Foreign Body in the Larynx and Tracheobronchial Tree

Foreign body in the larynx and tracheobronchial tree is one of the most important causes of stridor
and dyspnoea in infancy and childhood. There may or may not be a history of inhaling a foreign
body. Sudden occurrence of dyspnoea in a previously healthy child raises suspicion. Effects of the
foreign body vary according to its size, nature and location in the larynx and tracheobronchial tree.
Small and smooth metallic foreign bodies such as pins allow uninterrupted passage of air, while a
larger foreign body may cause a total occlusion of the airway. The nature of the foreign body is also
important. Vegetable foreign bodies like peas and beans produce severe pneumonitis and are also
difficult to remove. The effects on the patient and his respiratory system depend also on the location
of the foreign body in the respiratory tract. If the foreign body gets arrested in the larynx, it
obstructs both the phases of respiration and rapidly produces laryngeal oedema. In the trachea, if
the foreign body is large, there is an equal danger of total respiratory obstruction.
FOREIGN BODIES IN THE LARYNX
A foreign body lodged in the larynx obstructs inspiration as well as expiration and produces change
in the voice. There may occur complete asphyxia which is further aggravated by the glottic oedema.
FOREIGN BODIES IN THE TRACHEA
The main symptom is dyspnoea with stridor. The changing position of the foreign body in the
trachea may give rise to signs like an audible slap and a palpatory thud. Depending upon the
obstruction one can hear an asthamatic type of wheeze in such cases.
FOREIGN BODIES IN THE BRONCHUS
Foreign bodies usually get arrested in the right main bronchus because it is wide and is more in line
with the trachea than the left main bronchus. The immediate effect of the foreign body in the
bronchus is respiratory obstruction which could be partial or complete. Partial obstruction If the
foreign body is smaller than the size of the bronchus, initially it allows the passage of air in both
directions with little interference, like a bypass valve. A foreign body which is just of the size of the
bronchus allows the flow of air only on inspiration and blocks the expiratory phase. It thus acts as a
check valve. This sort of action depends upon the expansion of the bronchus on inspiration and its
contraction on expiration. Such foreign bodies will produce obstructive emphysema with
overdistension of the affected lobe and respiratory embarrassment.
Total obstruction If the blockage of the bronchus is complete, either by the foreign body itself or by
mucosal oedema, a stop valve type obstruction results. There occurs no passage of air even on
inspiration, so the air in the distal portion of the lung soon gets absorbed leading to collapse of a
segment or lobe of the lung. Sometimes the foreign body may get arrested at the bifurcation
producing a complete obstruction of one bronchus but only a partial obstruction in the other. Then
the blocked segment of the lungs shows collapse while the partially obstructed one becomes
emphysematous. Patients in whom the foreign bodies are neglected may develop bronchiectasis,
lung abscess and empyema in the long run.
Clinical Features
The clinical features of a case of foreign body in the larynx and tracheobronchial tree vary from mild
symptoms to asphyxia. These depend upon the site of lodgement of the foreign body and the
resultant pathological changes. The history may or may not be suggestive. A sudden episode of
choking, coughing and dyspnoea are important features. Such patients present with dyspnoea,
cough and wheezing. If the effect produced is partial obstruction, then there are signs of obstructive
emphysema with the trachea and mediastinum shifted away from the distended hyper-resonant
lobe. In patients with complete bronchial obstruction there are signs of collapse with shifting of the
mediastinum to the affected side.
Investigations
X-rays of the chest are of great help. These reveal the nature and position of the foreign body (if
radiopaque) as well as the effects produced in the lung, like collapse or obstructive emphysema (Fig.
62.1). Bronchoscopy may be done as diagnostic investigation and as a therapeutic procedure in cases
where X-rays are not helpful but the history is suggestive.
Treatment
Foreign bodies in the larynx and the subglottic region are removed by direct laryngoscopy.
Tracheostomy may be required initially to overcome the respiratory obstruction. The foreign body is
then removed by direct laryngoscopy. Foreign bodies in the trachea and bronchi are removed by
bronchoscopy. Impacted foreign bodies in the bronchus may require thoracotomy

FB in the pharynx or oesophagus

Causes
In children, this tends to be an inanimate object such as a coin . There should always be a high
suspicion of battery as these can look very similar to a coin on a plain X-ray. A battery causes a
chemical burn that can perforate the oesophagus within hours. In adults, it tends to be a food bolus.
The most important question is whether there is any bone as this requires immediate removal
because the oesophagus is at a higher risk of perforation.
Presentation
Dysphagia, odynophagia, drooling In children, the presentation can be very non-specific. e.g. off
their food, lethargic
Management
Depends upon the nature of the foreign body, duration of the symptoms and the clinical status of
the patient. Batteries – removal as soon as possible. This is a surgical emergency and should be
treated with the same urgency as a significant bleed or an airway problem. Food bolus with bone –
needs to be removed as soon as possible to minimize the possibility of perforation Food bolus
without bone – this may spontaneously pass overnight (the oesophageal muscles & sphincters relax
when a patient sleeps) or muscle relaxants such as hyoscine butylbromide (Buscopan) can be given.
If it does not pass, patient may need an upper rigid oesphagoscopy or an OGD (for a lower food
bolus). Asking the patient to swallow a sip of water can be useful (immediate regurgitation implies a
high obstruction whereas delayed regurgitation implies a low obstruction).

Foreign body in the nose

A foreign body in the nose is more common in children. Foreign body examples include beads, peas,
nuts and sweets.
This presentation can be dangerous if the foreign body is inhaled into the airway causing airway
obstruction. In particular, if the foreign body is a battery (button battery) this can quickly erode nasal
mucosa and cartilage leading to septal perforation. Figure 65: Foreign body (screw) in the nose of a
child. Symptoms Unilateral nasal discharge (often offensive if present for a while) Nasal obstruction
Irritability in infants
Management
Try positive pressure through mouth (can be done by the parents) Examine with the Thudichum’s
speculum. Earwax hook or alligator forceps may be used to extract the foreign body. Avoid pushing
the FB further back Removal under GA
Foreign body in the ear
A foreign body in the ear is more common in children. However, broken ends of cotton bud ends or
pieces of tissue can be found in the embarrassed adult! It is particularly dangerous if the foreign
body is a button battery as rapid erosion may occur.
Presentation Hearing loss Discharge- may be foul smelling or blood if FB is left long term.
Management The foreign body needs to be removed using appropriate equipment – the method
used depends upon what the object is and its shape. Examples include using a wax hook (e.g. small
hard, round objects), alligator forceps (paper) or microsuction.
Bibliography
1. Mohammad Maqbool, “Textbook of Ear, Nose and throat diseases”, 11 th edn, Jaypee
publications
Pg no; 344-345
2. Alexander yao, Ear, Nose and Throat: The Official Handbook for Medical Students and Junior
Doctors” “197- 198, 205-206
3. Petros Koltsidopoulos and Charalampos Skoulakis, Ënt Core knowledge “, Springer , USA
Pg:160 -61, 236-37

3.27 Aspiration of Foreign Body

The most common foods causing fatal aspiration are peanuts and grapes. – Smaller objects do not
cause complete airway obstruction. – Foreign bodies that do not cause obstruction are present with
wheezing and chronic cough. – An observed choking event may be followed by an asymptomatic
interval. – Recurrent pneumonia (late manifestation).
Diagnosis • Physical examination – tracheal: biphasic stridor – bronchial: expiratory wheeze,
decreased breath sounds on involved side. • Chest radiograph – only radiopaque foreign bodies are
visible. – inspiratory and expiratory films show atelectasis on inspiration and hyperinflation on
expiration on the affected side. – obstructive emphysema may be seen.
Therapy • Removal by rigid ventilation bronchoscope. – Bronchoscopy indicated whenever diagnosis
is suspected. All sign and symptoms need not be present. – General anesthesia is required with
spontaneous ventilation. – Steroids are recommended to reduce edema. Complications 1. bronchitis,
pneumonia, ulceration, granulation tissue. 2. pneomothorax, pneumomediastinum. 3. vegetable
matter may swell and become impacted. 4. total obstruction (as FB becomes lodged in larynx during
removal).
Foreign Bodies – Oesophagus is the most common site of foreign body impaction within the
gastrointestinal tract. Adults: history of having eaten fish or chicken. Children: the history may be
very misleading.
Symptoms – Dysphagia – Odynophagia – Drooling.
Diagnosis • Radiographs: both antero-posterior and lateral neck films and a chest X-ray. • Negative
X-ray findings do not rule out a foreign body. – In case of clinically or radiologically suspected foreign
body, endoscopy is necessary. – Foreign body endoscopy is an ENT emergency.
Therapy • Endoscopy in the first 6 h with a rigid oesophagoscope and removal of the foreign body. If
disk battery is ingested, it should be emergently removed (it may release a caustic solution and
cause injury to the mucosa). Chapter 7. Oesophagus 237 • After removal, patients need to be
observed for any signs of perforation. A Gastografin contrast study is done before oral food intake is
resumed.