Aero digestive tract foreign

bodies

By Macktevin Malamsha
 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.
 MINERAL & VEGETABLE FB

SYMPTOMS SIGNS
Unilateral foetid • Reddened
discharge, congested mucosa
mucopurulent, blood
• Granulation
stained
Unilateral nasal block • Ulceration
Pain • Necrosis
Epistaxis
Sneezing
 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
 MANAGEMENT
INANIMATE 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 pack

FB 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
Clinical features of oesophageal foreign body
Symptoms Signs

History – initial choking or gagging Tenderness – lower part of neck on

right/left of trachea

Discomfort/pain – just above clavicle Pooling of saliva – on I.D.L. Doesn’t

to right or left of trachea. Discomfort disappear on swallowing
increases on swallowing attempts.

Dysphagia - Obstruction to Sometimes, foreign body may be seen

swallowing – partial or total protruding from oesophageal opening in
post cricoid region.

Drooling of saliva
Respiratory distress
Substernal/epigastric pain
 Clinical features
Symptoms of laryngeal foreign body
• 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 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 SYMPTOMS
Typical 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