Foreign Body in Throat Dr. Vishal Sharma

Aspirated (Airway) Foreign Body

Clinical Staging 1. Initial phase: choking, coughing, wheezing, gagging 2. Asymptomatic phase: due to mucosal adaptation 3. Late phase: Laryngeal / Tracheal / Bronchial 4. Complication phase: pneumonia, emphysema, lung abscess, atelectasis

Late Clinical Features a. Laryngeal: partial or total airway obstruction, hoarseness, aphonia, hemoptysis b. Tracheal: airway obstruction, hemoptysis, wheezing, palpatory thud, auscultatory slap c. Bronchial: cough, ipsilateral wheezing, ipsilateral decreased breath sounds

Bypass valve & Stop valve effect Partial Obstruction Total Obstruction Wheezing Late Atelectasis

Check valve effect No Expiration No Inspiration Early Atelectasis Emphysema

Clinical Diagnosis Conscious pt: 1. Hoarseness / aphonia 2. Respiratory distress Unconscious pt: 1. No chest movement 2. No air exchange at nose / mouth. 3. Cyanosis.

Radio-opaque F.B. larynx

Radio-opaque F.B. Bronchus

Right Lung collapse & Left emphysema Radio-lucent F.B. Right Lung collapse & Left emphysema

Management of choking in an unconscious patient 1. Patient placed in supine position 2. Open airway + mouth to mouth ventilation 3. Correct airway obstruction

Opening the airway Head-tilt: Extension of neck by backward pressure on forehead

Opening the airway 2. Head-tilt, chin-lift: Extension of neck by backward pressure on forehead + lift pt’s chin keeping mouth open.

Opening the airway 3. Head-tilt, neck-lift: Lift pt’s neck while pushing down on forehead. Prevents falling back of tongue.

Opening the airway 4. Modified jaw-thrust: For pt with neck / spinal injuries. Push patient’s jaw forward by applying pressure at angle of mandible. Avoid head tilt.

Correcting airway obstruction Back blows Abdominal thrusts Chest thrusts (for pregnancy, age < 8 yrs) All 3 raise subglottic pressure, to dislodge out FB Open pt’s mouth Blind finger sweeps in mouth

Back blows Place pt in lateral position, supporting pt’s chest against your knees. Use free hand to deliver five rapid blows to spinal Area b/w scapulae, to dislodge F.B.

Abdominal thrusts Straddle supine pt at his hip. Place your hand heel b/w pt’s umbilicus & ribcage, in midline. Hold that hand with your other hand & apply 5 rapid, inward + upward thrusts, to dislodge FB.

Chest thrusts Kneel beside supine pt at chest level. Place hand heel on centre of pt’s sternum. Lock hands. Apply 5 rapid downward thrusts. Only 2 fingers used for a small child.

Opening patient’s mouth Tongue-jaw lift technique: Hold pt’s tongue + lower jaw b/w your thumb & fingers. Lift pt’s tongue to move it away from pharyngeal wall.

Opening patient’s mouth Crossed-finger technique: Cross your thumb under your index finger. Place your thumb against pt’s lower lip & index finger against his upper teeth. Uncross your fingers to open pt’s mouth.

Blind finger sweeps Open pt’s mouth. Insert index finger of free hand into pt’s mouth, along pt’s cheek, till tongue base. Use it as a hook to roll out FB. Avoid pushing FB further back. Avoid blind sweeps in a child. Attempt to remove visible FB only.

Correcting airway obstruction in an unconscious pt 5 Back blows  failure 5 Abdominal thrusts Or 5 Chest thrusts Open pt’s mouth + blind finger sweeps. Continue this sequence till FB is removed or pt is ready to be shifted to operation theatre.

Management of choking in a conscious pt If patient can speak, cough, or breathe: Do not interfere. Patient to be examined by an ENT specialist as soon as possible. If the patient cannot speak, cough, or breathe: Begin treatment for obstructed airway.

Correcting airway obstruction in a conscious pt > 1 yr old 5 Back blows  failure 5 Abdominal thrusts (Heimlich maneuver) Or 5 Chest thrusts (for pregnancy, age < 8 yrs) Continue this sequence till FB is removed or pt becomes unconscious.

Back blows Place pt in sitting / standing position. Support pt’s chest while bending pt at the waist. Use your free hand to deliver 5 rapid blows to spinal area b/w two scapulae.

Heimlich Maneuver

Heimlich Maneuver Stand behind sitting / standing pt & pass your arms around pt’s waist. Hold your fist against pt’s abdomen b/w umbilicus & ribcage. Lock hands & apply 5 rapid, inward + upward thrusts to dislodge FB.

Chest thrusts Stand behind standing pt & pass your arms around pt’s chest. Hold your fist against pt’s sternum in its centre. Lock hands & apply 5 rapid, back- ward thrusts to dislodge FB.

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.

Surgical Management For life threatening stridor Cricothyrotomy Emergency Tracheostomy For foreign body removal Direct Laryngoscopy Rigid Bronchoscopy Thoracotomy & Bronchotomy

Prevention of choking Adults: Infants & Children:  Cut food into small pieces  Chew food slowly & thoroughly  Avoid laughing / talking during eating  Avoid excess alcohol with / before meals Infants & Children:  Keep small objects away from children  Avoid playing with food or toys in mouth

Swallowed Foreign Body

Diagnosis Plain X-ray (PA & Lateral): soft tissue neck, chest, abdomen  for radio-opaque FB Fluoroscopy with Barium soaked cotton pledget  for radiolucent FB Barium Swallow Flexible Oesophagoscopy

Coin in cricopharynx

Meat bolus in Cricopharynx

Toe ring in cricopharynx

Razor blade

Open safety pin

Barium Swallow

Flexible Oesophagoscopy

Tooth brush in stomach

Pharyngeal FB Common sites: tonsil, pyriform fossa, vallecula, base tongue Diagnosis confirmed by indirect laryngoscopy Usually removed in OPD but may require removal by Hypo-pharyngoscopy  GA

Oesophageal & Gastric FB Common sites: cricopharynx, aortic indentation & cardiac end Usually removed by rigid oesophagoscopy  GA Advancement into stomach is safe in difficult FB Oesophagotomy rarely required for impacted FB FB reaching stomach, usually passes out in stool Emetic & Cathartic agents are contraindicated

Indications for Immediate Intervention  Associated respiratory obstruction  Total oesophageal obstruction  Disc battery (perforation occurs in 8-12 hrs)  Sharp, impacted foreign body  Gastro-intestinal FB > 5 cm in a child < 2 yr  Gastro-intestinal FB with acute abdominal pain  No progress of FB in serial X-ray after 24 hr  Gastric FB with pyloric stenosis

Disc battery in stomach

Complications of neglected FB Oesophageal ulceration & stricture Oesophageal perforation  mediastinitis Peri-oesophageal cellulitis Retro-pharyngeal abscess Respiratory obstruction due to tracheal compression laryngeal oedema

Retropharyngeal abscess

Instruments for FB removal

Instruments for FB removal

Optical Forceps

Net retrieval system

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