17. foreign bodies in aerodigestive tract
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Transcript of 17. foreign bodies in aerodigestive tract
Foreign Bodies of Aero-Digestive Tract
Dr. Krishna KoiralaMBBS, MS ( ENT-HNS)Associate Professor
MCOMS, Pokhara2016-05-24
Introduction• Foreign Body in Aero-digestive tract
is a common clinical occurrence
• It is an ENT Emergency
• Foreign Body enters the body by either
– Ingestion: “F.B. Esophagus”
–Aspiration: “F.B. Bronchus”
Foreign Body ingestion• Epidemiology
– Children >>> Adults
– Boys > Girls
– No Racial / Geographical Predisposition
Etiology• More common in children
– Lack Molar teeth, poor mastication
– Natural tendency to put objects in mouth
– Play with objects inside mouth
– Easy Distractibility
• Types of F.B
– Coins: Commonest in children
– Household items, Pen cap, Small Toys
– Meat Bone: Commonest in Adults
Pathogenesis• Foreign Body lodges in esophagus at
– Just below Crico-pharynx ; Commonest ; ??
–Above Crico-pharynx
–Above Aortic constriction
–Above Left Bronchial constriction
–Above Gastro-esophageal junction
Symptoms• Odynophagia /Dysphagia
• Drooling of Saliva
• Refusal to take oral feeds
• Fever + Prostration
• Difficulty breathing
• Chest / Back Pain
• Collapsing Child
• Hematemesis
Signs• Usually no clinically elicitable signs
• Drooling saliva
• Fever
• Tachypnea
• Tachycardia
• Hamman’s Sign– Seen in esophageal Perforation with
pneumomediastinum
– Quashing sound over precordium with each heartbeat
Investigations• X-ray Neck and Chest – Always get both AP and Lateral views
– Radio-opaque foreign body easily seen
– Radio-lucent F.B. evidenced by Air in the Esophagus
• Barium Swallow– Radio-lucent F.B well visualized
• Esophagoscopy– Diagnostic as well as Therapeutic
Radio - Opaque F.B Esophagus
Double Lumen Sign: Disc Battery
Radio-Lucent F.B Esophagus
Treatment• Observation
• Balloon Catheter Removal
• Rigid Esophagoscopy and removal with forceps
• Thoracotomy
1. Observation– Usually for 24 hours
• Immediate presentation
•Blunt foreign body below the cricopharynx
•Child Stable
– Spontaneous passage of foreign body into the stomach is expected
– If it doesn’t pass into stomach, Esophagoscopy is done
– C/I: Disc Battery Ingestion: emergency (Risk of liquifactive / coagulation necrosis)
2. Balloon Catheter Removal–Performed in centers where there is no
access to esophagoscopy
–90 % efficacy
–Advantages: No GA, Cost effective
–Complications: Emesis, Tracheal placement
–Esophagoscopy needed in case of failure
3. Rigid Esophagoscopy and foreign body removal with forceps
– Gold Standard Modality
– GA Needed
– Complications
•Iatrogenic Perforation, Oro-dental injury
4. Thoracotomy– Migrated F.B, unsuccessful rigid
esophagoscopy
• Epidemiology
– More common in children than adults
– Boys > girls
– No racial / geographical
predisposition
Foreign Body Aspiration
Etiology• Commonly seen in children
– Poor airway reflexes– Lack Molar teeth ,poor mastication
– Natural tendency to put objects in mouth
– Play with objects inside mouth– Easy distractability
• Type of F.B
– Vegetable Matter: Peanuts Commonest
– Pen cap, whistles, safety Pin
Pathogenesis• Foreign Body lodges in
– Bronchi
•Right Main Bronchus Commonest
•Sitting / Standing Position
–Rt. Lower Lobe- Lower portion •Supine Position
–Rt. Lower Lobe- Upper portion– Trachea– Larynx
Right main Bronchus- Straighter and Wider
Symptoms• Choking
• Gagging
• Violent Coughing
• Dyspnea
• Stridor
• Wheezing
• Cyanosis
• Hoarseness
Signs
• Inspiratory Stridor
• Bi-phasic Stridor
• Expiratory Stridor
• Unilateral Wheezing
• Decreased Breath Sounds
Investigations• X-ray Neck and Chest
– PA and Lateral Views– Inspiratory and expiratory films – air
trapping– Atelectasis– Pneumonitis– Consolidation
• Airway Fluoroscopy– Radio-lucent F.B
• Bronchoscopy – Diagnostic as well as therapeutic
Radio - Opaque F.B Rt. Main Bronchus
Radio-Lucent F.B. Rt. Lung ( Hyperinflation)
Radio-Lucent F.B Lt. Bronchus (Atelectasis)
Radiolucent F.B seen on Fluoroscopy
Treatment• Rigid Bronchoscopy and foreign body
removal
– Gold Standard
• Fiber-optic Bronchoscopy
– F.B in distal bronchus
• Tracheostomy & F.B Removal
– Large F.B in Sub-glottis
• Thoracotomy: Migrated F.B
F.B . Trachea
Bronchoscopes
Optical forceps
Net F.B retrieval system
First aid ‘choking’
• Back blows
• Abdominal thrusts /Heimlich maneuver
• Chest thrusts
Back Blows
Five rapid blows given by heel of hand between shoulder blades
Abdominal thrusts
5 rapid thrusts given between umbillicus and xiphisternum
Chest thrusts
5 rapid thrusts given in middle of sternum
Errors to avoid in suspected foreign body cases
• Do not reach for the foreign body with the fingers
• Do not blindly pass an esophageal bougie or other instruments
• Do not hold up the patient by the heels
• Do not fail to have an X-ray done
• Do not fail to search endoscopically for a foreign body in all cases of doubt
• Do not tell the patient he has no
foreign body until after X-Ray
examination, physical
examination, indirect examination
and endoscopy all have proven
negative