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. Laryngo-tracheo-bronchial Foreign Bodies Aspirated foreign bodies claim 1000 lives each year. Unfortunately these people rarely reach a physician in time for intervention. The successful diagnosis and treatment of this problem requires a good understanding of the signs and symptoms of foreign body aspiration. Gustav Killian in 1987 was the first person to remove a foreign body from the lower air passages with a rigid bronchoscope. During the first part of the twentieth century Chevalier Jackson perfected endoscopic techniques and made perioral endoscopy an important part of medical science. By 1936 the mortality from an aspirated foreign body had decreased from 24% to 2%. 75% of foreign body aspirations occur in children 1 to 3 years of age. In infants < 1 year of age, suffocation from foreign body aspiration is the leading cause of accidental death. Males outnumber females 1.4 to 1, and peanuts are the most commonly aspirated foreign objects in American and European literature. Foreign body aspiration is usually associated with significant coughing, choking, wheezing and gagging and usually calls attention to the problem, unfortunately one third of all foreign body aspirations go unrecognized. After a thorough history and physical examination the most important diagnostic study is radiographic assessment of the airway. This should include PA and lateral soft tissue neck films and inspiratory and expiratory chest films. The typical finding on chest x-ray is obstructive overinflation of the affected lobes during expiration. If expiratory films cannot be obtained fluoroscopy is recommended, especially in small children. Foreign bodies located in the larynx and trachea are most frequently misdiagnosed as croup. If these patients fail to improve on medical therapy or they recur after treatment is withdrawn foreign body aspiration should be suspected. The optimal treatment of an upper respiratory tract foreign body is reasonably prompt endoscopic removal. Emergency endoscopy should be considered in cases of laryngeal foreign bodies, foreign bodies of the tracheobronchial tree causing airway obstruction and potentially hazardous foreign bodies such as beans, which have strong hygroscopic properties and can swell to a large size. The open tube bronchoscope is the instrument of choice for foreign body work with the Holinger ventilating bronchoscope or the Storz bronchoscopes with rod lens telescopes being the instruments most commonly used. There is a wide variety of forceps available with either a passive action or positive center action mechanism. The advantage of the positive center action forceps is that they can be used to dilate the bronchial wall when advancing over the foreign body, if no forceps space is visible. The fundamental principles of extraction have changed little since they were formulated by Chevalier Jackson in the early twentieth century. The foreign body should be rotated so that the extraction, which is in the coronal plane in the esophagus and the sagittal plane in the larynx. Impacted foreign bodies, if radiopaque, can often be removed with the aid of fluoroscopy. If radiolucent, contrast dye should be injected into the bronchus and the outlined foreign body removed under fluoroscopy. If the object cannot be grasped with the available forceps a fogarty balloon catheter can be used to retrieve foreign material but care must be taken because catheter fracture and balloon rupture have occurred using this method. Postoperatively antibiotics and steroids are not routinely used. In cases of longstanding pneumonia, purulent bronchitis and atelectasis chest physical therapy is employed. Most patients can be discharged after 24 hours if the lungs are clear and they are afebrile. If there is persistent cough, fever, pulmonary congestion and respiratory obstruction repeat bronchoscopy may be indicated. Case Presentation A nine month old Latin American male presented to the Ben Taub General Hospital Pediatric Emergency Room with a one-day history of a nonproductive, hacking cough and labored, noisy breathing. Six days prior to this presentation the child had been admitted to the hospital with a croup-like illness and was treated for four days with gradual improvement of symptoms. On further questioning the mother noted that the child was staying with his grandparents the day he became ill six days before. She claimed the child was well that morning and when she picked him up that evening he had a hacking cough and labored breathing. When specifically asked about the aspiration of foreign bodies she revealed that a nut had been found in the childs mouth while at the grandparents' house. Examination was remarkable for tachypnea, inspiratory and expiratory stridor, a weak, hoarse cry, equal bilateral breath sounds and sternal notch retractions with inspiration. X-rays were only remarkable for some questionable subglottic narrowing on the neck films. Flexible fiberoptic exam of the larynx revealed a flat, tan-colored FB oriented just below and parallel to the true vocal cords. On inspiration the foreign body seemed to rise up into the glottis. In the OR the FB was removed with the aid of a pediatric laryngoscope and grasping forceps. The FB was a flat, hard irregularly shaped object that was thought to be a nut shell of some kind. Bibliography Banerjee A, et al. Laryngo-tracheo-bronchial foreign bodies in children. J Laryngol Otol 1988;102:1029-1032. Bunker PG. Foreign body complications. Laryngoscope 1961;71:903-927. Clerf LH. Historical aspects of foreign bodies in the air and food passages. Ann Otol Rhinol Laryngol 1952;61:5-17. Cohen SR et al. Foreign bodies in the airway. Five-year retrospective study with special reference to management. Ann Otol Rhinol Laryngol 1980;89:437-445. Cohen SR. Unusual presentations and problems created by mismanagement of foreign bodies in the aerodigestive tract of the pediatric patient. Ann Otol Rhinol Laryngol 1981;90:316-322. Esclamado RM, Richardson MA. Laryngotracheal foreign bodies in children: a comparison with bronchial foreign bodies. Am J Dis Child 1987;141:259-262. Healy GB. Management of tracheobronchial foreign bodies in children: an update. Ann Otol Rhinol Laryngol 1990;99:889-891. Hight DW, Philippart AI, Hertzler JH. The treatment of retained peripheral foreign bodies in the pediatric airway. J Pediatr Surg 1981;16:694-699. Holinger P. Foreign bodies in the air and food passages. Trans Am Acad Ophthalmol Otolaryngol 1961;8:193-210. Holinger LD. Foreign bodies of the larynx, tracheal and bronchi. In: Bluestone CD et al, editors. Pediatric Otolaryngology, 2nd ed. Philadelphia: Saunders, 1990. Jackson CL. Foreign bodies in the esophagus. Am J Surg 1957;93:308-312. Kim IG, et al. Foreign body in the airway: A review of 202 cases. Laryngoscope 1973;83:347-54. Kosloske AM. Bronchoscopic extraction of aspirated foreign bodies in children. Am J Dis Child 1982;136:924-927. Kramer TA, Riding KH, Salkeld ZJ. Tracheobronchial and esophageal foreign bodies in the pediatric population. J Otolaryngol 1986;15:355-358. Marsh BR. The problem of the open safety pin. Ann Otol Rhinol Laryngol 1975;84:624-626. 1975. McGuirt WF et al. Tracheobronchial foreign bodies. Laryngoscope 1988;98:615-618. Nussbaum M et al. Hypodermic needles: an unusual tracheobronchial foreign body. Ann Otol Rhinol Laryngol 1987;96:698-700. Puhakka H et al. Tracheobronchial foreign bodies. A persistent problem in pediatric patients. Am J Dis Child 1989;143:543-545. Ritter FN. Questionable methods of foreign body treatment. Ann Otol Rhinol Laryngol 1974;83:709-733. Seibert RW, Seibert JJ, Williamson SL. The opaque chest: when to suspect a bronchial foreign body. Pediatr Radiol 1986;16:193-196. Steen KH, Zimmerman T. Tracheobronchial aspiration of foreign bodies in children: a study of 94 cases. Laryngoscope 1990;100:525-530. Swensson EE et al. Extraction of large tracheal foreign bodies through a tracheostoma under bronchoscopic control. Ann Thor Surg 39: 1985;251-253. Weissberg D, Schwartz I. Foreign bodies in the tracheobronchial tube. Chest 1987;91:730-733. Wesenberg DL, Blumhagen JD. Assisted expiratory chest radiography: An effective technique for the diagnosis of foreign-body aspiration. Radiology 1979;130:538-539. Witt WJ. The role of rigid endoscopy in foreign body management. Ear Nose Throat J 1985;64:70-74.
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