Foreign Body Ingestion

Question 1

Discuss esophageal foreign bodies.

Answer 1

Esophageal foreign bodies represent a common clinical challenge for pediatric surgeons.

These children often present with chest pain, dysphagia, and inability to swallow.

Both rigid and flexible esophagoscopy are acceptable techniques.

Recent investigative work has focused on cost of care and consideration for advancement of the foreign body into the stomach.

Most of these cases are performed under general anesthesia.

The anesthesia team should be alerted to the increased possibility of tooth injury or accidental endotracheal tube dislodgement during the procedure.

Complications are increased with children suffering from esophageal food impaction or button battery ingestion.

These children are best served with early intervention.

Surgeons should have a host of techniques available for successful intervention.

Question 2

What are the most common esophageal foreign bodies?

Answer 2

In the United States, coins represent the most common esophageal foreign bodies; however fish bones are more common worldwide.

Question 3

What are the most common sites for esophageal foreign body impaction?

Answer 3

There are three areas of anatomical narrowing in the esophagus that could serve
as potential areas of impaction. These include the cricopharyngeus sling (70%), the level of the aortic arch in the mid esophagus (15%), and the lower esophageal
sphincter (15%).

Question 4

Should contrast examinations be routinely used to localize an esophageal
foreign body?

Answer 4

A contrast examination should not be performed routinely primarily because of the risk of aspiration and secondarily because coating of the foreign body and esophageal mucosa compromises subsequent esophagoscopy.

Question 5

Describe the workup for suspected radiopaque and radiolucent foreign bodies.

Answer 5

Radiopaque objects can easily be detected with routine chest x-ray; however radiolucent ones may require additional imaging.

Contrast esophagram is an option in select patients who can protect their airway.

Injected volume should be limited. A high index of clinical suspicion for a radiolucent foreign body combined with appropriate physical findings such as drooling may mandate esophagoscopy.

Question 6

How commonly will lodged esophageal coins pass spontaneously?

Answer 6

Coins pass naturally in up to 20 to 30% of children within 24 hours.

Criteria that may influence passage including child’s age, time of esophageal lodging, and type of coin are unpredictable.

Distal esophageal coins pass more commonly than proximal coins.

Thus a period of observation in select patients and consideration of a repeated x-ray is warranted prior to an invasive procedure [1, 2].

Question 7

Are sharp esophageal foreign bodies managed differently than smooth?

Answer 7

Smooth foreign bodies, with the exception of button batteries, rarely cause significant esophageal problems.

Interestingly, small sharp objects and straight pins can be managed conservatively in the majority of cases.

Larger sharp esophageal for- eign bodies such as nails, needles, screws, and bones have a risk of perforation of 15–35% and thus should be managed with endoscopic retrieval [3].

Question 8

What options exists for removal of an esophageal foreign body?

Answer 8

A successful endoscopist must have competence in several techniques when approaching a child with an esophageal foreign body.

Foley balloon extraction, flexible and rigid esophagoscopy (using various graspers), direct laryngoscopy, and push esophagoscopy are commonly described techniques.

Question 9

Describe the technique for Foley balloon extraction

Answer 9

This technique requires the fluoroscopic placement of a Foley catheter just distal to the foreign body.

Once catheter position has been confirmed, contrast is placed in the Foley balloon.

The catheter is then slowly withdrawn until the foreign body is expressed or readily visualized in the oral pharynx.

Children should be restrained, but sedatives are not required.

Resuscitation equipment should be readily available.

Question 10

What is the success rate for Foley balloon extraction of esophageal foreign
bodies?

Answer 10

Foley balloon extraction with fluoroscopy has been shown to have an 80% success rate [4].

Question 11

What are the fiscal benefits of Foley balloon extraction of esophageal foreign bodies?

Answer 11

Published data suggest significant potential cost savings for Foley balloon extraction compared to standard endoscopy under general anesthesia.

Cost for Foley balloon extraction averaged $1231 versus $3615 for standard endoscopy [5].

Question 12

What techniques can be used for very proximal esophageal foreign bodies lodged at the cricopharyngeus sphincter?

Answer 12

At times, especially in a young child, an esophageal foreign body can be lodged in the most proximal portion of the esophagus making standard esophagoscopy, whether rigid or flexible, more challenging.

In these cases, practitioners may opt to use a Miller direct laryngoscope blade to expose the proximal esophagus and Magill forceps to retrieve the foreign body.

Straight laparoscopic graspers are helpful if the Magill forceps prove to bulky for a small mouth.

Question 13

How are esophageal coins differentiated from esophageal button batteries?

Answer 13

Both esophageal coins and button batteries have a similar look on initial plain film.

They share a similar size and are smooth and round.

However, with closer inspection, one will note the double lucency shadow consistent with button batteries (Figs. 8.1 and 8.2).

This key finding is critical to detect and will influence timing of surgery and possible complications.

Question 14

Why are button batteries treated with more urgency than other esophageal foreign bodies?

Answer 14

Esophageal button battery ingestion should be treated as a true pediatric surgical emergency.

Standard NPO guidelines do not apply.

Button battery ingestions are associated with increased morbidity secondary to rapid tissue injury that occurs through leakage of alkali solution.

Liquefaction necrosis of the esophageal mucosa and muscularis can advance rapidly.

Experience suggests that initial mucosal injury may occur with contact time as little as one hour.

Question 15

Describe alternative management for esophageal button battery impaction if the battery cannot be retrieved via standard esophagoscopy.

Answer 15

Button batteries can be pushed into the stomach where most can successfully pass throughout the gastrointestinal tract without consequence.

Alternatively, a basket can be used to retrieve the gastric button battery at the time of esophagoscopy or if the patient manifests postoperative signs or symptoms of injury to the gastrointestinal tract.

Surgeons should consider retrieving button batteries larger than 20 mm diameter that remain in the stomach greater than 48 hours as determined by x-ray.

Emetics are not beneficial in the management of disk battery ingestions, and cathartics and acid suppression have no proven role in treatment of battery ingestion [6].

Question 16

Are special studies required following esophageal button battery removal?

Answer 16

This depends on the assessment of the esophageal mucosa at the time of button battery removal.

If concern exists, then an intraoperative esophagram or formal esophagram in the radiology department is warranted.

Mucosal irregularities and contained perforations are possible.

When concern exists, placement of a distal nasogastric feeding tube is helpful to allow direct enteral feeds while the esophageal mucosal injury heals.

In the absence of progressive symptoms, repeated esophagram in one week is recommended.

Question 17

Describe the short and long term complications of button battery impaction

Answer 17

Short term complications include mucosal injury and possible full thickness injury with esophageal contained perforation or even free rupture.

Long term complications include tracheoesophageal fistula, stricture, and death.

Question 18

What techniques are available to manage esophageal food impaction?

Answer 18

Both flexible and rigid esophagoscopy are practiced.

One benefit of rigid open channel esophagoscopy includes the use of internal extraction forceps to remove larger chunks of food (often chicken or hot dogs) or other debris without having to remove the rigid scope.

With patience, the job can also be accomplished with flexible techniques using the coin grasper or other grasping forceps.

However larger pieces cannot be removed inside the flexible scope. The scope must be removed multiple times as small pieces are extracted.

With repeated withdrawals and advancements of the flexible scope, one must be very attentive not to cause an accidental dislodgement of an endotracheal tube.

Question 19

Can the esophageal foreign body simply be advanced into the stomach and be allowed to pass naturally?

Answer 19

Historically, “pull techniques” have been favored over “push techniques.”

Recent data suggests that both techniques are safe and have similar success rates at 65% and 68% respectively [7].

If one technique is not successful, conversion to the other is the next move. Of note, in children with previous esophageal surgery the practitioner must be aware of a possible distal esophageal stricture.

Question 20

How do you recognize and manage incidental extubation during esophagoscopy?

Answer 20

Most pediatric anesthesiologists require endotracheal intubation prior to attempted removal of an esophageal foreign body.

Security of the endotracheal tube should be paramount.

In less experienced hands or in cases of repeated placement of the esophagoscope, dislodgement can occur.

Oxygen desaturation and loss of end tidal CO2 are early indicators for accidental extubation.

The surgeon should immediately withdraw the esophagoscope and allow the child to receive positive pressure ventilation and repeated intubation.

Question 21

Are tooth injuries common during esophagoscopy?

Answer 21

Generally speaking, tooth injuries in children should be uncommon.

However, the exploring nature of children often coincides when they may be losing their deciduous teeth.

Inspection of the oral cavity and documentation of loose teeth is recom- mended before proceeding.

Use of an endoscopic mouth guard is recommended with flexible esophagoscopy.

When rigid esophagoscopy is employed, mindful attention to not rear back or rest the scope of the upper teeth is prudent.

Question 22

How common are tracheobronchial foreign bodies?

Answer 22

The aspiration of tracheobronchial foreign bodies is fortunately not common.

However, asphyxiation caused by an inhaled laryngeal or tracheobronchial foreign bodies is one of the leading causes of accidental death in children under the age of 4 years in many countries.

In Europe, a retrospective study of 19 European countries was undertaken to determine the incidence of airway foreign bodies between 2000 and 2002 [1].

Cases were identified using hospital discharge records and International Classification of Disease (ICD-9) codes.

During this time period, 170 cases of laryngeal of pharyngeal foreign bodies (ICD 933) and 552 cases of tracheobronchial foreign bodies (ICD 934) were identified.

In the United States, non-choking rates were reviewed by the Morbidity and Mortality Weekly Report [2].

In 2001, approximately 17,537 children aged 14 years or less were treated in emergency departments for choking related episodes.

This incidence corresponds to a rate of 29.9 per 100,000 population.

The rates were reported for specific age groups.

Question 23

What is the age distribution of tracheobronchial foreign bodies?

Answer 23

In a European study, there was a higher reported incidence of tracheobronchial foreign body aspiration in males (63%) and the median age at presentation was 2 years [1].

In a review of cases presenting at a tertiary care center in Eastern India, 82 cases were identified between 2001 and 2008 [3].

The most common age at presentation was between 1 and 3 years (56.4%).

In the US, the highest rates of non-fatal choking events were found for infants aged <1 year (140.4 per 100,000 population) [2].

Overall, 82.3% of all cases were in children 0–4 years of age.

As found in the European study, most of the cases were in males (55%).

In a more recent review of the English literature, 12,979 children with suspected (11,145 cases confirmed) foreign body aspiration were reported between 2000 and 2010 [4].

Most of the children were under the age of 3 years.

The median age range was 1–2 years and the mean age range was 2.1–3.8 years.

It should be noted that foreign body aspiration is also reported in adolescents.

In these instances, the adolescent is commonly neurodevelopmentally delayed or incapacitated by alcohol or drug use.

In this age group, non-food foreign bodies are more common (pins, coins, pen caps, etc.).

Question 24

Why are tracheobronchial foreign bodies most common in very young children?

Answer 24

There are several factors that predispose very young children to accidental for- eign body aspiration [5].

A major factor is their inherent oral curiosity.

Infants typically explore their environment by placing objects in their mouth.

This behaviour can be particularly problematic when they begin to crawl or walk and gain access to many objects.

Young children lack molars to grind food adequately and prematurely swallow large food boluses.

Choking on food substances can occur when the children are given unsuitable foods such as nuts or raw vegetables by an unsuspecting parent or young sibling.

Young children typically demonstrate active behaviours while eating which may also predispose to accidental choking.

Finally, young children have very small airways that are susceptible to complete blockage of the airway by foods with a round shape such as uncut grapes and hotdogs.

Question 25

What is the mortality associated with tracheobronchial foreign bodies?

Answer 25

The mortality associated with tracheobronchial foreign bodies is not precisely known. However, national mortality data related to choking have been reported in the United States. In 2000, 160 children aged 14 years or less died from obstruction of the respiratory tract as a result of an inhaled or ingested foreign body (ICD 11 Tracheobronchial Foreign Bodies 71 W79–W80, 10th Edition) [2]. Death was more commonly caused by a non-food substance (59%) than a food substance (41%). In a review of the English literature, mortality data was reported in 26 of the 30 articles included in the review [4]. There were 43 deaths among 10,236 children with aspirated foreign bodies giving an overall mortality rate of 0.42%. It should be noted that many of the reported deaths occurred either during the treatment bronchoscopy or due to a complication of the procedure. The reported mortality rate is likely an underestimate of the true death rate as the review does not include deaths that occurred prior to reaching medical care.

Question 26

What are the most common tracheobronchial foreign bodies encountered?

Answer 26

It is clear from the literature that the nature of foreign bodies encountered varies according to geographical and cultural food preferences. In a European study, the most common foreign bodies were nuts, seeds, berries, corn and beans [1]. In an Indian study, food materials such as seeds and beans were encountered in 48.8% of cases [3]. In the United States MMWR report, 59.5% of reported cases involved food substances, 31.4% non-food substances and in 9% of cases the nature of the foreign body was not reported [2]. The most common food substances were “solid food” which included cookies, chips/crackers, popcorn, nuts/seeds, bones, bread, meats, fruit, pasta/rice/cereals and candy/gum. Common non-food foreign bodies encountered were coins, toys, marbles, balloons, puzzle pieces, paper, pen caps, tape, and screws.

Question 27

What are the most dangerous tracheobronchial foreign bodies?

Answer 27

It should be emphasized that all tracheobronchial foreign bodies are dangerous as they can cause immediate life-threatening airway compromise and serious longer-term complications such as pneumonia and lung collapse. However, there are several food and non-food foreign bodies that pose an added risk of injury, long term complication and death. The foreign bodies that fall into this category are summarized in Table 11.1.

Question 28

What are the most common clinical presentations associated with tracheo- bronchial foreign bodies?

Answer 28

A patient that presents to the emergency department with a history of a witnessed choking event should be considered to have a tracheobronchial foreign body until proven otherwise. The suspicion should remain high even if the patient does not have any signs or symptoms suggestive of a foreign body aspiration. If the choking event was not witnessed, children typically present with a recent onset of unexplained cough, wheezing, and shortness of breath. If the choking event occurred remotely, the patient may present with ‘atypical asthma’ that is not responsive to treatment with bronchodilators, chronic cough, or recurrent or non-resolving pneumonia.

Question 29

What are the most common presenting clinical signs associated with tracheobronchial foreign bodies?

Answer 29

The clinical signs of a tracheobronchial foreign body in children may range from acute airway distress to subtle chest findings. A child with acute airway distress may demonstrate nasal flaring, preference for an upright posture, tracheal and subcostal indrawing, tachypnea, tachycardia, cyanosis and sialorrhea. Careful inspection of the eyes may reveal multiple scleral hemorrhages. If the foreign body is lodged in the larynx, the child will also present with stridor, dysphonia or aphonia. Aphonia should alert the treating physician to the possibility of a laryngeal foreign body and the need for immediate intervention as laryngeal foreign bodies are associated with a very high risk of death. Foreign bodies in the lower airway are more commonly associated with diminished breath sounds in a unilateral lung field, ronchi, or wheezing. These clinical findings are more likely to be detected in the right lung field. Foreign bodies are more likely to migrate to the right main bronchus given its orientation which is more in line with the trachea.

Question 30

What are the most common and useful imaging modalities to assess a patient with a suspected tracheobronchial foreign body?

Answer 30

The chest radiograph is the most useful imaging modality for the initial assessment of a child with a suspected tracheobronchial foreign body. It is particularly useful for the detection and localization of radio-opaque foreign bodies. However, the chest radiograph may not be helpful with food substances or with objects that are typically non-radio-opaque. In several reported case series, chest radiographs were reported as normal in 17% of cases of confirmed FB aspiration [4]. In some instances, the chest radiograph may detect segmental collapse, atelectasis, hyperinflation of the affected infiltrate or deviation of the mediastinum. Lateral, inspiratory/expiratory, and lateral decubitus views may be required to detect air trapping caused by a foreign body. Computed tomography scans and virtual bronchoscopy are other useful imaging modalities to detect tracheobronchial foreign bodies. These investigations are more sensitive, especially for non-radio-opaque foreign bodies, when the diagnosis is equivocal, or if the patient presents with persistent symptoms after bronchoscopy. However, there are concerns with using computed tomography as a first-line investigation such as unnecessary radiation exposure to children, cost and availability. Most importantly, this should not be performed in an unstable or uncooperative patient especially if the imaging equipment is in a remote location or if the child requires sedation. In these instances, the patient should proceed directly to bronchoscopy.

Question 31

How should patients with tracheobronchial foreign bodies be prioritized for treatment?

Answer 31

Children with confirmed or a high suspicion of a tracheobronchial foreign body should be assigned the highest priority for treatment, especially if the patient is presenting with concerning clinical signs. For most institutions, the highest priority indicates that the procedure should be performed within 1 hour. With severe airway compromise, fasting rules may be compromised. An airway foreign body may lead to acute airway compromise, hypoxia and death. The most serious complications associated with delayed treatment of tracheobronchial foreign bodies include pneumothorax, pneumomediastinum, hypoxic brain injury, post-obstructive pulmonary edema, need for tracheostomy, cardiac arrest and death. Unrecognized and therefore delayed treatment of tracheobronchial foreign bodies may result in pneumonia and loss of lung function.

Question 32

How are tracheobronchial foreign bodies removed?

Answer 32

Tracheobronchial foreign bodies are removed under general anesthesia and bronchoscopy [6]. In most pediatric medical centres, tracheobronchial foreign bodies are removed with rigid ventilating bronchoscopes. A full range of ventilating rigid bronchoscopes, rigid telescopes and optical grasping forceps are required equipment. A variety of grasping forceps are commercially available that are designed for specific types of foreign bodies (Fig. 11.1). A thorough description of the tools, and methods to remove foreign bodies is beyond the scope of this chapter (see ref- erences). Foreign bodies can also be removed by flexible bronchoscopes with side ports that allow the introduction of grasping forceps. They are particularly useful for very distal foreign bodies that are beyond the reach of rigid bronchoscopes.

Question 33

When should a tracheostomy be performed to manage a tracheobronchial foreign body?

Answer 33

A tracheostomy is not usually required for the management of tracheobronchial foreign bodies. However, if the foreign body is firmly lodged at the glottic level, is causing severe airway obstruction, and cannot be easily removed, a tracheostomy may be required. A temporary tracheostomy may be required for large or irregularly shaped foreign bodies that cannot be withdrawn through the vocal folds. In these rare instances, the foreign body is removed through the tracheostomy. It should be noted that tracheostomies are not helpful with foreign bodies in the distal trachea or bronchi and therefore should not be performed.

Question 34

What are the important anaesthetic principles that should be considered when treating a child with a tracheobronchial foreign body?

Answer 34

Children undergoing rigid bronchoscopy for a tracheobronchial foreign body require a general anesthetic [4]. Anesthesia is induced and maintained by either inhalational agent, intravenous medication or a combination of the two modalities. An intravenous agent may be needed if the airway obstruction is severe and absorption of inhalational agent is compromised. Regardless of the agent used, it is preferable that the induction of anesthesia be gradual so that the patient can maintain spontaneous ventilation throughout the procedure. Spontaneous ventilation avoids dislodging a proximal airway foreign body and minimizes the hyperinflation of the involved lung and therefore the risk of pneumothorax. Patience must be exercised to allow the patient to achieve the ideal plane of anesthesia to avoid coughing, bucking, desaturation and injury to the airway lumen. Topicalization of the larynx and carina may facilitate rigid bronchoscopy by blunting the stimulation caused by the procedure. In severe cases, the surgeon may need to proceed expeditiously to relieve the airway obstruction and therefore forego an ideal anesthetic plane. The anesthesiologist should consider the use of anticholinergic medications to decrease the airway secretions and prevent bradycardia, and steroids to minimize glottic and subglottic edema caused by the procedure. It must be emphasized that rigid bronchoscopy for tracheobronchial foreign bodies requires excellent communication between surgeon and anesthesiologist for an uneventful procedure and best patient outcomes.

Question 35

What are the important surgical principles that should be considered when treating a child with a tracheobronchial foreign body?

Answer 35

The surgeon must develop and communicate the plan for the procedure with the anesthetist and nursing team prior to the start of the procedure. A detailed ‘time-out’ with the team will ensure that the necessary equipment and contingency plans are in place if there is difficulty with maintaining a safe airway during the procedure. The team should have at their disposal a wide array of laryngoscopes, bronchoscopes and optical grasping forceps to deal with any food and non-food foreign body [6]. The equipment should be well organized, easily accessible and familiar to the nursing team. In many institutions, a dedicated ‘airway room’ is established to manage tracheobronchial foreign bodies and other airway emergencies.

Question 36

What is the recommended post-operative care after removal of a tracheo- bronchial foreign body?

Answer 36

Infants and young children are typically admitted following a rigid bronchoscopy to remove tracheobronchial foreign bodies. A unit with monitored beds is advisable for the early detection of airway complications. A postoperative chest radiograph is considered if the procedure was prolonged, challenging or if there was injury to the airway lumen. Patients with signs of airway inflammation, granulation or purulent secretions during bronchoscopy may require systemic antibiotics and inhalational steroids as adjuvant treatment. Patients with persistent symptoms after bronchoscopy may require a repeat bronchoscopy or computed tomography imaging if residual foreign body fragments are suspected.

Question 37

Are there choking prevention programs available to physicians and parents?

Answer 37

There are several established choking prevention programs in North American that provide useful information to physicians and caregivers. The names and websites of available programs is presented below. American Academy of Pediatrics (www.healthychildren.org/English/health-is- sues/injuries-emergencies/Pages/Choking-Prevention.aspx). Canadian Paediatric Society (www.cps.ca/en/documents/position/preventing- choking-suffocation-children). University of British Columbia (https://dontchoke.ubc.ca).

Question 38

A 3-year-old boy is brought to the hospital by his parents with suspicion of foreign body ingestion. The child appears well and is in no distress. Plain films reveal a uniform, rounded metallic foreign body (on AP view) with a slight edge step-off noted on lateral views. The object appears to be in the esophagus. What is the next best step in the management of this patient? A. Send the patient home and observe, then repeat the chest xray 24h after ingestion. B. Admit the patient and encourage to eat to push the foreign body down into the stomach C. Induced vomiting D. Do an emergency endoscopic removal

Answer 38

D. Do an emergency endoscopic removal