Core Curriculum Syllabus: Emergencies in Otolaryngology

Core Curriculum Syllabus: Emergencies in Otolaryngology-Head and Neck Surgery
Foreign Bodies: Inspired or Ingested

Symptoms are related to the site of the foreign body and its composition.

Laryngeal or Supraglottic Foreign Bodies

Presentation - Sudden total or near total obstruction, usually during eating. Also known as "cafe coronary." Very common cause of death.

Heimlich maneuver (sudden, vigorous abdominal compression) has been recommended to dislodge objects from the larynx; however, this technique may convert a partial airway obstruction to a total occlusion; therefore, use this ONLY in the setting of TOTAL OBSTRUCTION.
Removal by direct laryngoscopy may be feasible in partial laryngeal obstruction, but only when equipment for emergency laryngoscopy or bronchoscopy are immediately at hand.
Tracheotomy is the most reliable treatment. Cricothyroidotomy may be performed with any available sharp object.

Tracheal or Bronchial Foreign Bodies

Presentation - Choking episode, usually followed by asymptomatic interval. Late symptoms and signs are related to air trapping distal to object(s).

Unilateral expiratory wheeze
Recurrent infections in one lobe
Air trapping

Diagnosis - Characteristic history and physical is suggestive and requires bronchoscopic evaluation. X-ray may demonstrate air trapping, localized infection, or in chronic cases, bronchiectasis. Foreign body seen only if it is radiopaque

Treatment - Rigid bronchoscopy. Removal of tracheal or bronchial foreign body is an extremely hazardous procedure, particularly in children; therefore, an optimal situation is imperative in regard to anesthesia, equipment, nursing staff. The worst objects are ones like pinto beans that can swell or ones like nuts and crayons that can fragment into smaller pieces with attempts to remove them.

Pharyngeal Foreign Bodies

Presentation - Sensation of something "sticking" in throat, typically following fish meal.

Diagnosis - Must be differentiated from superficial mucosal abrasion, which presents identically.

Soft tissue lateral x-ray - rarely helpful.
Direct oral and mirror pharyngeal exam. Typical site of fish bone is in base of tongue or tonsil. Fish bone may be mistaken for a strand of saliva.

Treatment

Perform oral removal as out patient - if object visible and easily accessible.
Endoscopy - if object visible but not accessible or if no foreign body seen and symptoms persist beyond 4-5 days.

Esophageal Foreign Bodies

Presentation - Sensation of something "sticking" after swallowing. This may result in severe dysphagia with inability to swallow even saliva.

Diagnosis

Mirror exam to rule out pharyngeal foreign body
Plain films - for radio opaque foreign bodies, such as coins
Barium swallow - Barium "burger", marshmallow, or barium soaked pledgets

Treatment

For mild symptoms and nonhazardous objects, watchful waiting. Many foreign bodies pass spontaneously, and mild symptoms may be secondary to local trauma, rather than an actual foreign body. Those foreign bodies that fail to pass into the stomach are usually trapped in the cervical portion of the esophagus below the cricopharyngeus muscle. If the foreign body reaches the stomach, it will, in most cases, pass completely through the remainder of the gastrointestinal tract.
For severe or persistent symptoms, or hazardous objects, rigid esophagoscopy. A meat bolus lodged in the esophagus can sometimes be pushed into the stomach or removed endoscopically, but do not use a meat tenderizer because it may injure the esophagus.
Follow carefully for possible perforation and mediastinitis.
After initial resolution, rule out underlying cause of impaction, such as stricture or tumor

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©2001-2006 Baylor College of Medicine
Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery
Mail: One Baylor Plaza, NA102, Houston, TX 77030
Phone: 713-798-5906
E-mail: oto@bcm.edu

Last modified: Jan. 23, 2006