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Foreign Bodies of the Airway, Esophagus and Ear Presented by Nannaphat pradutdecha Slide 2 References Lauren DH, Sheri AP. Foreign bodies of te airway and esophagus. Cummings otolayngology Head & neck surgery. 5 th ed. Philadelphia : Elsevier, 2010 : 2935-43 Nancy Sculerati. Foreign body of the nose. Pediatric otolaryngology. 4 th ed. Philadelphia : WB Saunders Co, 2002 : 1032-6 Slide 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 esophageal85% The highest incidence occurs between 1 and 3 years of age 25% of patients are younger than 1 year. Slide 4 Toddlers 1) Lack posterior dentition (molars - necessary for proper grinding of food) 2) Less-controlled coordination of swallowing, and immaturity in laryngeal elevation and glottic closure 3) Oral exploration (age-related tendency to explore the environment by placing objects in the mouth) 4) Easy distractibility (often running or playing at the time of ingestion) Slide 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 Slide 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. Slide 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) Slide 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 Slide 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.) Slide 10 Management of choking victims Note : Back blows or abdominal thrusts in individuals with only partial obstructions could lead to complete obstruction and are not recommended. Agemanagement Infantsrescue breaths and chest compressions Children > 1 yearrequire gentle abdominal thrusts while supine Older children and adultsHeimlich maneuver ( standing, sitting, or recumbent ) Slide 11 Slide 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 Slide 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 Slide 14 Daksheh H. pahrik. Paediatic thoracic surgery. P 359 Slide 15 Laryngotracheal Foreign Bodies http://www.hawaii.edu/medicine/pediatrics/pemxray/v1c08.html 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 Slide 16 Bronchial Foreign Bodies check-valve effect : expiration,resulting in hyperinflation of the affected side and mediastinal shift to the opposite side Slide 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 Slide 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 Slide 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 Slide 20 Guidelines for Selection of Bronchoscope, Esophagoscope, and Laryngoscope for Diagnostic Endoscopy by Age Slide 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. Slide 22 Anesthesia Laryngeal FB 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 Slide 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 Slide 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 Slide 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.) Slide 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 Slide 27 Kenny H. Chan, et al.Endoscopy of the Aerodigestive Tract. In : Bluesone CD. Surgical Atlas of Pediatric otolaryngology. 2002 :581 Slide 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 Slide 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 oxidecontaining batteries can cause systemic mercury poisoning if they open in the gastrointestinal tract Slide 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 Slide 31 From: Foreign body of the pharynx and esophagus. Pediatric otolaryngology. 4 th ed. Philadelphia : WB Saunders Co, 2002 : 1327 Slide 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 Slide 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 Slide 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 Slide 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. Slide 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 Slide 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 Slide 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 Slide 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) Slide 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) Slide 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. Slide 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 Slide 43 Foreign body of the nose Presentation Persistent rhinitis, unilateral purulent rhinorrhea Adenoiditis sinusitis Adult witness child putting something in nose Slide 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 Slide 45 Foreign body of the nose Management Decongestant Anterior rhinoscope : nasal speculum, otoscope Frazier suction tube Right angle hook, flexible cerumen curette and alligator forceps Restrain or sedate or under brief GA Slide 46 Foreign body of the nose Management guaze adrenaline or antibiotic oinment ATB Slide 47 Rhinolith Formed from intranasal FB that encrusted with mineral salt ( Calcium, Magnesium) Treatment : remove Slide 48 Management : , , ear hook, alligator forceps ATB Slide 49 Equipments Slide 50 Equipments Slide 51 Equipments Slide 52 Equipments Slide 53 Equipments Slide 54 Equipments