Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature.Foreign Bodies of The Airway And Esophagus Despite significant advances in prevention, first aid and endoscopic technology, foreign bodies of the pediatric airway and esophagus remain a diagnostic and therapeutic challenge. In the United States over the last quarter of a century, while there has been a dramatic decrease in childhood deaths from asphyxiation by ingested foreign bodies the incidence of foreign body aspiration has not changed significantly. But an early diagnosis remains the key to successful and uncomplicated management of these accidents. Today, we will review the history, epidemiology, clinical presentation, radiologic evaluation, management and possible complications of this commonly encountered problem. Before the advent of bronchoscopy, the mortality rate from aspiration of foreign bodies was approximately 50%. Many of these deaths were long and protracted and as a result of long-term complications of the chronic foreign body. Before the turn of the century, bronchotomy was the method of choice basically for removal of these foreign bodies with generally poor results. However, in 1897, Gustav Killian laid the groundwork for the field of bronchoscopy by successfully removing a bone from the right mainstem bronchus of a German farmer. But it is Dr. ChevalierJackson, seen here, who is credited with developing the field of bronchoesophagology as it is known today. In his landmark work from 1936, he revolutionized the field with the development of both sound surgical principles and innovative new instrumentation for the removal of foreign bodies. His techniques and equipment were paramount in reducing the mortality rate and they are still the basis of foreign body removal today. He also successfully lobbied to pass the Federal Caustic Act in 1927 that required compulsory poison and antidote labels for chemicals such as lye that at that time caused significant morbidity when ingested by children. Further advances were made with the introduction of rod-lens telescopes as seen here in the 1970s, which greatly improved the visualization and illumination for removal of foreign bodies. Additionally, advances in anesthetic agents and techniques have improved the field. Before the mid-1850s, the most common management for esophageal foreign body impaction was to attempt to push the object into the stomach with various instruments such as hooks, forceps and even walking canes were used. The first esophagoscope was used in 1890 by MacKenzie and was later improved by Jackson and Mosher. The earliest rigid esophagoscopes for foreign body extraction were used by Jackson on awake patients in the sitting position. Most victims of foreign body aspiration are older infants and toddlers. Most foreign body aspirations occur in patients younger than 15 years of age but the highest incidence occurs between one and three years as can be seen in the graph where they are concentrated in the two to three year age group. Case studies from the last decade reflect that children younger than five years of age account for about 84% of cases and children younger than three years of age account for 73%. The reason toddlers are more susceptible for foreign body aspiration is because they lack molars necessary for properly grinding the food. Their neuromuscular mechanism for swallowing and airway protection are not fully mature and their age-related tendency to explore the world using their mouth predisposes them to foreign body aspirations. Boys are affected more frequently than girls in a ratio of approximately two to one. The spectrum of airway foreign bodies varies from country to country depending on the diet and the customs of the population. Vegetable matter is uniformly the most common foreign body found in the pediatric airway. Nuts, particularly peanuts account for approximately 34% of cases. Commonly encountered as well in the airway are raw carrots, apples, dried beans, popcorn, sunflower and watermelon seeds. Coins and disks are the most common esophageal foreign bodies and with some series reporting coins in up to 75% of cases. This table illustrates some of the more common foreign bodies found in the esophagus. Less common are hardware and metal objects such as tacks, nails and screws. The duration of impaction before endoscopic removal is often less than 24 hours but can be greater than one week in 6% of cases and of unknown duration in about 10% of cases. The types of foreign bodies ingested has also evolved over time. Pictured here is a collection of esophageal foreign bodies from the National Taiwan University Hospital. Note the large array of size and shape. Metallic objects, especially safety pins which were once used in diapers have decreased in incidence in this current era of disposable diapers. Plastic foreign bodies have risen in frequency because of the use in parts in the toy industry. Airway foreign bodies can be lodged in a number of locations including the supraglottis, glottis, trachea or bronchi. Most airway foreign bodies become lodged in the bronchi because their size and configuration allow passage through the larynx and trachea. Bronchial foreign bodies are more common in the right mainstem bronchus in adults however, in children they occur with about equal frequency in the right or left mainstem bronchus. Most esophageal foreign bodies occur at the cervical esophagus just below the level of the cricopharynges. If they lodge lower, there may be an underlying condition such as a congenital or acquired esophageal stricture that must be investigated. Foreign body aspiration is suspected when a patient develops acute choking or severe coughing with respiratory distress. The diagnosis is obscured if the child does not have a witnessed event and many patients may be misdiagnosed with asthma, croup or an upper respiratory infection and treated with antibiotics and steroids or inhalers before it is identified that they have a foreign body. Classically, there are three stages of symptoms resulting from aspiration of a foreign body. The initial event, an asymptomatic interval and the final stage of complications. In the first stage, a history is given of violent paroxysms of coughing, choking, gagging, possibly airway obstruction which occur immediately when the foreign body is aspirated or swallowed. Such a history can be elicited in many cases. The second stage is an asymptomatic interval where the foreign body becomes lodged, the reflex is fatigue and the immediate irritating symptoms subside. The delayed diagnosis often occurs in this stage as parents may tend to think that the episode has passed. The third stage is a result of complications of chronic foreign body and may include fever, malaise, cough, hemoptysis, pneumonia, atelectasis or lung abscesses. Depending on where the foreign body lodges in the airway, the patient may present differently. Laryngeal foreign bodies may completely obstruct the airway with asphyxiation unless promptly relieved by the Heimlich maneuver usually before transport to the hospital. Objects that are only partially obstructing in the larynx are usually flat or thin and may present with croup, hoarseness, cough, stridor and varying degrees of dyspnea. This illustration is from a patient of Dr. Friedman’s who had had hoarseness and dyspnea for about two months. A toy star was found at the level of the glottis with surrounding granulation tissue. Laryngeal foreign bodies must be treated with caution as they could easily lead to a complete obstruction if removed improperly. Tracheal foreign bodies may present in a similar fashion to laryngeal but usually do not have hoarseness. Jackson and Jackson describe three features of tracheal foreign bodies; the audible slap and palpatory thud that result from the impact of the mobile foreign body against the wall of the trachea on deep inspiration or cough as well as the asthmatory wheeze. Of the airway foreign bodies, 80 to 90% are actually found in the bronchus though. These patients typically present with a triad of cough, wheezing and decreased breath sounds. Children with foreign bodies may present also as a migrating pneumonia where one lung segment clears with antibiotics then another becomes involved as the foreign body moves from one bronchial segment to the next. Bronchial foreign bodies can be a diagnostic dilemma as 20 to 40% of histories are negative, 40% of physical exams may be negative and as high as 40% of chest x-rays are negative as well. Esophageal foreign bodies present with a variety of symptoms. Many times, the parents may have seen the ingestion. The child may be vomiting, have odynophagia, dysphagia, drooling, gagging or choking and anorexia. Sometimes they’ll report a sensation of something being stuck in their throat if they are old enough. Small infants may take little or nothing by mouth and begin to have failure to thrive. Related airway symptoms such as dyspnea or stridor affect fewer than 10% of these patients. Most patients with foreign bodies have already passed the acute phase. When there is no acute respiratory distress and no immediate danger to their life, a thorough history and physical and imaging studies are indicated. Rushing to the O.R. only leads to complications. PA and lateral soft tissue neck films are the x-ray of choice in cases of suspected esophageal and upper laryngotracheal foreign bodies. Seen here is a lateral neck film showing a jack wedged in the supraglottis just above the glottic inland. PA and lateral chest x-rays are standard in the assessment of children suspected of aspirating or swallowing a foreign body. Included in the chest x-ray is an expiratory film looking for obstructive emphysema. The position of the foreign body relative to the surrounding structures must be noted carefully. This PA and lateral chest x-ray show what looks to be a coin lodged in the esophagus. CT scans are rarely used in cases in which standard radiograph studies failed to demonstrate a foreign body. When a suspected bronchial foreign body that is not radiopaque exists, a good inspiratory and expiratory PA and chest film are often helpful. During inspiration, air passes into the lung and there is a normal chest x-ray as seen here on the right. During expiration, the bronchial foreign body obstructs the exit of the air from the lung producing an obstructive emphysema or air trapping seen here on the left, with persistent inflation of the obstructed lung and shift of the mediastinum towards the opposite site. Air trapping is an immediate complication in contrast to atelectasis and pneumonia which are late complications. In this case, edema and granulation tissue around the foreign body completely block the segmental bronchus preventing both entry and exit of air as seen here. Oxygen is absorbed and the involved segment loses volume which is evidenced by atelectasis on the x-ray. In this case, the mediastinum might shift towards the site of obstruction due to the loss of volume. In an infant who is not cooperative or unable to do good expiratory films, lateral decubitus films or fluoroscopy may provide the same information as chest x-ray. On lateral decubitus., the dependent lung should collapse normally but remains inflated in a bronchial obstruction due to a foreign body. It is important to remember that the radiographic findings often suggest but do not diagnose foreign body aspiration. So a high degree of clinical suspicion remains the most important factor in the work-up. Fluoroscopy is another very helpful tool for localizing foreign bodies preoperatively and will again demonstrate the air trapping and mediastinal shift as in the expiratory films. It can be used intraoperatively as well as in this image showing a foreign body that was distal being approached then grasped with forceps and sheathed into the bronchoscope in a child who had aspirated an earring clasp in the distal bronchus. In contrast to foreign bodies of the tracheobronchial tree, esophageal foreign bodies are often radiopaque and readily show up on chest x-ray. PA and lateral chest x-ray and neck films are ordered to assess location and size and to anticipate possibility of multiple foreign bodies. Coins, which are the most common esophageal foreign bodies will be oriented in the coronal plane so it is important to get the lateral films to assess for the number. The lateral view also confirms the presence of a foreign body in the esophagus and not in the airway. Barium is not recommended to localize radiolucent esophageal foreign bodies because it complicates endoscopic removal, can be aspirated during the study and delays the case for at least six hours. Management of airway and esophageal foreign bodies is a team effort including the surgeon, anesthesia and O.R. staff and adequate workup including history and physical and pertinent imaging are critical as rushing to the case without a full array of information is a setup for a poor outcome. Setting up the room, having appropriate instruments and clear communication between all the O.R. staff are all critical. We will first discuss anesthesia involved in airway foreign bodies. Tracheobronchial foreign bodies generally should be taken to the O.R. as soon as all pertinent studies and diagnostic workup are complete. Mask induction is undertaken until the patient achieves a level of anesthesia adequate for surgical manipulation but maintains spontaneous respiration. Topical lidocaine is applied to the hypopharynx and larynx. Paralytic agents are generally avoided as complete obstruction may occur if a muscle relaxant is administered. Another possible anesthetic option is the apneic technique where a paralytic is given with subsequent insufflation or positive pressure ventilation through the bronchoscope once it is in place. However, this requires a prompt and expeditious removal of the foreign body before a true desaturation and is not commonly used. Esophageal foreign bodies are done under general anesthesia, however the patient undergoes endotracheal intubation helping to maintain the airway and prevent compression when undergoing esophagoscopy as well as preventing the loss of a foreign body to the airway. Ideally, the surgeon should set up the instruments needed before the patient is brought to the O.R. Choice of an appropriately sized endoscopic equipment is based on the age of the patient as seen in this table. If a duplicate foreign body is available, instruments must be chosen and practiced with prior to going to the O.R. A variety of forceps are available for endoscopic removal of foreign bodies. Passive action forceps offer a wide range in blades include forward grasping, rotation, ball bearing and hollow object forceps as seen here and they may be single or double action. No fewer than 60 variations of these four have been designed so it is most important as far as instrumentation goes, that the surgeon be familiar with the tools before he goes in. More recently, the rod lens telescopes and optical forceps have improved the magnification and illumination for extraction. However, they may decrease the available space for ventilation in the bronchoscope lumen. It is critical that a complete set of instruments be available with the most likely ones needed ready for immediate use. Once induction is achieved, the laryngoscope tip is passed into the valleculae to expose the larynx and the rigid bronchoscope is then passed into the airway turning the scope at a 90 degree angle allowing the beveled tip to enter the glottis parallel to the true vocal cords. The anesthesia circuit is then attached and ventilation occurs through the bronchoscope for the remainder of the procedure. The tracheobronchial tree should first be inspected completely beginning with the normal side. The location of the foreign body is then identified and approached slowly and carefully to avoid overriding or displacement and secretions are suctioned. One has to resist the urge to immediately grab the object. Its size, shape and current position must be fully evaluated before removal. The forceps are then advanced until they lightly touch the foreign body and the scope withdrawn a short distance. The blades are advanced past the equator of the object, avoid biting motions or excessive pressure. If the object is grasped too tightly, it may fragment sending smaller pieces distally. The scope is then advanced against the foreign body and if too large to pull through the bronchoscope, all three are removed as a unit keeping a tight grip on the foreign body so it does not become lodged higher in the airway. After the foreign body is removed, the scope is passed again to suction residual secretions and check for a second foreign body as can be seen in the lower image here where there are multiple foreign bodies present. Pointed, sharp and cutting objects pose a unique dilemma for the endoscopist. An attempt must be made to release the embedded point and sheathe it within the scope. It often is necessary to accomplish this by first moving the object distally to disengage the coin then advancing the scope over the object instead of pulling it into the tube. Long pointed objects may require lining the bronchus by turning the child’s head as seen in the upper image to approach the object in its long axis so the bronchial wall does not tear on extraction. Tacks, pins and nails with embedded tips are released by the inward rotation method seen below here where the side grasping forceps capture the pin at the point, a corkscrew motion is used to push the pin distally while rotating it clockwise thus aligning the axis and then the scope is advanced over the point. When a point cannot be sheathed, rotation forceps are used to rotate the point so it will trail behind as the object is being pulled out as seen in this diagram and illustration. Unlike tracheobronchial foreign bodies, ingested foreign bodies in the esophagus do not require immediate operative intervention unless there are associated respiratory symptoms, total esophageal obstruction or a risk of esophageal perforation such as a disk battery which will be mentioned momentarily. The appropriately-sized rigid esophagoscope must first be chosen after adequate general anesthesia and intubation. The laryngoscope is used to examine the laryngeal area and expose the post-cricoid region. Most esophageal foreign bodies are located at the cricopharyngeus such as this coin seen here. The esophagoscope is advanced to the foreign body, grasped with the forceps, abutted against the scope and all three are again removed as a single unit. Similar techniques are used for sharp objects as seen in the bronchial foreign body. If the object is pushed distally into the stomach, it is not pulled back through the esophagus unless it may be harmful for the lower GI tract. Disk batteries are a special case when dealing with esophageal foreign bodies. They are used to power small hand-held video games, calculators, hearing aids and such and they contain sodium hydroxide, potassium hydroxide and mercury, all producing a caustic esophageal injury. Data has been shown that mucosal injury occurs within one hour, erosion into the muscular layer within two to four and perforation of the esophagus within 8 to 12 hours. This can lead to strictures, perforations or fistulas. It is therefore very important that these be removed as soon as possible. In 1960, the technique of balloon catheter extraction of esophageal foreign bodies was introduced but is now controversial as the risk of general anesthesia has decreased. For smooth blunt objects under fluoroscopy, a Foley catheter is introduced and advanced into the esophagus distal to the foreign body. With the child awake and head down in the prone and oblique position, the balloon is inflated and the catheter is withdrawn under direct visualization. Advocates of this technique cite the lack of general anesthesia, reduced hospitalization and lack of need for O.R. and staff and cost effectiveness. However, a large number of authors express concern over the safety, especially the risk of aspiration and airway compromise in an uncontrolled setting as well as the psychological stress of doing this to an awake child likely strapped down, must be considered. Such blind manipulation may also result in mucosal lacerations or perforations. Esophageal bougie dilators have also been used to push smooth objects into the stomach and this is known as the push technique. Again, this is outpatient, inexpensive with no need for general anesthesia. Although the risk of aspiration is not present, this method is also uncontrolled with similar limitations as with the Foley catheter. Use of papain, such as Adolph’s meat tenderizer to dissolve meat lodged in the esophagus is not recommended as deaths have been reported from necrosis of the esophagus with major blood vessel rupture. All of these techniques however, are inferior to the classic rigid esophagoscopy. Nowadays, a number of foreign bodies are being removed with a flexible endoscope however, if there is a known airway foreign body, rigid bronchoscopy is indicated. Whenever performing a diagnostic flexible endoscopy, successful extractions of tracheobronchial foreign bodies have been reported. If performed, provisions must be made for immediate control of the airway with a rigid bronchoscope if the airway is either lost or the extraction fails. The flexible endoscope is a reasonable alternative to the rigid for removal of esophageal foreign bodies sometimes. Successful extractions are reported under local anesthesia with only mild sedation but any respiratory distress is a contraindication to flexible scope. The variety of grasping forceps is reduced and cannot be tailored to the contour of the foreign body. Objects can also not be drawn back and sheathed on removal as with the rigid scope. Generally, this technique is considered in older children with blunt foreign bodies and a reliable history of a recent ingestion. Most complications are the result of delayed diagnosis which emphasizes the importance of having a high index of suspicion for a foreign body. Immediate complications of rigid endoscopic extraction of laryngotracheal bronchial foreign bodies include: pneumomediastinum, and complete obstruction as seen in laryngeal or tracheal and failure to recover the object requiring a thoracotomy or tracheotomy. One of the most feared complications is moving a foreign body from a favorable position to an unfavorable position with obstruction. One may also see obstructive emphysema as seen in the immediate complications or atelectasis, one of the late findings. Longer-term complications include pneumonia, atelectasis, granuloma and stricture formation. Complications of esophageal foreign bodies are characterized into those occurring before, during or after endoscopy. Vomiting and respiratory distress can occur preoperatively. Intraoperatively, the ET tube may be dislodged with the removal of the foreign body. One will often see mucosal edema or maceration at the site of impaction, especially with increased duration of impaction. If perforation occurs, the child is given IV fluids, antibiotics and made NPO with close monitoring and serial chest x-rays. After esophagoscopy, one may see vomiting, fever or a second missed foreign body. Rare complications include perforations as seen here on the top where the air is tracking behind the esophagus, or in retropharyngeal abscesses seen here in the lateral neck film and possibly even death. Foreign bodies of the airway and esophagus remain a significant source of morbidity and mortality in the pediatric population. It is critical for the primary practitioner and otolaryngologist to be familiar with the presentation and appropriate radiologic evaluation as delay of removal leads to more complications. Cases must be promptly managed but a too hasty workup will lead to more complications. Communication between the otolaryngologist, anesthesia and O.R. personnel is essential during the endoscopic removal. Technical advances such as optical forceps, telescopes and safer general anesthesia have improved retrieval of foreign bodies but complications must be avoided by timely removal. Familiarity with instruments and technique is critical to success. Although other non-operative techniques exist, removal of foreign bodies in the airway and esophagus under direct visualization through the rigid endoscope is still the safest and most reliable management of foreign bodies. Case Presentation A.R. is a 20-month-old male who was brought to the Texas Children’s Hospital emergency room by his mother because he was drooling and would not eat. The mother had left him at his grandmother’s house for the day while she was at work. When she came to pick him up, the grandmother noted that he was acting fussy since earlier that morning and she could not convince him to eat, and he would only take small sips of juice all day. The mother noted he was irritable, and seemed to be drooling. She denied any evidence of respiratory distress, no cough or rattled breathing. The grandmother denied witnessing any choking, gagging or coughing and did not witness him put anything in his mouth. She did note he had been playing in the living room next to the coffee table unobserved for some time that morning with loose change present. In the emergency room the child was comfortable, in no respiratory distress with 100% saturation on room air, and stable vital signs. His oral exam was unremarkable, there was no evidence of respiratory stridor, and he had equal breath sounds bilaterally with no wheezing. PA and lateral neck films and chest X-ray were obtained, which revealed a radiopaque foreign body in the shape of a coin at the level of the cricopharyngeus of the esophagus. His last po intake had been earlier that day, so IV fluids were started and the patient was rehydrated. Later that day, he was taken to the operating room for direct laryngoscopy and esophagoscopy. After general anesthesia and endotracheal intubation, with no noted foreign body by anesthesia, a cervical esophagoscope was passed into the postcricoid region into the esophagus where two pennies were noted to be lodged at the level of the cricopharyngeus. They were grasped with the alligator forceps and removed as a unit without difficulty. On re-examination, the patient had no esophageal lesions and no other foreign bodies. He tolerated the procedure without difficulty. He was observed overnight and po challenged with good oral intake and sent home in good condition the next morning. Bibliography: Arana A, Hauser B, Hachimi-Idrissi S, Vandenplas Y. Management of ingested foreign bodies in childhood and review of the literature. Eur J Pediatr 2001;160:468-472. Baharloo F, Veyckemans F, Francis C, Biettlot MP, Rodenstein DO. Tracheobronchial foreign bodies: Presentation and management in children and adults. Chest 1999;115:1357-1362. Banerjee A. Laryngo-tracheo-bronchial foreign bodies in children. J Laryngol Otol 1988;102:1029-1032. Black RE, Johnson DG, Matlak ME. Bronchoscopic removal of aspirated foreign bodies in children. J Pediatr Surg 1994;29:682-684. Bowen A, Ledsma-Medina J, Fujioka M, Oh KS, Young LW. Radiologic imaging in otorhinolaryngology. Pediatr Clin North Am 1981;28:905-939. Chen MK, Beierle EA. Gastrointestinal foreign bodies. Pediatr Ann 2001;30:736-742. Clerf LH. Historical aspects of foreign bodies in the air and food passages. Ann Otol Rhinol Laryngol 1952;51:5-16. Cohen SR, Lewis GB, Herbert WI, Geller KA. Foreign bodies in the airway: Five year retrospective study with special reference to management. Ann Oto Rhinol Laryngol 1980;89:437-442. Conners GP. A literature-based comparison of three methods of pediatric esophageal coin removal. Pediatr Emerg Care 1997;13:154-157. Deskin R, Young G, Hoffman R. Management of pediatric aspirated foreign bodies. Laryngoscope 1997;107:540-543. Dikensoy O, Usalan C, Filiz A. Foreign body aspiration: Clinical utility of flexible bronchoscopy. Postgrad Med J 2002;78:399-403. Esclamado RM, Richardson MA. Laryngotracheal foreign bodies in children. Am J Dis Child 1987;141:259-262. Fraga JC, Neto AM, Seitz E, Schopf L. Bronchoscopy and tracheotomy removal of bronchial foreign body. J Pediatr Surg 2002;37:1239-1240. Friedman EM. Caustic ingestions and foreign body aspirations: An overlooked form of child abuse. Ann Otol Rinol Laryngol 1987;96:709-712. Friedman EM. Caustic ingestions and foreign bodies of the aerodigestive tract of children. Pediatr Clin North Am 1989;36:1403-1409. Friedman EM. Foreign bodies in the pediatric aerodigestive tract. Pediatr Ann 1988;17:640-647. Friedman EM. Tracheobronchial foreign bodies. Otolaryngol Clin North Am 2000;33:179-185. Healy GB. Management of tracheobronchial foreign bodies in children: An update. Ann Otol Rhinol Laryngol 1990;99:889-891. Holinger LD, Lusk RP, Green CG. Pediatric Laryngology and Bronchoesophagology. Philadelphia: Lippincott-Raven; 1997. Jackson C. The Life of Chevalier Jackson – An Autobiography. New York: Macmillan; 1938. John SD, Swischuk LE. Stridor and upper airway obstruction in infants and children. Radiographics 1992;12:625-643. Kelly SM, Marsh BR. Airway foreign bodies. Chest Surg Clin N Am 1996;6:253-276. Lemberg PS, Darrow DH, Holinger LD. Aerodigestive tract foreign bodies in the older child and adolescent. Ann Otol Rhinol Laryngol 1996;105:267-271. Malis DJ, Hayes DK. Retained bronchial foreign bodies: Is there a role for high-resolution computed tomography scan? Otolaryngol Head Neck Surg 1995;112:341-346. Marks SC, Marsh BR, Dudgeon DL. Indications for open surgical removal of airway foreign bodies. Ann Otol Rhinol Laryngol 1993;102:690-694. Morrow SE, Bickler SW, Kennedy AP, Snyder CL, Sharp RJ, Ashcroft KW. Balloon extraction of esophageal foreign bodies in children. J Pediatr Surg 1998;33:266-270. Murray AD, Mahoney EM, Holinger LD. Foreign bodies of the airway and esophagus. In: Cummings CW, Fredrickson JM, Harker LA, Krause CJ, Richardson MA, Schuller DE, editors. Pediatric Otolaryngology-Head & Neck Surgery, 3 rd ed. St Louis: Mosby; 1998. pp.377-387. Murthy PS, Ingle VS, George E, Ramakrishna S, Shah FA. Sharp foreign bodies in the tracheobronchial tree. Am J Otolaryngol 2001;22:154-156. Myer CM, Cotton RT, Shoff SR. The Pediatric Airway: An Interdisciplinary Approach. Philadelphia: Lippincott-Raven; 1995. Oliveira CF, Almeida JF, Troster EJ, Vaz FA. Complications of tracheobronchial foreign body aspiration in children: Report of 5 cases and review of the literature. Rev Hosp Clin Fac Med Sao Paulo 2002;57:108-111. Reilly JS, Cook SP, Stool D, Rider G. Prevention and management of aerodigestive foreign body injuries in childhood. Pediatr Clin North Am 1996;43:1403-1411. Reilly JS, Walter MA, Beste D, Derkay C, Muntz H, Myer CM, et al. Size/shape analysis of aerodigestive foreign bodies in children: A multi-institutional study. Am J Otolaryngol 1995;16:190-193. Samad L, Ali M, Ramzi H. Button battery ingestion: Hazards of esophageal impaction. J Pediatr Surg 1999;34:1527-1531. Singh B, Har-El G, Kantu M, Lucente FE. Complications associated with 327 foreign bodies of the pharynx, larynx, and esophagus. Am Otol Rhinol Laryngol 1997;106:301-304. Swanson KL, Edell ES. Tracheobronchial foreign bodies. Chest Surg Clin N Am 2001;11:861-872. Swanson KL, Prakash UB, Midthun DE, Edell ES, Utz JP, McDougall JC, Brutinel WM. Flexible bronchoscopic management of airway foreign bodies in children. Chest 2002;121:1695-1700. Tan HK, Brown K, McGill T, Kenna MA, Lund DP, Healy GB. Airway foreign bodies (FB): A 10-year review. Int J Pediatr Otorhinolaryngol 2000;56:91-99. Tucker GR Jr. Chevalier Jackson Lecture: Pediatric laryngobronchoesophagology. Am Otol Rhinol Laryngol 1979;88:784-793. Vicari JJ, Johanson JF, Frakes JT. Outcomes of acute esophageal food impaction: Success of the push technique. Gastrointest Endosc 2001;53:178-181. Wai PM, Chung LW, Kwok FH, van Hasselt CA. A prospective study of foreign-body ingestion in 311 children. Int J Pediatr Otorhinolaryngol 2001;58:37-45. Webb WA. Management of foreign bodies of the upper gastrointestinal tract. Gastroenterology 1988;94:204-216. Wood RE. The emerging role of flexible bronchoscopy in pediatrics. Clin Chest Med 2001;22:311-317. 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