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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"This material was prepared by resident physicians in partial

fulfillment of educational requirements established for Postgraduate
Medical Education activities 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 subscribers or other professionals and should not be
used for purposes of diagnosis or treatment without consulting
appropriate literature sources and informed professional opinion."
Introduction

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.

Evaluation

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.

Radiography
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.

Management

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.

Summary

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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