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.

MINERAL & VEGETABLE FB

SYMPTOMS
Unilateral foetid discharge, mucopurulent, blood stained Unilateral nasal block Pain Epistaxis Sneezing

SIGNS Reddened congested mucosa Granulation Ulceration Necrosis

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

Discomfort/pain just above clavicle to right or left of trachea. Discomfort increases on swallowing attempts. Dysphagia - Obstruction to swallowing partial or total Drooling of saliva Respiratory distress Substernal/epigastric pain

Tenderness lower part of neck on right/left of trachea

Pooling of saliva on I.D.L. Doesnt disappear on swallowing

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

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
Heimlichs 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 pts 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/fogartys 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