps in defining the anatomy prior to retrieval. If a history of ingestion of a foreign body which is likely to be radiopaque is given but none is noted on films of the neck and chest, a radiograph of the abdomen may reveal its progression into the stomach or beyond.
Frequently, foreign objects are not readily noticed on plain films. In this case, inspiratory and expiratory films of the chest should be attained. This often reveals air trapping in the affected area of the lung due to complete obstruction of the airway during expiration. With inspiration, the diameter of the airway increases enough to allow the ingress of air, but with expiration the airway diameter decreases resulting in complete obstruction and emphysema distal to the foreign body. A late finding on chest radiography is atelectasis distal to an obstructing foreign body with surrounding inflammation and granulation tissue. In an uncooperative patient, fluoroscopy is often needed to attain expiratory films or a lateral decubitus film may provide the same information by utilizing the patient’s body weight to promote expiratory excursion. It is also helpful in children to attain a lateral chest radiograph with the arms behind the back, the neck flexed and the head extended to visualize the entire airway from the mouth to the carina. Bronchograms are sometimes useful in locating foreign bodies too distal in the tracheobronchial tree for endoscopic evaluation. It is helpful to remember that radiographs are frequently normal in the first 24 hours after the initial event, but may become abnormal over time.
Barium studies should be used with great caution when there is suspicion of a non- radiopaque foreign body of the esophagus. Complete obstruction may result in aspiration of the contrast material. In addition, residual contrast in the esophagus may delay the endoscopic procedure and obscure the findings. These studies should only be performed when the suspicion of esophageal foreign body is low and then only a minimal amount of contrast material administered. CT scanning and MRI are rarely useful in the evaluation of foreign bodies in the aerodigestive tract, but are indicated in the event that the object is not found during endoscopic examination and migration from the airway or esophagus is suspected.
Almost without exception, the treatment of choice for foreign bodies of the upper aerodigestive tract is reasonably prompt endoscopic retrieval in the operating suite under general anesthesia. It is occasionally possible to retrieve an oro- or hypopharyngeal foreign body lodged in the lymphoid tissue at the base of the tongue in a cooperative patient with only local anesthesia, but one should be aware of the risk of dislodging the object and causing aspiration.
Many alternative treatments for airway and esophageal foreign bodies have been proposed but rigid endoscopy has proven over time to be the safest and most efficacious therapy. Flexible endoscopes have some utility and are the best method for retrieving objects which have passed into the stomach and halted in progression, but are limited by the types of instruments available with which to grasp the foreign body. In addition, flexible bronchoscopes lack the ability to ventilate afforded by their rigid counterparts. Some physicians have reported success in the retrieval of smooth foreign bodies of the esophagus using catheters with inflatable balloons under fluoroscopic guidance. This treatment is limited by rather strict indications and run the risk of dislodging the foreign body into the airway. Others have used smaller catheters in conjunction with rigid endoscopy and fluoroscopy for the retrieval of distal airway foreign bodies.
Bronchodilators and postural therapy for dislodgment of airway foreign bodies is to be condemned due the risk of mobilizing the object from its distal position only to cause its impaction in the narrow subglottis or glottis causing complete airway obstruction. The enzymatic degradation of food lodged in the esophagus should be relegated to history as well due to the risk of esophageal perforation and its complications.
Once the diagnosis of foreign body ingestion or aspiration is secured or the history and investigations are highly suggestive of foreign body accident, preparations should be made for endoscopic retrieval under general anesthesia. The vast majority of foreign bodies that reach the otolaryngologist for examination have passed the acute stage and need not always be regarded as emergencies. The procedure should be attempted after the completion of the appropriate studies, the assembly of experienced personnel, the location and arrangement of the proper equipment, and proper preparation on the part of the endoscopist.
Several situations can be regarded as urgent or emergent with endoscopy performed as soon as possible:
(1) actual or potential airway obstruction - while these episodes are rare due high mortality from asphyxiation before reaching the hospital, they still present from time to time. In complete obstruction, the airway should be restored immediately with the Heimlich maneuver or tracheotomy if necessary. If the airway is intact but the object is in such a position as its patency is tenuous, emergent endoscopy for removal should be performed. The incidence of asphyxiation in the pediatric population has shown a steady decline over the past 30 years largely to public awareness and education in the Heimlich maneuver.
(2) aspiration of dried beans or peas - with prolonged periods in the airway, the bean or pea absorbs moisture, causing swelling and airway obstruction or the obliteration of forceps spaces making removal more complicated.
(3) ingestion of disc batteries with esophageal lodging - Maves and associates have shown that mucosal damage occurs after only one hour in the esophagus progressing to perforation in 8 to 12 hours.
(4) signs or symptoms of esophageal perforation - these patients should undergo the appropriate diagnostic studies and the emergent retrieval of the foreign body followed by proper medical and surgical management of the perforation.
With the exception of these situations, adequate time should be taken for careful preparation.
The procedure should be delayed for the assembly of an experienced endoscopy team. This includes support staff familiar with the instruments and equipment and an experienced anesthesiologist. The plan for the procedure should be discussed and the possible complications reviewed with the entire team before taking the patient to the operating suite.
Time should be taken by the endoscopist in careful thought and consideration of the task at hand. If the foreign body is known to the patient or the patient's family, someone should be sent to retrieve an exact duplicate. If this is not possible, a precise drawing or replica with emphasis on angles and corners which could serve as grasping points should be constructed. The endoscopist should then spend adequate time selecting the appropriate instrument with which to grasp the object and practice this multiple times on the replica. Several alternative instruments should also be prepared and tried should unexpected circumstances arise. All of the instruments should be inspected to assure that they are in proper working order and minimize the risk of equipment failure.
The types of forceps and instruments available for the retrieval of foreign bodies is quite impressive and a thorough knowledge of the tools available should be attained. The types of forceps include both passive and center action forceps. The more common types of passive action forceps include forward grasping, rotation, ball-bearing or globular object forceps and hollow object forceps. Center action forceps include both optical and non-optical varieties with optical peanut forceps being one of the most commonly used. A wide variety of alligator and smooth forceps are also available. The importance of locating the right tool for the job cannot be over-emphasized and a significant amount of thought should be spent with this portion of the preparatory phase.
The proper size bronchoscope should be prepared with alternate sizes available when planning the retrieval of an airway foreign body. This is most important in children where laryngeal and tracheal sizes are highly variable and the effects of swelling from use of too large an endoscope and excessive airway trauma are poorly tolerated. The use of too small a scope can compromise removal and cause excessive leak with ventilation.
Once adequate preparation has been completed and the plan and potential complications reviewed, the patient is brought to the operating suite. For esophageal foreign bodies, routine general anesthesia is induced and the patient is endotracheally intubated as this affords maximum airway protection. If the foreign body is lodged high in the esophagus, the shorter cervical esophagoscope may be used. Sound techniques of esophagoscopy are employed without forcing the scope and advancing only when the is lumen visualized taking care to completely inspect the mucosa. When the foreign body is localized, suction is used as needed and the position of the object assessed. Grasping forceps are then introduced and the object engaged. The scope is advanced in order to cover the object completely. A pointed or irregular edge may need to be rotated to be protected within the scope during removal. The endoscope, forceps, and foreign body are then removed simultaneously.
With foreign bodies of the tracheobronchial tree, it is desirable to perform the procedure with the patient breathing spontaneously. If there is no significant airway obstruction, the patient may be administered IV or IM sedation prior to the procedure. Anesthesia is then induced by mask avoiding nitrous oxide as this may induce apnea. Positive pressure ventilation should also be avoided as this may drive the foreign body further toward the periphery. Following the induction of anesthesia, the endoscopist exposes the larynx and 2% lidocaine is applied. The bronchoscope is then inserted and ventilation through the side arm of the bronchoscope is established. It is necessary to have the eyeglass in place on the bronchoscope in order to create a closed system for ventilation. This may be removed and finger occlusion of the scope performed during attempts at retrieval.
The endoscopist must resist the urge to immediately seek out and remove the object unless it is seen lodged in the hypopharynx or larynx on laryngoscopy. The entire tracheobronchial tree should be inspected beginning with the non-affected segments to assure adequate respiratory function while attempts at removal are made. Occasionally, there is the unexpected discovery of an additional foreign body. The suspected location of the object is then addressed. Once the foreign body is located, all secretions and debris should be cleared from around the object using suction. Attempted removal with the suction tip should not be performed as it is rarely adequate to hold the object. The object is examined for size, shape, orientation, and forceps spaces. If bleeding occurs due to granulation tissue or trauma, topical epinephrine may be applied.
The object is then addressed with the previously chosen forceps. The blades of the forceps should be placed around the object with care to avoid driving the object further to the periphery. Foreign bodies which are prone to fragmentation should be grasped only firmly enough to assure adequate grip. Once the forceps are secure on the object, the bronchoscope is advanced and the foreign body secured against the mouth of the scope and the scope, forceps and foreign body removed as a single unit. After removal, the airway should be reinspected for signs of trauma or the presence of additional foreign bodies.
Many endoscopists have been troubled by the stripping of the object from the grasp of the forceps, most commonly at the narrow glottis with the possibility of complete airway obstruction. If this situation occurs it is imperative that the obstruction be relieved immediately. This may be accomplished by completing the removal of the object. When this is not feasible, the object should be pushed distally in order to relieve the obstruction, or occasionally, it is necessary to fragment the object. If the object must be pushed distally, it is most desirable to return it to its original location. Several factors related to the forceps and the foreign body are often the cause of stripping off. Those related to the forceps include faulty application of the forceps, poor choice of forceps for the foreign body and malfunction of the instrument.
The potential for these complications may be minimized during the preparation for the procedure by careful inspection of the instruments and adequate time spent in considering the forcep - object relationship. Those factors related to the foreign body include poor orientation of the foreign body, which may be solved by rotation of the object at the vocal folds, failure to secure the foreign body against the mouth of the endoscope, and a foreign body which is too large for the lumen and may have to be fragmented or removed through a tracheotomy. On occasion, the endoscopist is faced with a difficult dilemma as to the proper way to extract an irregularly shaped foreign body. The open safety pin is one such dilemma which has caused many endoscopists much distress and anxiety. Sharp or pointed objects should be removed with the dangerous edge ensheathed in the endoscope or with the points trailing. This often requires such techniques as endogastric version or inward rotation.
A number of specialized instruments have been designed for just such occasions including pin bending forceps, broad staple forceps, rotation forceps and safety pin closing forceps. Many of these instruments have subtle nuances to their use and should not be employed by the casual user so as to avoid entangling the forceps, endoscope and foreign body to the point that none of them may be removed without causing excessive trauma.
Complications encountered with foreign bodies of the upper aerodigestive tract are usually related to anesthetic complications or those occurring from long-standing, undiagnosed foreign bodies. These include stridor, wheezing, pneumonia, and lung abscess for foreign bodies in the airway, while perforation of the esophagus with resultant mediastinitis and erosion into vascular structures may result from indwelling esophageal foreign bodies. Complications related more directly to the procedure include pneumothorax, pneumomediastinum, laryngospasm, and subglottic edema. Occasionally, endoscopic examination may be unrewarding despite obvious presence of a foreign body on radiography. This may occur due to the hiding of the foreign body in a mucosal fold in advance of the endoscope, obscuring the object from view and preventing its tactile detection. Withdrawal of the scope and reinsertion will usually reveal the foreign body's location. Negative endoscopy may also represent the migration of the object from the aerodigestive tract necessitating further radiographic studies such as CT scanning or MRI in order to better define its position. In such situations, removal of the object may require thoracotomy.
Post operative care is usually straightforward and antibiotics or corticosteroids are necessary only for the treatment of complications. Most patients are able to be discharged home the day following the procedure if the lungs sounds are clear and the patient is afebrile.
Foreign bodies of the upper aerodigestive tract are common problems encountered by the otolaryngologist. While the diagnosis seems straightforward, it is sometimes delayed until after serious complications have occurred. The treatment of choice is endoscopic retrieval under general anesthesia. The procedure should be preceded by the completion of appropriate radiographic and other indicated studies, and careful thought on the part of the endoscopist and endoscopy team. Time invested in preparation and planning will usually yield great rewards with the successful and uncomplicated retrieval of the offending object and speedy recovery of the patient.
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