3. Introduction
• Three normal areas of
esophageal narrowing
1) UES (Cricopharyngeus)
-luminal dm- 1.5cm
2)Mid-Esophagus(aortic arch)
-luminal dm- 1.6cm
3)LES (Diaphrgmatic hiatus)
-luminal dm- 1.6 -1.9cm
4. The trachea (the windpipe) is a
cartilaginous and membranous tube,
extending from
the lower part of the larynx, on a level
with the sixth cervical vertebra, to the
upper border of the fifth thoracic
vertebra, where it divides into the two
bronchi, left and right, one for each lung.
The trachea is nearly but not quite
cylindrical, being flattened posteriorly; it
measures about 11 cm. in length; its
diameter, from side to side, is from 2 to
2.5 cm., being always greater in the male
than in the female. In the child the
trachea is smaller, more deeply placed,
and more movable than in the adult
5. Ingestion of Foreign Bodies
1. Esophageal Foreign Bodies
Foreign body (FB) ingestions are a common
occurrence in infants and young children.
The vast majority of ingestions in children are
accidental.
6. EPIDEMIOLOGY
• The highest incidence occurs between 1 and 3 years of age;
• 25% of patients are younger than 1 year.
• The reasons toddlers are most susceptible are
• (1) they lack molars necessary for proper grinding of food;
• (2) they have less-controlled coordination of swallowing, and immaturity
in laryngeal elevation and glottic closure;
• (3) there is an age-related tendency to explore the environment by placing
objects in the mouth; and
• (4) they are often running or playing at the time of ingestion
• The most common esophageal foreign bodies are coins (75% of cases).
• Meat and vegetable matter impactions are less common in children.
• Round objects, trinkets, disk batteries, and sharp objects constitute less
than 20% of impacted esophageal foreign bodies
• Of patients with multiple esophageal foreign body impactions, 80% have
an esophageal anomaly on further evaluation.
• Of patients with recurrent esophageal foreign bodies, 19% have
esophageal anomalies that previously required surgical repair.
7. • Most esophageal foreign bodies lodge at
either the level of the cricopharyngeus (upper
esophageal sphincter [UES]), the aortic arch,
or just superior to the diaphragm at the
gastroesophageal junction (lower esophageal
sphincter [LES])
8. LOCATION
• The esophagus is the narrowest portion of the alimentary tract and is
thus a common site for FB impaction.
• Within the esophagus itself, there are three areas of anatomical narrowing
that are potential areas of impaction:
• the cricopharyngeus sling (70%),
• the level of the aortic arch in the mid-esophagus (15%), and
• the lower esophageal sphincter at the gastroesophageal junction (15%).
• Other areas of potential impaction may be found in the esophagus of
children who have underlying esophageal pathology (i.e., strictures
• or eosinophilic esophagitis) or prior esophageal surgery (i.e., esophageal
atresia).
• Although usually asymptomatic, sharp foreign bodies may penetrate the
mucosa at any level and cause mediastinitis, aortoenteric fistula, or
peritonitis.
9. CLINICAL PRESENTATION
• At least 30% of children with esophageal foreign bodies
may be totally asymptomatic, so any history of foreign body
ingestion should be taken seriously and investigated.
• An initial bout of choking, gagging, and coughing may be
followed by excessive salivation, dysphagia, food refusal,
emesis, or pain in the neck, throat, or sternal notch regions.
• Respiratory symptoms such as stridor, wheezing, cyanosis,
or dyspnea may be encountered if the esophageal foreign
body impinges on the larynx or membranous posterior
tracheal wall.
• Cervical swelling, erythema, or subcutaneous crepitations
suggest perforation of the oropharynx or proximal
esophagus.
10. • FB ingestions usually present after a witnessed event
or disappearance of an object.
• Also, there may be heightened suspicion for ingestion
by a caregiver based on the child’s description.
• The majority of patients will have a normal physical
exam; however, the child should be evaluated for
signs of complications.
Physical exam findings that raise suspicion of potential
complications include oropharyngeal abrasions, crepitus,
or signs of peritonitis.
11. X-R(Neck, Chest & Abd) AP/Lat
• a radiologic evaluation is performed to assess its
location and size, and to anticipate the possibility of
multiple foreign bodies.
• PA and lateral airway films and PA and lateral chest
films, including the abdomen, are performed.
• Foreign bodies rotate to the greatest diameter of the
lumen; flat objects in the esophagus usually are
oriented in the coronal plane.
• It is imperative to obtain a lateral airway and chest film
to evaluate for possible battery ingestion because a
battery can easily mimic a coin on PA view.
12. • The flat surface of a coin in the esophagus is seen
on the AP view and the edge on the lateral view.
• The reverse is true for coins lodged in the
trachea; here, the edge is seen AP and the flat
side is seen laterally
• Disk-shaped button batteries can look like coins
and be differentiated by the double halo and
step-off on AP and lateral views, respectively
13.
14. CT scan
• Computed tomography (CT) scan with 3-D
reconstruction may increase the sensitivity of
imaging a foreign body .
15. Barium Esophagram
• Materials such as plastic, wood, glass, aluminum,
and bones may be radiolucent;
• Although barium contrast studies may be helpful
in the occasional asymptomatic patient with
negative plain films, their use is to be discouraged
because of the potential of aspiration as well as
making subsequent visualization and object
removal more difficult.
• failure to visualize the object with plain films in a
symptomatic patient warrants urgent endoscopy.
16. TREATMENT
• Sharp objects in the esophagus, disc button batteries,
or foreign bodies associated with respiratory symptoms
mandate urgent removal.
• Button batteries, in particular, must be expediently
removed because they can induce mucosal injury in as
little as 1 hr of contact time and involve all esophageal
layers within 4 hr.
• Asymptomatic blunt objects and coins lodged in the
esophagus can be observed for up to 24 hr in
anticipation of passage into the stomach.
• If there are no problems in handling secretions, meat
impactions can be observed for up to 12 hr.
17. • The location of the object on the radiograph is
important in determining the treatment
options.
• Most FB impactions are located in the
proximal esophagus at the level of the upper
esophageal sphincter or thoracic inlet.
• The majority of FB impactions found in the
upper or mid esophagus will remain
entrapped and require retrieval.
18. Endoscopic FB removal
• The type and size of endoscope depend on the
age of the patient and the location of the
object
19.
20. Foley balloon extraction with
fluoroscopy
• The Foley balloon extraction technique should
• be limited to round, smooth objects that have
been impacted for <1 week in appropriately
selected children without any evidence of
complications.
• This technique was found to have a success
rate of 80% while significantly lowering costs.
21. Foley balloon extraction with
fluoroscopy
• The technique consists of passage of a Foley
catheter beyond the coin at fluoroscopy,
inflating the balloon, and then pulling the
catheter and coin back simultaneously with
the patient in a prone oblique position.
Concerns about the lack of direct mucosal
visualization and, when tracheal intubation is
not used, the lack of airway protection prompt
caution in the use of this technique.
23. Bougienage
• Certain lower esophageal impactions can be
observed for a brief duration of time as most
of them pass spontaneously to stomach or
attempted to be advanced into the stomach
with bougienage or a nasogastric tube in the
ED without anesthesia.
24. Gastrointestinal Foreign Bodies
• FB ingestions that are found to be distal to the
esophagus are usually asymptomatic when discovered.
• Signs and symptoms including significant abdominal
pain, nausea, vomiting, fevers, abdominal distention, or
peritonitis should alert the provider to potential
complications including obstruction and/or perforation.
• The majority of FBs that pass into the stomach will
usually pass through the remainder of the
gastrointestinal (GI) tract uneventfully
• These patients can be managed as an outpatient
25. Gastrointestinal Foreign Bodies
• Occasionally, a FB will remain present in the bowel
after a period of observation and serial radiographs .
• Prokinetic agents and cathartics have not been found
to improve gut transit time and passage of the FB.
• Often parents are instructed to strain the child’s stool;
however, in up to 50% of cases, the FB is not identified
even with successful passage.
• If the child remains asymptomatic and the FB has not
been identified, a repeat abdominal radiograph can be
performed at 2- to 3-week intervals.
• Subsequent endoscopy is usually deferred for 4–6
weeks.
26. BATTERIES
• Button batteries will appear as a round, smooth object on
radiographs and are often misdiagnosed as coins.
• However, on close inspection, some larger button batteries
will demonstrate a double contour rim
• Esophageal batteries are associated with increased
morbidity due to the tissue injury that can occur through
pressure necrosis, release of a low-voltage electric current,
or leakage of an alkali solution, which causes a liquefaction
necrosis.
• This mucosal injury may occur in as little as 1 hour of
contact time and may continue even after removal.
• Therefore, any suspected case of esophageal battery
impaction warrants immediate removal.
27. • Battery size appears to be important as a battery diameter >20 mm
has been associated with greater risk of esophageal impaction and
higher grade injury.
• Following removal, an intraoperative esophagram may be helpful in
identifying a full-thickness injury.
• Mucosal irregularities and even contained perforations can be seen
and may necessitate enteral tube feedings.
• Early and late complications of esophageal battery impaction
include esophageal perforation, tracheoesophageal fistula ,
stricture and stenosis, and death.
• If the battery is confirmed to be distal to the esophagus in the GI
tract and the patient is asymptomatic, then it can be observed,
similar to other GI FBs.
• More than 80% of batteries that are distal to the esophagus will
pass uneventfully within 48 hours
28.
29. MAGNETS
• Single magnet ingestion distal to the esophagus can be observed in
the outpatient setting similar to other GI foreign bodies.
• If multiple magnets or a single magnet and a second metallic FB are
identified in the esophagus or stomach, endoscopy should be
performed to prevent potential subsequent complications.
• Once the objects pass distal to the stomach, if separated within the
GI tract, they may attach to each other and lead to obstruction,
volvulus, perforation, or fistula through pressure necrosis .
• Therefore, these children, even if asymptomatic, should be
observed as an inpatient with serial abdominal exams and
radiographs.
• If the child becomes symptomatic, develops signs of obstruction on
the abdominal radiograph, or shows failure of the objects to
progress in 48 hours, then intervention may be warranted
30. MAGNETS
• Plain radiographs are most commonly used to
confirm the diagnosis.
• However, radiographs should be interpreted
with caution because multiple magnets may
appear to be attached at a single point in the
GI lumen when, in fact, they are reall attached
across the bowel wall from two different
intestinal lumens
33. SHARP FOREIGN BODIES
• Ingestion of sharp foreign bodies can cause significant
morbidity with an associated 15–35% risk of perforation.
• Commonly ingested objects include nails, needles, screws,
toothpicks, safety pins, and bones.
• Perforation is most likely to occur in narrowed portions or
areas of curvature in the alimentary tract, especially the
ileocecal valve.
• Smaller objects and straight pins are associated with lower
rates of perforation and can be conservatively managed.
• However, other objects should be retrieved endoscopically
if possible or observed closely for potential development of
complications.
34. BEZOARS
• A bezoar is a tight collection of undigested material
that may often present as a gastric outlet or intestinal
obstruction.
• These can include lactobezoars (milk), phytobezoars
(plant), or trichobezoars (hair).
• Presenting symptoms can include nausea, vomiting,
weight loss, and abdominal distention.
• The diagnosis may be confirmed on plain radiographs,
upper GI contrast studies, or endoscopy.
• Often due to the size and density of the bezoar,
medical management and endoscopic removal are
unsuccessful, and operation is necessary
35.
36. FOOD IMPACTION
• Historically, children presenting with food impaction were
taken to the OR for a piecemeal removal of the impaction.
• This “pull” technique would often require multiple passes
of the endoscope, thus increasing patient morbidity.
• More recently, the “push” technique has been studied
where a provider would slowly “push” the FB into the
stomach.
• With proper technique, the historical concerns over distal
perforation have been ameliorated.
• In a recent study, initial endoscopic disimpaction success
rates were 65% for pull and 68% for push endoscopy.
• Unsuccessful attempts using one technique were rescued
with the other method.
37. AIRWAY FB (FB ASPIRATION)
• The highest incidence occurs in children 1 to 3
years old.
• Most airway foreign bodies are located in the
bronchi.
• One third of aspirated objects are nuts
particularly peanuts.
• Fragments of raw carrot, apple, dried beans,
popcorn, and sunflower or watermelon seeds
are also common, as are small toys or toy parts.
38. • The most common objects on which children
choke are food items (59.5–81% of all choking cases).
• Nuts, seeds, hot dogs, hard candy, gum, bones and raw
fruits and vegetables are the most frequently
aspirated food items.
• Common inorganic objects on which children choke
include coins, latex balloons, pins, jewelry ,magnets,
pencaps, and toys
• The most serious complication of foreign body aspiration
is complete obstruction of the airway.
• Complete airway obstruction is recognized in the
conscious child as sudden respiratory distress followed by
inability to speak or cough.
39. CLINICAL MANIFESTATIONS
• Three stages of symptoms may result from aspiration of an object into the
airway:
1. Initial event— violent paroxysms of coughing, choking, gagging, and
possibly airway obstruction occur immediately when the foreign body is
aspirated.
2. Asymptomatic interval— the foreign body becomes lodged, reflexes
fatigue, and the immediate irritating symptoms subside. This stage is most
treacherous and accounts for a large percentage of delayed diagnoses and
overlooked foreign bodies. It is during this 2nd stage that the physician may
minimize the possibility of a foreign body accident, being reassured by the
absence of symptoms that no foreign body is present.
3. Complications— obstruction, erosion, or infection develops to direct
attention again to the presence of a foreign body. In this 3rd stage,
complications include fever, cough, hemoptysis, pneumonia, and atelectasis.
40.
41. Radiographic Evaluation
Neck (AP/Lat), CXR
• 80-96% of airway bodies are radiolucent
• Rely on secondary findings to indicate FBs
-air trapping
-asymmetric hyperinflation
-obstructive emphysema
-atelectasis
-mediastinal shift
-consolidation
Children with bronchial foreign bodies can be radiographically normal or may
show obstructive emphysema (air trapping or hyperinflation—an early
finding) and atelectasis or consolidation (late findings).
Foreign bodies lodged in the larynx or trachea tend to have a higher
radiographic detection rate (90%) than those in the bronchus (70%).
42.
43.
44.
45.
46. CT/MRI
• Highly sensitive for radiolucent
• Radiographic imaging remains helpful in
children with a history of choking, yet definitive
diagnosis still requires bronchoscopy.
56. • The child should be placed supine on the operating table.
• The neck should be extended with a shoulder roll and the head supported
by a head ring
• Children should be premedicated with atropine in order to reduce airway
secretions and facilitate the effective application of topical anesthesia to
the larynx. Following the application of topical anesthesia to the larynx to
prevent laryngospasm, a nasopharyngeal airway is passed in order to
deliver inhalational anesthesia and/or oxygen until the bronchoscope is in
place.
• Liberal use of lidocaine (2–4 mg/kg) applied to the glottic area may
minimize laryngospasm
• Dilute epinephrine solution (1–2 mL of 1:10,000) may be instilled around
the foreign body using the flexible suction catheter, provided there is no
contraindication.
• This reduces mucosal edema and facilitates foreign body removal
57. Complications
• Intra-operative
-Dental injury
-Bleeding
-Hypercarbia
Post-operative
● Laryngospasm: this may be minimized by good anesthetic technique, use of topical
local anesthetic to
the larynx, minimal mucosal contact and ensuring there is no active bleeding at the
end of the procedure.
● Airway obstruction may occur as a result of trauma to an already compromised
airway along with the effects of anesthesia. Nebulized epinephrine and oral or
intravenous dexamethasone may provide time for edema to settle, but in severe
cases intubation or tracheostomy may be necessary.
● Aspiration: sufficient time should elapse following the application of topical
anesthesia to the larynx before feeding in order to prevent aspiration
58. RESUL TS AND COMPLI CA T I ONS
• Successful extraction of foreign bodies with
bronchoscopy is between 93.7% and 99.7%.
• Intraoperative complication s include
failure to remove the object requiring either
tracheostomy or thoracotomy for rem oval
,airway injury bleeding ,an d hypoxia.
• Postoperative complications include laryngeal
edema, bronchospasm ,bleeding ,atelectasis,
pneumonia, and pneumothorax .
