PREPARED BY : NURUL SYAZWANI RAMLI

Foreign Bodies of Air Passages and Food Passage

Foreign Bodies of Air Passages

A foreign body (FB) aspirated into air passage can lodge in the larynx, trachea, or bronchi (depend on size and nature of FB).

Large FB = can’t pass thru glottis lodge in supraglottic area.

Smaller FB = pass down thru larynx into trachea or bronchi.

Aetiology

Vegetable Peanut (most common) Almond seed Peas Beans Wheat seed Water melon seed Piece of carrot or apple,

etc

Nonvegetable Plastic whistle Plastic toys Safety pins Nails / Screws Coins Bones Buttons Hair clips Marble, etc

Nature of Foreign Body

Non-irritating type Eg: plastic, glass, metallic FB symptomless for a long time

Irritating type Eg: vegetable (peanuts, beans, seeds, etc) Set up diffuse violent reaction congestion and

oedema of tracheobronchial mucosa (vegetal bronchitis)

swell up with time causing airway obstruction and later suppuration in the lung.

Clinical Features

Symptomatology of FB is divided into 3 stages:1) Initial period of choking, gagging and wheezing

Last for a short time FB may be coughed out or it may lodged in the larynx

or further down in tracheobronchial tree

2) Symptomless interval Resp. mucosa adapts initial symptoms dissappear

3) Later symptoms Caused by obstruction to the airway, inflammation or

trauma induced by FB and would depend on site of its lodgement.

Cont. Clinical Features

Sites of its lodgement:a) Laryngeal FB

Large FB totally obstruct airway sudden death (unless resuscitative measures urgently).

Partial obstructive discomfort, pain in throat, hoarseness of voice, croupy cough, aphonia, dyspnoea, wheezing and haemoptysis.

b) Tracheal FB Sharp FB cough, haemoptysis Loose FB move up and down the trachea btwn carina and

undersurface of vocal cords ‘audible slap’, ‘palpatory thud’ and asthmatoid wheeze.

c) Bronchial FB Right Bronchus (most) becoz wider and more in line with tracheal lumen Totally obstruct lobar or segmental bronchus atelectasis Produce check valve obstruction obstructive emphysema Emphysematous bulla rupture spontaneous pneumothorax Retained FB in lung pneumonitis, bronchiectasis or lung abscess.

Diagnosis

Detailed Hx (FB ingestion)PE of neck and chest

Classical triad Sudden onset of coughing Wheezing Diminished air entry

Radiology: Plain X-Ray CXR at end of inspiration and expiration Fluoroscopy/videofluoroscopy CT chest

Management

Laryngeal FB First aid measures:

1) Pounding on the back shud not be done

2) Turning the patient upside down if pt. partially

3) Heimlich’s manoeuvre obstructed

4) Cricothyrotomy or emergency tracheostomy (if Heimlich’s manoeuvre fails)

5) Once emergency over, FB can be removed by direct laryngoscopy or laryngofissure (if found impacted)

Cont. Management

Tracheal and Bronchial FBs Can be removed by bronchoscopy with full preparation and

under GA Emergency removal not indicated unless there’s airway

obstruction or vegetable nature and likely to swell up. Methods to remove tracheobronchial FB:

1) Conventional rigid bronchoscopy2) Rigid bronchoscopy with telescopic aid3) Bronchoscopy with C-arm fluoroscopy4) Use of Dormia basket or Fogarty’s balloon for rounded objects5) Tracheostomy 1st and then bronchoscopy thru the

tracheostome6) Thoracotomy and bronchotomy for peripheral FBs7) Flexible fibre optic bronchoscopy in selected adult pt.

Foreign Bodies of Food Passage

An ingested FB may lodge in: The tonsil The base of tongue/vallecula The pyriform fossa The oesophagus

Aetiology

Age (children)Loss of protective mechanism

Use upper denture (prevents tactile sensation) Loss of consciousness Epileptic seizures Deep sleep Alcoholic intoxication

Carelessness Poorly prepared food Improper mastication Hasty eating and drinking

Narrowed oesophageal lumen (oesophageal stricture or ca.)

Psychotics (attempt to commit suicide)

Site of Lodgement of FB

Just below the cricopharyngeal sphincter (commonest site)

FB which pass the sphincter can be held up at next narrowing at broncho-aortic constriction or at the cardiac end.

Sharp or pointed objects lodge anywhere in the oesophagus.

Clinical Features

Symptoms H/O initial choking or gagging Discomfort or pain ( increase on attempts to swallow) Dysphagia Drooling of saliva Respiratory distress Substernal or epigastric pain

Cont. Clinical Features

Signs Tenderness (lower part of neck) Pooling of secretions in pyriform fossa on indirect

laryngoscopy and not disappear on swallowing FB may be seen protruding from oesophageal opening

in postcricoid region.

Investigation

Plain X-raysFluoroscopy

Management

Oesophagoscopic removal (under GA)Cervical oesophagotomyTransthoracic oesophagotomy

FB which has reached stomach may pass thru GIT w/o

difficulty; stool shud be carefully examined every day.Operative interference may be required when:

Pain and tenderness in abdomen FB not showing any progress on serial X-rays FB is 5cm or longer in a child belor 2 years Presence of pyloric stenosis

Complication of Oesophageal FB

Respiratory obstructionPerioesophageal cellulitis and abscess in neckPerforationTracheo-oesophageal fistula (rare)Ulceration and stricture.

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