eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Pediatric Otolaryngology

Foreign Bodies of the Airway

Updated: Oct 16, 2009

Introduction

The diagnosis and treatment of foreign bodies in the airway are a challenge for otolaryngologists. Despite improvements in medical care and public awareness, approximately 3000 deaths occur each year from foreign body aspiration, with most deaths occurring before hospital evaluation and treatment. A high index of suspicion is needed for foreign body aspiration to allow for prompt treatment and avoidance of complications.

Aspirated foreign body (backing to an earring) lodged in the right main stem bronchus.

History of the Procedure

Until the late 1800s, airway foreign body removal was performed by bronchotomy. The first endoscopic removal of a foreign body occurred in 1897. Chevalier Jackson revolutionized endoscopic foreign body removal in the early 1900s with principles and techniques still followed today. The development of the rod-lens telescope in the 1970s and improvements in anesthetic techniques have made foreign body removal a much safer procedure.

Frequency

Most airway foreign body aspirations occur in children younger than 15 years; children aged 1-3 years are the most susceptible. Vegetable matter tends to be the most common airway foreign body; peanuts are the most common food item aspirated. The incidence of metallic foreign body aspirations, particularly of safety pins, has decreased in frequency secondary to the advent of disposable diapers.

Etiology

Young children comprise the most common age group for foreign body aspiration because of the following:

They lack molars for proper grinding of food.
They tend to be running or playing at the time of aspiration.
They tend to put objects in their mouth more frequently.
They lack coordination of swallowing and glottic closure.

Pathophysiology

After foreign body aspiration occurs, the foreign body can settle into 3 anatomic sites, the larynx, trachea, or bronchus.

Of aspirated foreign bodies, 80-90% become lodged in the bronchi.
In adults, bronchial foreign bodies tend to be lodged in the right main bronchus because of its lesser angle of convergence compared with the left bronchus and because of the location of the carina left of the midline.
Several papers have demonstrated equal frequency of right and left bronchial foreign bodies in children.
Larger objects tend to become lodged in the larynx or trachea.

Presentation

In general, aspiration of foreign bodies produces the following 3 phases:

Initial phase - Choking and gasping, coughing, or airway obstruction at the time of aspiration
Asymptomatic phase - Subsequent lodging of the object with relaxation of reflexes that often results in a reduction or cessation of symptoms, lasting hours to weeks
Complications phase - Foreign body producing erosion or obstruction leading to pneumonia, atelectasis, or abscess

Clinical presentation depends on the location of the foreign body. A large foreign body lodged in the larynx or trachea can produce complete airway obstruction from either the dimensions of the object or the resulting edema.

Laryngeal foreign bodies present with airway obstruction and hoarseness or aphonia.
Tracheal foreign bodies present similarly to laryngeal foreign bodies but without hoarseness or aphonia. Tracheal foreign bodies can demonstrate wheezing similar to asthma.
Bronchial foreign bodies typically present with cough, unilateral wheezing, and decreased breath sounds, but only 65% of patients present with this classic triad.

Foreign body aspiration can mimic other respiratory problems, such as asthma. Foreign body aspiration differs in the presence of unilateral wheezing and decreased breath sounds.

Indications

Perform surgical intervention with rigid bronchoscopy on patients who have a witnessed foreign body aspiration, those with radiographic evidence of an airway foreign body, and those with the previously described classic signs and symptoms of foreign body aspiration. The history and physical examination are the most important aspects in the decision for surgical intervention. A strong history of suspected foreign body aspiration prompts an endoscopic evaluation, even if the clinical findings are not as conclusive or are not present.

Relevant Anatomy

Airway foreign bodies can become lodged in the larynx, trachea, and bronchus. The size and shape of the object determine the site of obstruction; large, round, or expandable objects produce complete obstruction, and irregularly shaped objects allow air passage around the object, resulting in partial obstruction.

Contraindications

No contraindications exist to the removal of an airway foreign body from a child. If necessary, health problems can be optimized before surgical intervention. However, even children who are at high risk due to health reasons still need surgical intervention to remove the foreign body.

Workup

Imaging Studies

High-kilovolt anteroposterior and lateral radiographs of the airway are the tests of choice in patients in whom laryngeal foreign bodies are suspected. The high kilovoltage used produces greater definition of the airway while reducing the effect of the surrounding bony structures.
Posteroanterior and lateral chest radiographs are an adjunct to the history and physical examination in patients in whom foreign body aspirations are suspected. To at least have a baseline study for future comparison, perform chest radiographs on all such patients.
- Radiopaque objects are visible, but radiolucent objects (eg, plastic) are not.¹
- Chest radiographs may reveal obstructive emphysema or hyperinflation, atelectasis, and consolidation.
Lateral decubitus chest films may be helpful in children in whom the dependent lung remains inflated with bronchial obstruction. Typically, the dependent lung collapses.
Chest radiographs (inspiratory and expiratory films) demonstrate atelectasis on inspiration and hyperinflation on expiration with a foreign body obstructing the bronchus.
Biplane fluoroscopy uses intraoperative fluoroscopic evaluation while identifying and locating a foreign body within the lung periphery.

Diagnostic Procedures

Chest auscultation is critical in the evaluation of a patient in whom a foreign body aspiration is suspected. Typically, these patients have wheezing, decreased breath sounds, or both on the side of the foreign body. Patients may have normal examination findings despite having a foreign body within the airway because it may partially obstruct the airway.

Treatment

Medical Therapy

Patients with complete airway obstruction require immediate medical attention and typically are aphonic and unable to breathe. Patients who are coughing, gagging, and vocalizing have partial obstruction.

Use of the Heimlich maneuver has improved the mortality rate of patients with complete airway obstruction, but use of it in patients with partial obstruction may produce complete obstruction.
Most patients who arrive at the hospital are beyond the acute stage and are not in respiratory distress.
After a complete history and physical examination are completed and radiographic studies are performed, a decision is made in regard to the need for surgical intervention.
In most cases, antibiotics and steroids are not administered initially.

Surgical Therapy

An operating room well equipped with proper endoscopic equipment of various sizes, personnel familiar with the use of the instrumentation, and anesthesiologists experienced in foreign body removal are critical for safe removal of airway foreign bodies.

Preoperative Details

Select and organize age-appropriate endoscopic equipment before the patient enters the operating room. Various foreign body forceps should be available for use, and a similar object should be available for comparison. Communication between the endoscopist and anesthesiologist before the procedure to outline a plan of action is critical. Prior to surgical intervention in patients who are not in respiratory distress, the patient should remain on nothing by mouth (NPO) status for an adequate period to prevent aspiration.

Intraoperative Details

Use inhalational anesthetics to anesthetize patients. Apply 1-2% lidocaine to the larynx to reduce reflexes and prevent laryngospasm. Keep patients spontaneously breathing throughout the procedure for control of the airway.

With laryngeal foreign bodies, use an insufflation catheter through the nose with the tip in the hypopharynx to maintain anesthesia and oxygenation. The laryngoscope tip is placed in the vallecula for exposure, and the foreign body is visualized in the larynx and removed with appropriate foreign body forceps. After removal, reassess the larynx for other foreign bodies. Perform rigid bronchoscopy afterward to assess for other foreign bodies in the lower airway.

In tracheobronchial foreign body removal, the bronchoscope is inserted into the airway after exposure to the larynx, and continuous ventilation of the patient is provided through the bronchoscope. In a patient with a bronchial foreign body, the unaffected side is examined first. The bronchoscope then is placed immediately above the foreign body. Secretions are gently suctioned around the object. The patient is oxygenated with 100% oxygen before any attempt at removal. The forceps are placed through the bronchoscope, and the object is grasped after complete visualization of the foreign body. The bronchoscope is advanced to the foreign body while the surgeon continues to grasp the object. The foreign body, foreign body forceps, and bronchoscope are removed as a unit, and the bronchoscope immediately is returned to the airway for ventilation and reassessment for other foreign bodies.

Occasionally, easy retrieval of the foreign body is not possible. Larger objects unable to pass through the larynx can be broken into pieces and removed. If the object cannot pass through the larynx, a tracheotomy can be performed to remove the object through the tracheostoma. At times, the object becomes embedded into the surrounding mucosa because of edema caused by the object or because of multiple failed attempts at removal. In this situation, stop and to wait 48-72 hours to allow the edema to subside for a repeat attempt at removal. Thoracotomy may be necessary when the object stays embedded after failed endoscopic attempts.

Foreign bodies in the distal bronchial segments may be removed with the use of a Fogarty endovascular catheter through the suction port of a rigid bronchoscope. Flexible bronchoscopy as an adjunct may be beneficial in the removal of distal objects.

Sharp objects are extremely challenging for endoscopic removal. The pointed end tends to engage in the mucosa, causing the object to tumble with the point trailing. Pointed objects tend to be bendable or breakable. The bronchoscope is placed into the airway, and, using foreign body forceps, the pointed end of the object is disengaged from the mucosa, moved distally, and then removed. Pin-bending forceps may be used in certain situations. Safety pin removal is uniquely challenging; removal is performed endoscopically by sheathing the pointed end into the endoscope and locking the keeper outside the endoscope. Open removal by thoracotomy may be necessary when the sharp object is severely embedded into the mucosa.²

Postoperative Details

The use of steroids or racemic epinephrine is not necessary when age-appropriate endoscopes are used. Antibiotics typically are not prescribed because the source of infection has been removed. Chest physiotherapy is performed after foreign body removal to help remove secretions. Patients are discharged when fully awake and breathing comfortably without the need for supplemental oxygen. Chest radiographs are performed postoperatively if the patient's signs and symptoms persist or worsen.

Follow-up

Follow-up care is necessary if the patient's signs and symptoms return after discharge. For excellent patient education resources, visit eMedicine's Procedures Center. Also, see eMedicine's patient education article Bronchoscopy.

Complications

Most complications are the result of a delay in diagnosis.

Of patients with laryngotracheal foreign bodies, 67% experience associated complications when the removal delay is more than 24 hours.

Pneumonia and atelectasis are the most common complications secondary to and after removal of bronchial foreign bodies.

Bleeding can occur from granulation tissue surrounding the foreign body or erosion into a major vessel.

Pneumothorax and pneumomediastinum can result from an airway tear.

Future and Controversies

Literature describes other means of foreign body removal. Chest physiotherapy and bronchodilators have been suggested in the past but are not currently recommended as treatment. Some have advocated flexible bronchoscopic removal of all foreign bodies in children, but poor airway control and the need for the immediate availability of rigid endoscopic equipment limit its use as an exclusive intervention.

Predictive models using computerized scoring systems may help in more specifically identifying those children with and without foreign body aspiration.³ Simulation training may aid in preparation of future otolaryngologists involved with foreign body removal in children.

Multimedia

Media file 1: Aspirated foreign body (backing to an earring) lodged in the right main stem bronchus.

References

Bloom DC, Christenson TE, Manning SC, et al. Plastic laryngeal foreign bodies in chidren: A diagnostic challenge. Int J Pediatr Otorhinolaryngol. 2005;69:657-662.
Holinger LD. Management of sharp and penetrating foreign bodies of the upper aerodigestive tract. Ann Otol Rhinol Laryngol. Sep 1990;99(9 Pt 1):684-8. [Medline].
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].
Black RE, Johnson DG, Matlak ME. Bronchoscopic removal of aspirated foreign bodies in children. J Pediatr Surg. May 1994;29(5):682-4. [Medline].
Chatterji S, Chatterji P. The management of foreign bodies in air passages. Anaesthesia. Oct 1972;27(4):390-5. [Medline].
Deutsch ES, Dixit D, Curry J, et al. Management of aerodigestive tract foreign bodies: innovative teaching concepts. Ann Otol Rhinol Laryngol. May 2007;116(5):319-23. [Medline].
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].
Holinger PH. Foreign bodies of the air and food passages. Trans Am Acad Ophthalmol Otolaryngol. 1966.
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].
McGuirt WF, Holmes KD, Feehs R, Browne JD. Tracheobronchial foreign bodies. Laryngoscope. Jun 1988;98(6 Pt 1):615-8. [Medline].
Mu L, He P, Sun D. Inhalation of foreign bodies in Chinese children: a review of 400 cases. Laryngoscope. Jun 1991;101(6 Pt 1):657-60. [Medline].
Murray AD, Mahoney EM, Holinger LD. Foreign bodies of the airway and esophagus. In: Cummings, et al. (eds). Otolaryngology-Head and Neck Surgery. Vol 5. (ed 3). St. Louis, MO: 1998:p 377.
Murray AD, Walner DL. Methods in instrumentation for removal of airway foreign bodies. Operative Techniques in Otolaryngology-Head and Neck Surgery. March 2002;0(1):2-5.
Ritter F. Questionable methods of foreign body treatment. Ann Otol Rhinol Laryngol. 1974;83:729.
Svedstrom 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].
Swanson KL, Prakash UB, Midthun DE, et al. Flexible bronchoscopic management of airway foreign bodies in children. Chest. May 2002;121(5):1695-700. [Medline].

Keywords

foreign bodies of the airway, bronchial foreign bodies, tracheobronchial foreign bodies, aerodigestive foreign bodies, foreign body aspiration, choking, foreign body aspiration, airway obstruction

Contributor Information and Disclosures

Author

Alan D Murray, MD, Pediatric Otolaryngologist, ENT for Children; Full-Time Staff, Medical City Dallas Children's Hospital; Consulting Staff, Department of Otolaryngology, Medical Center of Lewisville, Children's Medical Center at Dallas, Cook Children's Medical Center; Full-Time Staff, Texas Pediatric Surgery Center, The Pediatric Surgery Center
Alan D Murray, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American College of Surgeons, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Daniel J Kelley, MD, Consulting Staff, Eastern Shore ENT and Allergy Associates and Peninsula Regional Medical Center
Daniel J Kelley, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Laryngological Rhinological and Otological Society, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gregory C Allen, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Gregory C Allen, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, Christian Medical & Dental Society, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position

Further Reading