eMedicine Specialties > Radiology > Pediatrics

Airway Foreign Body

Author: Henrique M Lederman, MD, PhD, Consulting Staff, Department of Radiology, LeBonheur Children's Medical Center and St Jude Children's Research Hospital; Professor of Radiology and Pediatric Radiology, Chief, Division of Diagnostic Imaging in Pediatrics, Federal University of Sao Paulo, Brazil
Contributor Information and Disclosures

Updated: Feb 25, 2009

Introduction

Background

Historically, airway foreign bodies have been a major cause of morbidity and mortality in the United States. Although foreign body aspiration most frequently occurs in children, it happens in adults as well. Foreign body aspiration is commonly referred to as a "café coronary" (elderly adults).1,2,3

Inspiratory chest radiograph in a 12-month-old bo...

Inspiratory chest radiograph in a 12-month-old boy with a 2-month history of wheezing demonstrates moderate hyperlucency and hyperexpansion of the right hemithorax. A mild deviation of the mediastinum toward the left chest is noted. Courtesy of Brit B. Gay, Jr, MD, Radiology Department, Egleston Children's Hospital, Atlanta, Ga.

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Inspiratory chest radiograph in a 12-month-old bo...

Inspiratory chest radiograph in a 12-month-old boy with a 2-month history of wheezing demonstrates moderate hyperlucency and hyperexpansion of the right hemithorax. A mild deviation of the mediastinum toward the left chest is noted. Courtesy of Brit B. Gay, Jr, MD, Radiology Department, Egleston Children's Hospital, Atlanta, Ga.


In the United States, approximately 500-2000 deaths occur each year from foreign body aspiration.4 Despite advances in radiologic techniques, the diagnosis of foreign body aspiration can be difficult, and endoscopy may be required.5,6

For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center and Procedures Center. Also, see eMedicine's patient education articles Choking, Swallowed Object, and Bronchoscopy.

Pathophysiology

Food items are the most commonly aspirated foreign bodies; peanuts are the most frequently aspirated food. Other aspirated foods include carrots, popcorn, and fruit. Commonly aspirated nonfood items include rubber balloons, plastic toys, teeth, and dental appliances.7

The severity of foreign body aspiration depends on whether the airway obstruction is complete or partial. Complete airway obstruction occurs in the airway at levels above the carina; it causes acute onset of respiratory distress in which the patient is unable to speak or cough. Unfortunately, complete airway obstruction may rapidly proceed to death if the foreign body is not immediately dislodged or removed.7

Partial airway obstruction occurs when the airway is partially occluded or if the obstruction occurs distal to the carina. Patients with partial airway obstructions may present weeks to months after the foreign body aspiration, and the condition may be diagnosed because of sequelae, such as recurrent pneumonia, persistent cough, hemoptysis, wheezing, or atelectasis.

Most foreign bodies lodge in the peripheral airways. However, foreign bodies that are large or sharp or that have irregular borders have a greater tendency to become lodged in the larynx or trachea.7

Mortality/Morbidity

  • Estimates indicate that in the United States, foreign body aspiration is fatal in 2000 children each year.8
  • Complications from foreign body aspiration include respiratory distress, asphyxia, cardiac arrest, fever, laryngeal edema, pneumothorax, hemoptysis, pneumonia, bronchiectasis, and bronchial stricture.4

Race

No racial predilection has been reported in the United States.

Sex

For unknown reasons, foreign body aspiration occurs more frequently in boys than in girls, with a male-to-female ratio of 2:1.9

Age

  • Foreign body aspiration is most common in children aged 6 months to 4 years, a time when they are exploring their surroundings and placing objects into their mouth.7
  • Persons with decreased airway protective mechanisms, such as with mental retardation, neurologic disorders, psychoses or alcoholism, also are at risk of aspiration.10

Anatomy

Most foreign bodies become lodged in the right mainstem bronchus. Reasons for this include the following7 :

  • The diameter of the right main bronchus is larger than the left.
  • The angle of divergence from the tracheal axis is smaller on the right.
  • Airflow through the right lung is greater than it is through the left.
  • Upright position at the moment of aspiration will locate the foreign body in the right middle or lower lobe.

Presentation

Foreign body aspiration may appear as an acute onset of respiratory distress, or patients may have a silent presentation manifested by secondary complications. Most patients with foreign body aspiration present with an acute onset of choking, respiratory distress, cyanosis, severe coughing, and wheezing.11 A history of aspiration often is lacking, and patients may present days to weeks after the event. On examination, patients may have stridor, crackles, wheezing, decreased breath sounds in the affected lung, or normal results on pulmonary physical examination.

Typical symptoms of complete airway obstruction that occurs while a person is eating a meal include severe respiratory distress and the inability to speak or cough. Individuals typically place their thumbs and index fingers around their neck.7

Patients with partial airway obstruction may present with a sudden onset of coughing, difficulty in breathing, wheezing, or stridor while eating a meal. Unfortunately, a history consistent with foreign body aspiration is usually available in only 70% of patients. After the acute episode of airway distress, patients may continue to experience episodes of persistent coughing and wheezing, or they may become asymptomatic. Moreover, some patients experience recurrent episodes of pneumonia in the same topographic area. Other patients develop complications, such as hemoptysis, bronchiectasis, and bronchial stricture.4

Preferred Examination

When foreign body aspiration is suspected in a patient, screening radiographic studies employed include anteroposterior (AP) and lateral imaging of the soft tissues of the neck, inspiratory and expiratory posteroanterior (PA) chest radiographs (CXRs), and lateral CXRs. Lateral decubitus chest radiography, fluoroscopy, or both may help in diagnosing foreign body aspiration in patients who are unable to cooperate with inspiratory and expiratory CXRs, such as young pediatric patients. If findings are negative for foreign bodies in all radiographic studies and if the clinical suspicion still remains high, bronchoscopy should be performed in the operating room by an airway endoscopist for definitive diagnosis and treatment.

Limitations of Techniques

Radiopaque foreign bodies are easy to diagnose by using radiographs. With radiolucent foreign bodies, secondary radiographic signs, such as obstructive emphysema, atelectasis, pneumonia, and a mediastinal shift, help in diagnosing foreign body aspiration.12

Differential Diagnoses

Atelectasis, Lobar
Bronchiectasis
Foreign Body Aspiration
Pneumonia, Aspiration

Other Problems to Be Considered

Atelectasis
Bacterial tracheitis
Carcinoma
Croup (laryngotracheobronchitis)
Epiglottitis
Esophageal foreign body
Granuloma
Papilloma
Retropharyngeal abscess
Tracheal mucus

More on Airway Foreign Body

Overview: Airway Foreign Body
Imaging: Airway Foreign Body
Follow-up: Airway Foreign Body
Multimedia: Airway Foreign Body
References
Further Reading
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References

  1. Mittleman RE, Wetli CV. The fatal cafe coronary. Foreign-body airway obstruction. JAMA. Mar 5 1982;247(9):1285-8. [Medline].

  2. Little DC, Shah SR, St Peter SD, et al. Esophageal foreign bodies in the pediatric population: our first 500 cases. J Pediatr Surg. May 2006;41(5):914-8. [Medline].

  3. Kadmon G, Stern Y, Bron-Harlev E, Nahum E, Battat E, Schonfeld T. Computerized scoring system for the diagnosis of foreign body aspiration in children. Ann Otol Rhinol Laryngol. Nov 2008;117(11):839-43. [Medline].

  4. Limper AH, Prakash UB. Tracheobronchial foreign bodies in adults. Ann Intern Med. Apr 15 1990;112(8):604-9. [Medline].

  5. Boyd M, Chatterjee A, Chiles C, Chin R Jr. Tracheobronchial Foreign Body Aspiration in Adults. South Med J. Jan 9 2009;[Medline].

  6. Roda J, Nobre S, Pires J, Estêvão MH, Félix M. Foreign bodies in the airway: A quarter of a century's experience. Rev Port Pneumol. Nov/Dez 2008;14(6):787-802. [Medline].

  7. Tan HK, Brown K, McGill T, et al. Airway foreign bodies (FB): a 10-year review. Int J Pediatr Otorhinolaryngol. Dec 1 2000;56(2):91-9. [Medline].

  8. Aytac A, Yurdakul Y, Ikizler C, et al. Inhalation of foreign bodies in children. Report of 500 cases. J Thorac Cardiovasc Surg. Jul 1977;74(1):145-51. [Medline].

  9. Rothmann BF, Boeckman CR. Foreign bodies in the larynx and tracheobronchial tree in children. A review of 225 cases. Ann Otol Rhinol Laryngol. Sep-Oct 1980;89(5 Pt 1):434-6. [Medline].

  10. Kavanagh PV, Mason AC, Muller NL. Thoracic foreign bodies in adults. Clin Radiol. Jun 1999;54(6):353-60. [Medline].

  11. Silva AB, Muntz HR, Clary R. Utility of conventional radiography in the diagnosis and management of pediatric airway foreign bodies. Ann Otol Rhinol Laryngol. Oct 1998;107(10 Pt 1):834-8. [Medline].

  12. Kimura H, Aso S, Asai M, et al. Magnetic resonance imaging of an inhaled peanut. Ann Otol Rhinol Laryngol. Jul 1996;105(7):574-6. [Medline].

  13. Assefa D, Amin N, Stringel G, et al. Use of decubitus radiographs in the diagnosis of foreign body aspiration in young children. Pediatr Emerg Care. Mar 2007;23(3):154-7. [Medline].

  14. Esclamado RM, Richardson MA. Laryngotracheal foreign bodies in children. A comparison with bronchial foreign bodies. Am J Dis Child. Mar 1987;141(3):259-62. [Medline].

  15. Svedström E, Puhakka H, Kero P. How accurate is chest radiography in the diagnosis of tracheobronchial foreign bodies in children?. Pediatr Radiol. 1989;19(8):520-2. [Medline].

  16. Newton JP, Abel RW, Lloyd CH, et al. The use of computed tomography in the detection of radiolucent denture base material in the chest. J Oral Rehabil. Mar 1987;14(2):193-202. [Medline].

  17. Berger PE, Kuhn JP, Kuhns LR. Computed tomography and the occult tracheobronchial foreign body. Radiology. Jan 1980;134(1):133-5. [Medline]. [Full Text].

  18. Adaletli I, Kurugoglu S, Ulus S, Ozer H, Elicevik M, Kantarci F, et al. Utilization of low-dose multidetector CT and virtual bronchoscopy in children with suspected foreign body aspiration. Pediatr Radiol [serial online]. Jan 2007;37:33-40. [Medline]. Available at http://medline.com.

  19. Zissin R, Shapiro-Feinberg M, Rozenman J, et al. CT findings of the chest in adults with aspirated foreign bodies. Eur Radiol. 2001;11(4):606-11. [Medline].

  20. Kitanaka S, Mikami I, Tokumaru A, et al. Diagnosis of peanut inhalation by MRI. Pediatr Radiol. 1992;22(4):300-1. [Medline].

  21. O'Uchi T, Tokumaru A, Mikami I, et al. Value of MR imaging in detecting a peanut causing bronchial obstruction. AJR Am J Roentgenol. Sep 1992;159(3):481-2. [Medline].

  22. Morijiri M, Seto H, Kageyama M, et al. Assessment of peanut aspiration by MRI and lung perfusion scintigram. J Comput Assist Tomogr. Sep-Oct 1994;18(5):836-8. [Medline].

  23. Imaizumi H, Kaneko M, Nara S, et al. Definitive diagnosis and location of peanuts in the airways using magnetic resonance imaging techniques. Ann Emerg Med. Jun 1994;23(6):1379-82. [Medline].

  24. Leonidas JC, Stuber JL, Rudavsky AZ, et al. Radionuclide lung scanning in the diagnosis of endobronchial foreign bodies in children. J Pediatr. Oct 1973;83(4):628-31. [Medline].

  25. Rudavsky AZ, Leonidas JC, Abramson AL. Lung scanning for the detection of endobronchial foreign bodies in infants and children. Clinical and experimental studies. Radiology. Sep 1973;108(3):629-33. [Medline].

  26. Gencer M, Ceylan E, Koksal N. Extraction of Pins from the Airway with Flexible Bronchoscopy. Respiration. May 3 2007;[Medline].

  27. Latifi X, Mustafa A, Hysenaj Q. Rigid tracheobronchoscopy in the management of airway foreign bodies: 10 years experience in Kosovo. Int J Pediatr Otorhinolaryngol. Dec 2006;70(12):2055-9. [Medline].

  28. Zaupa P, Saxena AK, Barounig A, Höllwarth ME. Management strategies in foreign-body aspiration. Indian J Pediatr. Jan 5 2009;[Medline].

  29. Folch E, Mehta AC. Airway interventions in the tracheobronchial tree. Semin Respir Crit Care Med. Aug 2008;29(4):441-52. [Medline].

  30. Abramson AL, Rudavsky AZ. Use of lung scanning for the detection of endobronchial foreign bodies. Clinical and experimental studies. Ann Otol Rhinol Laryngol. Dec 1972;81(6):832-9. [Medline].

  31. Adler OB, Rosenberger A. Localization of metallic foreign bodies in the chest by computed tomography. J Comput Assist Tomogr. Oct 1982;6(5):955-7. [Medline].

  32. Alford BR, Chenault DI, Danziger J. Detection of foreign bodies with computerized tomography. Arch Otolaryngol. Apr 1979;105(4):203-4. [Medline].

  33. Baharloo F, Veyckemans F, Francis C, et al. Tracheobronchial foreign bodies: presentation and management in children and adults. Chest. May 1999;115(5):1357-62. [Medline]. [Full Text].

  34. Bissonnette RT, Connell DG, Fitzpatrick DG. Preoperative localization of low-density foreign bodies under CT guidance. Can Assoc Radiol J. Dec 1988;39(4):286-7. [Medline].

  35. Darrow DH, Holinger LD. Aerodigestive tract foreign bodies in the older child and adolescent. Ann Otol Rhinol Laryngol. Apr 1996;105(4):267-71. [Medline].

  36. Darrow DH, Holinger LD. Foreign bodies of the larynx, trachea, and bronchi. Pediatr Otolaryngol. 1996;2:1390-401.

  37. Davis SW, Heitmiller RF, Davis F, et al. Intrapulmonary foreign body simulating pulmonary AVM: CT findings. J Comput Assist Tomogr. Sep-Oct 1997;21(5):769-70. [Medline].

  38. Franquet T, Gimenez A, Roson N, et al. Aspiration diseases: findings, pitfalls, and differential diagnosis. Radiographics. May-Jun 2000;20(3):673-85. [Medline]. [Full Text].

  39. Gupta AK, Berry M. Detection of a radiolucent bronchial foreign body by computed tomography. Pediatr Radiol. 1991;21(4):307-8. [Medline].

  40. Hoeve LJ, Rombout J, Pot DJ. Foreign body aspiration in children. The diagnostic value of signs, symptoms and pre-operative examination. Clin Otolaryngol. Feb 1993;18(1):55-7. [Medline].

  41. Ikeda M, Himi K, Yamauchi Y, et al. Use of digital subtraction fluoroscopy to diagnose radiolucent aspirated foreign bodies in infants and children. Int J Pediatr Otorhinolaryngol. Dec 1 2001;61(3):233-42. [Medline].

  42. Ikeda M, Kitahara S, Inouye T. Large radiolucent tracheal foreign body found by CT scan caused dyspnea: an admonition on flexible fiberscopic foreign body removal. Surg Endosc. Feb 1996;10(2):164-5. [Medline].

  43. Inglis AF Jr, Wagner DV. Lower complication rates associated with bronchial foreign bodies over the last 20 years. Ann Otol Rhinol Laryngol. Jan 1992;101(1):61-6. [Medline].

  44. Kjhns LR, Borlaza GS, Seigel RS, et al. An in vitro comparison of computed tomography, xeroradiography, and radiography in the detection of soft-tissue foreign bodies. Radiology. Jul 1979;132(1):218-9. [Medline].

  45. Lue AJ, Fang WD, Manolidis S. Use of plain radiography and computed tomography to identify fish bone foreign bodies. Otolaryngol Head Neck Surg. Oct 2000;123(4):435-8. [Medline].

  46. Malis DJ, Hayes DK. Retained bronchial foreign bodies: Is there a role for high-resolution computed tomography scan?. Otolaryngol Head Neck Surg. Feb 1995;112(2):341-6. [Medline].

  47. Man DW, Engzell UC, Hadgis C, et al. An unusual laryngeal foreign body in an infant. J Otolaryngol. Apr 1986;15(2):127-9. [Medline].

  48. Wolkove N, Kreisman H, Cohen C, et al. Occult foreign-body aspiration in adults. JAMA. Sep 17 1982;248(11):1350-2. [Medline].

  49. Zerella JT, Dimler M, McGill LC, et al. Foreign body aspiration in children: value of radiography and complications of bronchoscopy. J Pediatr Surg. Nov 1998;33(11):1651-4. [Medline].

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Keywords

airway foreign body, foreign body aspiration, aspiration, airway obstruction, choking, café coronary, airway obstruction

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Contributor Information and Disclosures

Author

Henrique M Lederman, MD, PhD, Consulting Staff, Department of Radiology, LeBonheur Children's Medical Center and St Jude Children's Research Hospital; Professor of Radiology and Pediatric Radiology, Chief, Division of Diagnostic Imaging in Pediatrics, Federal University of Sao Paulo, Brazil
Henrique M Lederman, MD, PhD is a member of the following medical societies: Society for Pediatric Radiology
Disclosure: Nothing to disclose.

Medical Editor

Lori Lee Barr, MD, FACR, FAIUM, Clinical Associate Professor of Radiology, University of Texas Health Science Center in San Antonio; Clinical Assistant Professor of Radiology, University of Texas Medical Branch at Galveston; Member, Board of Directors, Austin Radiological Association; Consulting Staff, Seton Health Network, Columbia/St David's Healthcare System, Healthsouth Rehabilitation Hospital of Austin, Georgetown Hospital, St Mark's Medical Center, Cedar Park Regional Medical Center
Lori Lee Barr, MD, FACR, FAIUM is a member of the following medical societies: American Association for Women Radiologists, American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, American Society of Pediatric Neuroradiology, Association of University Radiologists, Radiological Society of North America, Society for Pediatric Radiology, Society of Radiologists in Ultrasound, Southern Medical Association, Texas Radiological Society, and Undersea and Hyperbaric Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

John Karani, MBBS, FRCR, Consulting Staff, Department of Radiology, King's College Hospital, London
Disclosure: Nothing to disclose.

 
 
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