FOREIGN BODY IN

PHARYNX,LARYNX, TRACHEA &

TRACHEOBRONCHIAL TREE
Foreign Bodies of Food Passage
• Site of lodgement
• Aetiology
• Signs & symptoms
• Investigation
• Management
• Complication
Foreign Bodies of Food Passage
• An ingested foreign body (FB) may lodge in:
1. The tonsil
2. The base of tongue/vallecula
3. Posterior pharyngeal wall
4. The pyriform fossa
5. The oesophagus
SITE OF LODGEMENT OF FOREIGN BODY
• The commonest site is at or just below the cricopharyngeal sphincter.
• Flat objects like coins are held up at the sphincter while others are held in
the upper oesophagus just below the sphincter due to poor peristalsis.
• Foreign bodies which pass the sphincter can be held up at the next
narrowing at bronchoaortic constriction or at the cardiac end.
• Sharp or pointed objects lodge anywhere in the oesophagus.
• Once object passes the oesophagus it is likely to pass per rectum but
sometimes it gets obstructed at pylorus, duodenum, terminal ileum,
ileocaecal junction, caecum, sigmoid colon or even at the rectum.
• Size and shape of the object and its nature, sharp or pointed plays an
important part in its lodgement in oesophagus or lower down.
AETIOLOGY
1. Age.
o Children below 5 years old
o Put anything in the mouth
o Educate parents to avoid such accidents .
2. Loss of protective mechanism
o Swallowed of foreign body undetected
o loss of consciousness, epileptic seizures & deep sleep.
3. Carelessness
o Poorly prepared food
o improper mastication
o Hasty eating and drinking.
4. Narrowed oesophageal lumen
o Oesophageal stricture or carcinoma.
5. Psychotics
o Attempt to commit suicide.
CLINICAL FEATURES
SYMPTOMS
1) History of initial choking or gagging
2) Discomfort or pain located just above the clavicle on the right or left of trachea.
Discomfort increases on attempts to swallow.
3) Dysphagia.
4) Drooling of saliva.
5) Respiratory distress.
6) Substernal or epigastric pain.
7) In partial obstruction, patient may still be taking normal food with little or no
discomfort for a few days. Even X-rays may be normal. No complacency should
be observed and an endoscopic examination performed when history and
physical examination strongly suggest a foreign body
CLINICAL FEATURES
SIGNS
1) Tenderness in the lower part of neck on the right or left of trachea
2) Pooling of secretions in the pyriform fossa on indirect laryngoscopy.
They do not disappear on swallowing
3) Sometimes a foreign body may be seen protruding from the
oesophageal opening in the postcricoid region.
INVESTIGATIONS
• Posteroanterior & lateral view of chest X-Ray.
• Radio-opaque foreign body & location detected.
• Failure to see FB doesn’t rule out FB (small, plastic or radiolucent).
• Barium swallowing avoided as delays other procedures.
MANAGEMENT
1. Endoscopic removal.
2. Cervical oesophagotomy.
3. Transthoracic oesophagotomy.
COMPLICATIONS OF OESOPHAGEAL FOREIGN
BODY
1) Respiratory obstruction. This is due to tracheal compression by the
FB in the oesophagus, or laryngeal oedema especially in infants and
children.
2) Perioesophageal cellulitis and abscess. It occurs in the neck.
3) Perforation. Sharp objects may perforate the oesopha- geal wall,
setting up mediastinitis, pericarditis or empy- ema. They may
perforate the aorta and prove fatal.
4) Tracheo-oesophageal fistula. Rare
5) Ulceration and stricture. Overlooked foreign bodies maycause slow
ulceration and stricture formation.
FOREIGN BODIES OF AIR PASSAGE
• Site of lodgement
• Aetiology
• Signs & symptoms
• Diagnosis
• Investigation
• Management
FOREIGN BODIES OF AIR PASSAGE
• A foreign body aspirated into air passage can lodge in the larynx,
trachea or bronchi.
• Site of lodgement would depend on the size, shape and nature of the
foreign body.
• A large foreign body, unable to pass through the glottis, will lodge in the
supraglottic area while the smaller one will pass down through the
larynx into the trachea or bronchi.
• Foreign bodies with sharp points, e.g. pins, needles, fish bones, etc. can
stick anywhere in the larynx or tracheobronchial tree.
AETIOLOGY
• Children below 4 years old are often affected.
• Accidents occur when they suddenly inspire during play or fight while
having something in the mouth.
• In adults, foreign bodies are aspirated during coma, deep sleep or
alcoholic intoxication. Loose teeth or denture may be aspirated during
anaesthesia
• Common in children:
vegetable foreign body Non vegetable body
Peanut plastic whistle
almond seed plastic toys
peas, beans safety pins
gram or wheat seed Nails
watermelon seed all-pin
pieces of carrot or apple twisted wires
ball bearings
CLINICAL FEATURES
• Initial period of choking, gagging and wheezing
• Symptomless interval
• Later symptoms – due to airway obstruction, inflammation or trauma
Laryngeal foreign body
 Large FB can totally obstruct the airways causing sudden death unless urgent resuscitation.
 Partial obstruction cause discomfort or pain in throat, hoarseness of voice, croupy cough,
aphonia, dyspnoea, wheezing and haemoptysis.
Tracheal foreign body
 Sharpe FB produce cough & haemoptysis.
 Loose foreign body like seed may move up and down the trachea between the carina and the
undersurface of vocal cords causing “audible slap” and “palpatory thud.”
 Asthmatoid wheeze may also be present. It is best heard at patient’s open mouth.
Bronchial foreign body
 Most foreign bodies enter the right bronchus because it is wider and more in line with the
tracheal lumen.
 A FB may totally obstruct a lobar or segmental bronchus causing atelectasis or it may produce
a check valve obstruction, allowing only ingress of air but, not the egress, thus leading to
obstructive emphysema
DIAGNOSIS
• Detailed history of the foreign body “ingestion”.
A history of sudden onset of coughing
Wheezing
Diminished entry of air into the lungs on auscultation
High index of suspicion in children with wheezing, stridor, cough or asthma
Those with recurrent chest infections being treated with steroids and
antibiotics
• Physical examination of the neck and chest.
INVESTIGATION
• Plain X-ray chest in posteroanterior and lateral views.
• X-ray chest at the end of inspiration and expiration.
• Fluoroscopy/videofluoroscopy.
• CT chest
MANAGEMENT OF LARYNGEAL FB
• Heimlich manoeuvre. Stand behind the person and place your arms
around his lower chest and give four abdominal thrusts. The residual
air in the lungs may dislodge the foreign body providing some
airway.DO NOT PERFORM THIS MEASURES IN PARTIALLY OBSTRUCTED
PATIENT.
• Cricothyrotomy or emergency tracheostomy should be done if
Heimlich manoeuvre fails.
• Once acute respiratory emergency is over, foreign body can be
removed by direct laryngoscopy or by laryngofissure, if impacted.
MANAGEMENT OF TRACHEOBRONCHIAL FB
• Methods to remove tracheobronchial foreign body:
1) Conventional rigid bronchoscopy
2) Rigid bronchoscopy with telescopic aid
3) Bronchoscopy with C-arm fluoroscopy
4) Use of Dormia basket or Fogarty’s balloon for rounded objects
5) Tracheostomy first and then bronchoscopy through the
tracheostomy
6) Thoracotomy and bronchotomy for peripheral foreignbodies
7) Flexible fibreoptic bronchoscopy in selected adult patients
MANAGEMENT OF TRACHEOBRONCHIAL FB
1) Bronchoscope, appropriate for the age of patient and a size smaller
and the other a size larger
2) Telescope or optical forceps
3) Two laryngoscopes
4) Foreign body forceps, Dormia basket, Fogarty’s catheterand a
syringe to inflate it.
THE END