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Aerodigestive tract foreign bodies
By Dr. Abhilash Antony
Introduction
• Foreign bodies in upper aerodigestive tract – important cause of morbidity & mortality in young and old
• Management of foreign body can be difficult or routine
FB IN THE NOSE AETIOLOGY:Ant. Nares Post. Nares : vomiting, coughing regurgitation, palatal incompetence Penetrating wounds and nasal surgery Sequestration of bone in situ after trauma Calcification in situ of inspissated mucopus around FB ►Rhinolith
• Location : Anywhere in nasal fossa
• Types of FB: • Inanimate : -vegetable : peas,beans,paper etc -mineral FB : metal parts,plastic toys -post surgical : swabs,packs left behind -sequestra : syphillis• Animate : maggots, round worms.
SYMPTOMS SIGNS
Unilateral foetid discharge, mucopurulent, blood stained
Unilateral nasal block Pain EpistaxisSneezing
• Reddened congested mucosa
• Granulation• Ulceration• Necrosis
MINERAL & VEGETABLE FB
RHINOLITH
• Increasing in size slowly • Initially asymptomatic & later nasal block
• Brown or grey irregular mass near floor of nose
• Feels stony hard & gritty on probing
RHINOLITH
DIAGNOSIS
• Anterior rhinoscopy • Posterior rhinoscopy • DNE • Nasopharyngoscopy • X ray nose & PNS
o U/L purulent nasal discharge in a child must be regarded as d/to FB unless proved otherwise……
INSTRUMENTS
• Suitable size speculum • Probe • Hook • Forceps • Suction
MANAGEMENTINANIMATE FB:If FB is seen : Anterior removal with no anesthesia or with
LA GA in case of : - Uncooperative pt.- In anticipation of severe bleeding - Posteriorly placed FB - Strongly suspected FB but not seen in AR & radiolucent
Cuffed oral endotracheal tube with pharyngeal packFB removal anteriorly or through the NPx.A course of Abx,decongestants & analgesics.
RHINOLITH
• With LA for small rhinolith• Under GA for large rhinolith • Through Lat. Rhinotomy approach for very
large rhinolith • Through Caldwell-Luc approach for extension
into the antrum
Lateral rhinotomy
ANIMATE FB
• Instilling 25% chloroform solution into the nasal cavities TID for 6 wks
• Periodic manual removal of maggots• Ascaris : removal with forceps & systemic
treatment
Anatomy of larynx
• Larynx – – Lies in front of hypopharynx (C3 – C6)– 3 paired and 3 unpaired cartilages– 2 joints – cricoarytenoid & cricothyroid
PHYSIOLOGY OF LARYNX
– PROTECTION OF LOWER AIRWAYS• Sphincteric closure of laryngeal opening
– Laryngeal inlet (AE fold, tubercle of epiglottis, arytenoids)– False cords– True cords
• Cessation of respiration• Cough reflex – important and powerful mechanism
– Phonation– Respiration– Fixation of chest
TRACHEOBRONCHIAL TREE
ANATOMY OF OESOPHAGUS
• Muscular tube extending from the pharynx to the stomach.
• 25 cm long.
• Extends from crico-pharyngeal sphincter (C6 vertebra) to cardiac orifice of stomach (T11 vertebra)
• Constrictions of oesophagus:– Pharyngo-oesophageal junction (C6) – 15 cm from
upper incisors– Crossing of arch of aorta (T4) – 25 cm from upper
incisors– Crossing of left main bronchus (T5) – 28 cm from
upper incisors– Oesophageal hiatus (T10) – 40 cm from upper
incisors
• Other sites for foreign body to lodge in food passage are:
• Tonsils
• Base of tongue/vallecula
• Pyriform fossa
Aetiology
• Age• Loss of protective mechanism• Carelessness• Narrowed lumen• Mental state
Types of foreign bodies
– Non irritant - Plastic, glass, metal, COINS
– Irritant Organic – fish and chicken bones, meat, vegetable matter, beans, seeds
• Sharp objects – safety pin
Clinical features
Symptoms Signs
History – initial choking or gagging Tenderness – lower part of neck on right/left of trachea
Discomfort/pain – just above clavicle to right or left of trachea. Discomfort increases on swallowing attempts.
Pooling of saliva – on I.D.L. Doesn’t disappear on swallowing
Dysphagia - Obstruction to swallowing – partial or total
Sometimes, foreign body may be seen protruding from oesophageal opening in post cricoid region.
Drooling of saliva
Respiratory distress
Substernal/epigastric pain
Clinical features of oesophageal foreign body
Clinical features
• Initial period – choking, gagging, wheezing.• Symptomless interval – respi mucosa adapts
to foreign body.• Later symptoms –
• Laryngeal foreign body • Tracheal foreign body• Bronchial foreign body
Symptoms of laryngeal foreign body
Symptoms of laryngeal foreign body
• Symptoms of obstruction ( partial/complete )
• Hoarseness of voice
• Partial obstruction may lead to complete obstruction as laryngeal oedema increases
TRACHEAL FB SYMPTOMS
• Similar to laryngeal FB without hoarseness• Edema can progress to complete obstruction
• 3 signs : - Asthmatoid wheeze - Audible slap produced from FB contact with the
trachea - Palpable thud over the trachea
BRONCHIAL FB SYMPTOMSTypical triad : (65% of pts)
- Cough- Wheezing- Decreased breath sounds
Sudden onset of wheezing particularly if unilateral Respiratory compromise as a result of swelling of dried vegetable matter or edema around the object leading to complete obstruction & lobar collapse (ATELECTASIS) Respiratory distress due to movement of FB
Diagnosis
• Foreign bodies in airway:– Soft tissue x-ray - PA and lateral view of neck in
extended position– Plain X-ray chest PA and lateral view– X-ray chest at inspiration and expiration– Flouroscopy/videoflouroscopy– CT chest
• Foreign bodies in oesophagus:• Plain X-rays – Soft tissue lateral view neck, PA and
lateral view• Flouroscopy
Management
• Laryngeal foreign bodies – • Heimlich’s maneouvre in children and adult/chest
thrusts, back blows in infant• Cricothyrotomy/emergency tracheostomy
Correcting airway obstruction in an infant
5 Back blows - failure
5 Chest thrusts
Continue this sequence till FB is removed or pt
is ready to be shifted to operation theatre.
Back blows in an infant
• Straddle infant face down,
head lower than trunk, over
your forearm, supported on
your thigh.
• Deliver five rapid back blows,
with heel of other hand b/w
shoulder blades.
Chest thrusts in an infant
Supporting pt’s head, keep
infant supine b/w your
hands, with head lower
than trunk.
Using 2 fingers, deliver 5
rapid backward thrusts on
sternum.
cricothyrotomy
• Tracheal & Bronchial foreign bodies –• Conventional rigid bronchoscopy• Rigid bronchoscopy• Bronchoscopy with C-arm flouroscopy• dormia basket/fogarty’s balloon• Tracheostomy first – bronchoscopy through
trachostoma• Flexible fibre optic bronchoscopy
• Oesophageal foreign body• Oesophagoscopic removal• Cervical oesophagotomy• Transthoracic oesophagotomy
BRONCHIAL FB REMOVAL
• Healthy bronchus examined first • Secretions gently suctioned • 100% oxygen • Forceps are placed through the bronchoscope & FB is engaged • Bronchoscope, Forceps & FB removed as a unit • Bronchoscope is returned to airway immediately for
ventilation & assessment of other FB • Large FB may be broken or tracheotomy performed • If endoscopic retrieval fail, thoracotomy required
ESOPHAGEAL FB REMOVAL• Esophagoscope passed through the right side of mouth &
directed toward PF • Scope angled toward the sternal notch
• Esophagoscope, Forceps & FB removed as a unit
• Esophagoscope is reinserted to assess the condition of mucosa & other FB
SHARP & LONG OBJECTS REMOVAL • Tip of pointed object engages the mucosa • Endoscope is aligned parallel to long axis of airway or
esophagus • Object first moved distally & then removed • Pin-bending forceps may be used for bendable objects
• If severely impacted, open surgical approach may be the safest
• In children < 2yrs , endoscopic removal of long or large ingested objects is preferred
Following removal
• Second look for other / remnant FB
• Aspiration of pus & mucus • Inspection of all major bronchopulmonary segments including
upper lobe orifices
DISK BATTERY INGESTION
• Peak incidence : 1-2 yrs old
• Requires immediate action
• In 1 hr : mucosal damage • In 4 hrs : erosion of muscular wall of esophagus • In ≥ 6hrs : esophageal perforation mediastinitis / ►
tracheoesophageal fistula / death
• Radiography • Check the pts stool in asymptomatic pts
• Return to the hospital if fever or abdominal pain occur
• In children < 6yrs , endoscopic removal of a battery ≥15mm in diameter preferred if not passed out within 48hrs
PILL INGESTION • Pills may lodge in esophagus due to delayed transit, dry
swallow, adherent tablets or supine swallow • Caustic injury to eso. mucosa on prolonged contact
• Symptoms : sudden onset of retrosternal pain, dysphagia, odynophagia, fever, hematemesis & dehydration
• Most resolve within days to weeks
ESOPHAGEAL PERFORATION Caused by : object , length of time the object has been lodged , attempts
to retrieve the object
Radiography : cervical subcutaneous emphysema, retroesophageal abscess, obvious extraluminal portion of FB
Signs : fever, tachycardia, tachypnea, increased pain Esophagography to locate & evaluate extent of injury
Pharyngoesophageal perforation : most common area injured in esophagoscopy
NPO / Broad spectrum antibiotics In more severe cases : drainage, closure, surgical repair
POSTOP MANAGEMENT NPO for 4 hrs
Monitoring for fever, tachycardia, tachypnea, increased pain Antibiotics in significant esophageal injury
Systemic corticosteroids (dexamethasone 0.5 mg/kg) if bronchoscopy prolonged or bronchoscope tight fit in subglottic larynx
When appropriate-sized bronchoscopes used, epinephrine or corticosteroids are not given
Chest physiotherapy Repeat x rays in persistent or progressive symptoms If extraction fail or incomplete, pt. is rested for several days
Complications of Bronchial foreign body removal
• Most complications result from delayed diagnosis & treatment
• Pneumonia & atelectasis are the most common after
bronchial FB removal
• Bleeding • Pneumothorax & Pneumomediastinum • Granulation tissue/ stricture formation
ESOPHAGEAL FB COMPLICATIONS
• Rare • COMPLICATIONS:
– retroesophageal abscess, –mediastinitis, –death
Complications of neglected FB
• Oesophageal ulceration & stricture• Oesophageal perforation mediastinitis• Peri-oesophageal cellulitis• Retro-pharyngeal abscess• Respiratory obstruction due to – tracheal compression – laryngeal oedema
THANK YOU