1. Foreign Bodies of the Airway, Esophagus and Ear
Presented by
Nannaphat pradutdecha

2. References
Lauren DH, Sheri AP. Foreign bodies of te airway and esophagus. Cummings otolayngology Head & neck surgery. 5th ed. Philadelphia : Elsevier, 2010 :
Nancy Sculerati. Foreign body of the nose. Pediatric otolaryngology. 4th ed. Philadelphia : WB Saunders Co, 2002 :

3. Epidemiology
FB result in approximately 150 deaths per year in children secondary to asphyxiation.
Most deaths occur before hospital intervention
Most aerodigestive foreign bodies are esophageal—85%
The highest incidence occurs between 1 and 3 years of age
25% of patients are younger than 1 year.

4. Toddlers
Lack posterior dentition (molars - necessary for proper grinding of food)
Less-controlled coordination of swallowing, and immaturity in laryngeal elevation and glottic closure
Oral exploration (age-related tendency to explore the environment by placing objects in the mouth)
Easy distractibility (often running or playing at the time of ingestion)

5. Epidemiology The most common esophageal FB are coins ,75%
Round objects, trinkets, disk batteries, and sharp objects constitute less than 20% of impacted esophageal FB
Multiple esophageal FB impactions, 80% have an esophageal anomaly
Recurrent esophageal FB, 19% have esophageal anomalies that previously required surgical repair

6. Epidemiology
Vegetable matter is seen in 70-80% of airway FB ingestions
the most common
peanuts in the United States
watermelon seeds in Egypt
pumpkin seeds in Greece
Plastic pieces constitute approximately 5- 15% of airway FB -tend to remain longer because they are inert and radiolucent.

7. Location Most airway FB lodged in bronchi
common in the right main bronchus in adults
position of the carina to the left of the midline
lesser angle of divergence from the tracheal axis
children : right = left main bronchi (no clear explanation)

8. Location
Most esophageal FB impact in cervical esophagus just below cricopharyngeus muscle
Another 4% to 5% of esophageal foreign bodies become lodged at
midesophagus
distal esophagus
often caused by extraluminal compression --aortic arch or left main bronchus

9. Figure 72-1.  Schematic view of the esophagus and its relationship to neighboring structures. LES, Lower esophageal sphincter; UES, upper esophageal sphincter. (Reprinted with the permission of the Cleveland Clinic Foundation.)

10. Management of choking victims
Infants
rescue breaths and chest compressions
Children > 1 year
require gentle abdominal thrusts while supine
Older children and adults
Heimlich maneuver
(standing, sitting, or recumbent)
Note : Back blows or abdominal thrusts in individuals with only partial obstructions could lead to complete obstruction and are not recommended.

12. Symptoms Three clinical phases of FB aspiration
Initial phase occur at the moment of during aspiration--choking, gagging, and paroxysms of coughing or airway obstruction
Asymptomatic phase when FB becomes lodged, and the reflexes fatigue --choking, gagging, and coughing are subside, can last hours to weeks
Third phase--complications from obstruction, erosion, or infection causes hemoptysis, pneumonia, atelectasis, abscess, or fever

13. Site of the obstruction
Symptoms
Laryng
Irregular FB or orientation in sagittal plane may produce only partial obstruction, allow air flow but laryngeal edema can lead to complete obstruction.
Typical: symptoms of obstruction and hoarseness, some mimic croup
Trachea
Typically do not have hoarseness
Three signs associated with tracheal FB: asthmatoid wheeze, audible slap and palpable thud
Bronchus
airway foreign bodies, 80-90% are found in the bronchi
Triad of cough, wheezing, and decreased breath sounds. One large series reported that 65% have the classic triad but 95% have at least one finding.
Esophagus
vomiting, odynophagia, dysphagia, ptyalism
A large FB may cause symptoms of airway obstruction and cough (compression or irritation of upper airway)
In long-standing impaction, fever and other symptoms of respiratory infection may be present

14. Daksheh H. pahrik. Paediatic thoracic surgery. P 359

15. Laryngotracheal Foreign Bodies
patient was taken to the operating room for bronchoscopy. At bronchoscopy, about pieces of nut particles in the lower trachea and in both major bronchi were found. They were somewhat difficult to remove because of their small size. Most were removed with grasping forceps and suction. He did well postoperatively.
A 17 month old male presents to the ED in the evening with a one-hour history of noisy and abnormal breathing after a choking episode while he was eating a chocolate and almond bar. He was able to speak and drink fluids without difficulty VS T36.8, P200 (crying), R28 (crying), oxygen saturation 99% in room air. He appeared alert, with no signs of respiratory distress. He was able to speak, had no cyanosis, no drooling, and no dyspnea. His lung sounds showed mild wheezing with possible mild inspiratory stridor. An albuterol aerosol was administered but no improvement was noted. A chest radiograph was ordered

16. Bronchial Foreign Bodies
check-valve effect : expiration ,resulting in hyperinflation of the affected side and mediastinal shift to the opposite side

17. Bronchial Foreign Bodies
ball-valve effect is produced later when FB obstruct on inspiration and open on expiration, producing atelectasis on the affected side and a mediastinal shift toward the affected side

18. Esophageal Foreign Bodies
Food or true foreign bodies
Chicken bones (opaque), fish bones (non-opaque)
Coins, toy trucks
Most often they impact just below cricopharyngeous (70%)
Another 20% impact at the level of the aortic arch
Another 10% at EG junction

19. Management Airway History taking
standard radiographic : posteroanterior and lateral airway and chest films
NPO for 6 hours, and adequately hydrated
Age-appropriate equipment for endoscopic foreign body removal
If a suspected esophageal foreign body is radiolucent, a barium contrast study should be avoided because it would delay endoscopy in that the patient can no longer take anything by mouth, and the foreign object may be obscured by the material swallowed

20. Guidelines for Selection of Bronchoscope, Esophagoscope, and Laryngoscope for Diagnostic Endoscopy by Age

21. Anesthesia
under GA : provide optimal airway control and patient comfort
method of evaluation and removal of FB should be communicate with anesthesiologist
Patients are placed supine for mask induction using volatile inhalational agents
Eye protection prevents corneal abrasions
Topically anesthetized with 1% to 4% lidocaine to inhibit laryngeal reflexes and to reduce the incidence of laryngospasm.

22. Anesthesia Laryngeal FB Tracheobronchial FB removal
Preoxygenated then mask induction
anesthesia is maintained with an insufflation catheter through the nares into the hypopharynx
Tracheobronchial FB removal
laryngoscope tip is placed in the vallecula to expose the larynx for passage of the bronchoscope
breathes through bronchoscope until finish

23. Anesthesia Esophageal FB patient undergoes ETT
ETT prevents inadvertent aspiration of FB into the airway during attempted removal
minimizes any tracheal compression caused by a rigid esophagoscope

24. Technique Bronchial FB Healthy bronchus is examined first
Bronchoscope is positioned above the foreign body, and secretions are gently suctioned to expose the object fully
Preoxygenated before the attempt at removal
Bronchoscope, forceps, FB are removed as a unit
Bronchoscope is returned immediately to the airway for ventilation and assessment for other FB
simultaneous biplane fluoroscopy can be used for extraction of radiopaque foreign bodies in the lung periphery

25. Technique esophageal FB
Esophagoscope is passed through right side of mouth and directed toward pyriform sinus, angled toward sternal notch
Esophageal lumen is kept in view at all times while gently advanced until FB is visualized
FB is engaged with the forceps; esophagoscope is advanced toward the object and removed as a single unit
Esophagoscope is reinserted to assess esophageal mucosa and to identify additional FB below the primary one. (Multiple foreign bodies are found in 5% of pt.)
Coins generally can be removed safely with an optical forceps
through a rod-lens esophagoscope or with a grasping forceps
through an esophageal speculum.
♦ Round objects generally are removed easily with the bead-grasping
forceps through a Jackson esophagoscope.
♦ Sharp objects are sheathed into the esophagoscope by using a grasping
forceps through a rod-lens esophagoscope.
♦ Jackstones are difficult to remove because of their size and sharp
points. Figure 25–21 illustrates how the sharp point is rotated into
a Jackson esophagoscope and the jackstone is removed using a
grasping forceps. Mucosal tears are common and may result in
pneumomediastinitis and esophageal perforation.

26. Technique Removal of Sharp Objects
Tip of a pointed object engages mucosa, causing point trailing
Safety pins : Two methods of removal are suggested
1) sheathing the point within the endoscope while locking the forceps closed to hold the keeper against the outside of the tube particularly during extraction through the larynx
2) gastric version (under fluoroscopic guidance) of esophageal safety pins, using rotation forceps to flip the safety pin point down within the stomach

27. Safety pins have rarely been seen at our institution during the past
two decades. The original techniques described by Jackson are presented
Kenny H. Chan, et al.Endoscopy of the Aerodigestive Tract. In : Bluesone CD. Surgical Atlas of Pediatric otolaryngology :581

28. Technique Removal of Sharp Objects
Severely impacted or embedded sharp object , open surgical approach may be the safest method of FB removal
Long or large objects in children younger than 2 years may not pass through the duodenum, remove these objects from the stomach endoscopically before they migrate further or perforate a bowel wall

29. Technique Disk batteries
are commonly used in hearing aids, calculators, watches, and other portable electronic devices
Peak incidence of ingestion occurs at age 1 to 2 years
33% of cases, the ingested battery is from the child's hearing aid
Mercuric oxide–containing batteries can cause systemic mercury poisoning if they open in the gastrointestinal tract

30. Technique Disk batteries In 1 hour, esophageal mucosa damaged
In 4 hours, leakage of caustic battery contents cause erosion muscular wall of esophagus
Within 6 or more hours, esophageal perforation leading to mediastinitis, tracheoesophageal fistula, or death may occur

31. From: Foreign body of the pharynx and esophagus
From: Foreign body of the pharynx and esophagus. Pediatric otolaryngology. 4th ed. Philadelphia : WB Saunders Co, 2002 : 1327

32. Technique
Esophageal Perforation
Caused by the object itself, length of time that lodged, attempts to retrieve object
Preoperatively esophageal perforation may be diagnosed on preoperative radiographic, cervical subcutaneous emphysema, retroesophageal abscess or obvious extraluminal portion of the esophageal FB
Early signs of a perforation: fever + tachycardia, tachypnea, increased pain

33. Technique
Esophageal Perforation
Early recognition and management, decreased mortality rate for esophageal perforation has from 60% to 9%
NPO and broad-spectrum ATB,necessary in pharyngoesophageal perforations (the most common area injured in endoscopic removal of esophageal FB)
In more severe injuries, drainage, closure, or more complex surgical repairs may be necessary

34. Postoperative Management
After esophagoscopy
NPO for 4 hours
monitored signs of perforation: fever, tachycardia, and tachypnea
ATB are not routinely given unless significant esophageal injury

35. Postoperative Management
After bronchoscopy
When appropriate-sized bronchoscopes are used for brief procedures, epinephrine or corticosteroids are not given.
Chest physiotherapy may help to clear inspissated secretions
Routine postoperative radiograph is unnecessary unless the patient's symptoms persist or progress.

36. Postoperative Management
After bronchoscopy
Fail extraction or incomplete, patients are rested for several days, and then returned to the OR for repeat endoscopy
Recovery time of more than 1 week was associated with preoperative inflammatory findings by radiologic study, procedure time greater than 50 minutes, and worsening postoperative radiologic findings

37. Complications
Pneumonia and atelectasis are the most common complications after bronchial FB removal.
Pt. usually respond to intravenous ATB and chest physiotherapy
Bleeding can occur because of granulation tissue or erosion into a major vessel
Pneumothorax and pneumomediastinum can result from an airway tear.
Laryngeal inflammation and edema have decreased significantly with the use of appropriate-sized endoscopic

38. Complications
Long-term complications : granulation tissue, stricture formation occur at site of lodged
During esophagoscopy, ETT may be dislodged, and the patient may have cricopharyngeal spasm, esophageal mucosal injury, or perforation
After esophagoscopy, vomiting, aspiration, a second missed FB and fever are the most common complications
Esophageal perforation, retroesophageal abscess, mediastinitis, and death are rare

39. Controversies in Management
Flexible bronchoscopic removal is not recommended, especially in small children- -poor control airway and FB
Impacted esophageal FB, nasogastric tube has been proposed to push FB into stomach, blind technique may cause esophageal injury (not universally accepted)

40. Controversies in Management
Foley catheter removal with fluoroscopic control of blunt radiopaque esophageal FB, recommended for a single object lodged below cricopharyngeus for a short duration
Advantages : reduced cost and avoidance of general anesthesia.
Disadvatage: not allow a postretrieval assessment of esophageal mucosa or identification of a nonradiopaque second FB
coin is not grasped using this technique, loss of control of coin at the level of posterior pharynx can result in an airway emergency
risk of vomiting and aspiration with an unprotected airway, emotional traumaand (awake and restrained in a steep head- down position)

41. Controversies in Management
Papain (meat tenderizer) has been used in impacted esophageal meat boluses
Papain was given as a 5% solution to adult patients, with the meat passing in most instances.
at least two cases of mediastinitis and death in these patients caused by necrosis of the esophagus and perforation.
Glucagon produces relaxation of the smooth muscle of the esophagus, promoting passage into the stomach. One open-label study in pediatric patients failed to show a higher incidence of passage in patients who received glucagon versus placebo.[51] Sumatriptan prolongs fundic relaxation and delays gastric emptying. Studies conducted so far have revealed an increase in the rate of gastroesophageal reflux and the number of esophageal mother waves

42. Controversies in Management
Flexible esophagoscopy has been used for removal of blunt objects or meat impaction. Sharp objects pose a greater risk because of inability to sheath the object as with a rigid esophagoscope
Glucagon produces relaxation of the smooth muscle of the esophagus, promoting passage into the stomach. One open-label study in pediatric patients failed to show a higher incidence of passage in patients who received glucagon versus placebo.[51] Sumatriptan prolongs fundic relaxation and delays gastric emptying. Studies conducted so far have revealed an increase in the rate of gastroesophageal reflux and the number of esophageal mother waves

43. Foreign body of the nose
Presentation
Persistent rhinitis, unilateral purulent rhinorrhea
Adenoiditis
sinusitis
Adult witness child putting something in nose

44. Foreign body of the nose
Sequelae
Seeds swell when moisted by nasal secretion , Increase impact overtime
Foam rubber increase irritation with oxidation and breakdown material
Plastic or other inert material gradual formation of granulation obscure FB cause pressure erosion of surrounding bone
Button batterries rapidly cause severe mucosal burn  septal perforation , saddle nose deformities

45. Foreign body of the nose
Management
Decongestant
Anterior rhinoscope : nasal speculum, otoscope
Frazier suction tube
เตรียมRight angle hook, flexible cerumen
curette and alligator forceps
Restrain or sedate or under brief GA

46. Foreign body of the nose
Management
ใส่guazeชุบadrenaline or antibiotic oinment
ให้ATB
ให้ยาแก้ปวด

47. Rhinolith
Formed from intranasal FB that encrusted with mineral salt ( Calcium, Magnesium)
Treatment : remove

48. สิ่งแปลกปลอมในหู Management ถ้าช่องหูบวม ทำให้ยุบบวมก่อน
ส่องดูในหูว่ามีสิ่งแปลกปลอมหรือไม
เลือกวิธีนำสิ่งแปลกปลอมออก : ดูดออก, ฉีดน้ำ, ear hook, alligator forceps
ให้ATBหยอดหู หรือกิน
ให้ยาแก้ปวด

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