FOREIGN BODY

IN
OROPHARYNX
OR
ESOPHAGUS

Pathophysiology - 1

Foreign bodies in oropharynx and upper 1/3 of esophagus

are easily localized due to good innervation

Foreign bodies in lower 2/3 of esophagus are poorly

localized due to poor innervation

Chronic foreign body Infection of surrounding soft tissue

of neck/throat

Pathophysiology - 2

Esophagus has 3 areas of narrowing:

Upper esophageal sphincter (cricopharyngeus)
Crossover of the aorta
Lower esophageal sphincter

Structural abnormalities of esophagus:

Stricture
Web
Diverticulum
Malignancy

Motor abnormalities of esophagus:

Scleroderma
Diffuse esophageal spasm
Achalasia

Pathophysiology - 3

After reaching the stomach, a foreign body has a >90%

chance of passage

>2 cm length: may get stuck at pylorus

>5-7 cm diameter: may get stuck at pylorus or duodenal

sweep

Coin: will pass through

Objects occasionally get stuck at ileocecal valve and rarely

at Meckels diverticulum

Epidemiology - 1

Incidence: Unknown

Sex:
Children: M=F
Adults:
Accidentally swallowed: M>F
Intentionally swallowed: M>>F

Epidemiology - 2

Patient types:
Children:
~ 80% of patients
preponderant age is 1 yr to 2 yr
objects include coins, buttons, marbles, crayons, etc.
Entrapment in children is mostly at UES
Psychiatric patients and prisoners:
bizarre objects and multiple objects

Edentulous patients:
food bolus, chicken bone, fish bone, fruit pit, denture,

toothpick
entrapment in adults is mostly at LES

Epidemiology - 3

Morbidity / Mortality:
~ 1500 deaths annually from foreign bodies in upper GI tract
Complications of oropharyngeal foreign body:
Abrasion / Laceration / Puncture
Associated with abscess / perforation / soft tissue infection

Epidemiology - 4
Complications of esophageal foreign body:
Abrasion / Puncture / Perforation
Injury or infection of surrounding structures:
Abscess
Pneumomediastinum
Mediastinitis
Pneumothorax
Pericarditis
Tamponade
Fistula
Injury to aorta
Injury to pulmonary vasculature
Button batteries can rapidly create esophageal necrosis
Complications of stomach/small intestine foreign body:
Perforation with associated infection, e.g. peritonitis

History - 1

Oropharnygeal foreign body:

Foreign body sensation (esp. chicken or fish; but even

toothpick, etc.) in oropharynx

Discomfort (mild, moderate, severe)
Inability to swallow or handle secretions
Airway compromise, rarely (typically if delayed

presentation with subsequent infection or perforation)

History - 2

Esophageal foreign body in adults:

Acute presentation with history of ingestion
Dysphagia
Foreign body sensation or vague discomfort in

epigastrium entrapment in LES

Inability to handle secretions complete obstruction

History - 3

Esophageal foreign body in children:

History may be less clear
35% of cases are asymptomatic!
History given by parent must be taken seriously and

investigated
Gagging
Vomiting
Neck or throat pain

History - 4
Large esophageal foreign body at UES Stridor or

airway compromise
Chronic esophageal foreign body:
Poor feeding
Irritability
Failure to thrive
Fever
Stridor
Repititive pneumonias (from aspiration)

Stomach / small intestine foreign body:

History of swallowing object, which has passed through
the esophagus
Vague symptoms, e.g. fever, abdominal pain, vomiting

Physical Examination

Typically not helpful, but carefully examine oropharynx, neck,

chest, lungs, heart, abdomen

Occasionally, foreign body in oropharynx can be visualized

and removed

IDL or fiberoptic nasopharyngoscopy in co-operative patients

Stridor in children large foreign body at UES

Drooling (and inability to swallow) complete obstruction

Signs of infection (e.g. peritonitis) delayed presentation

Etiology - 1

Mostly food bolus or accidental swallowing of an object

Children:
Young children often put any object they find into their

mouth and may accidentally swallow it

Older children may also put smooth object in mouth (e.g.

coin, marble) but diameter of esophagus chance of

entrapment in esophagus
Abused children may be forced to swallow object; rare

Etiology - 2

Adults:
Most commonly, food stuck in esophagus because of

underlying mechanical problems

Often, toothpick or denture
Psychiatric patients: wide variety of objects, multiple

objects, large objects, bizarre items

Prisoners: intentional swallowing to hide object or to seek

medical care
Drug smugglers: Body packing, Stuffing

Workup - 1

Lab studies:
Mostly not needed
CBC if suggestion of infection or complication
Pre-operative studies

Imaging studies:
Plain X-ray(s) mandated if radio-opaque foreign body
Small children:
Mouth-to-anus X-ray

Workup - 2
Older children and adults:
Chest X-ray, PA & lateral views

Bones visible in only 20-50% of cases of bone swallowing

Coins visible in coronal alignment on PA view
Button battery can be differentiated from coin on plain

X-ray
If unable to ascertain whether button battery or not, then

intervene urgently

Workup - 3
Drug packets have characteristic appearance on plain X-

ray
Foreign body in trachea presents in sagittal orientation
X-ray is not needed in adult with food impaction where

endoscopy is planned

Coin (quarter) lodged at

the level of the
cricopharyngeus
muscle

Coin lodged at the level

of the aortic crossover

Coin lodged at the lower

esophageal sphincter

Workup - 4
Barium swallow:
May be indicated if ingestion of non-opaque foreign

body, e.g. toothpick (but CT scan is better)

Contra-indicated if suspicion of esophageal rupture
CT scan:
Highly reliable in localizing foreign body in esophagus
The imaging modality of choice to locate non-radio-

opaque foreign body in oropharynx or esophagus

(But not warranted in every case of acute bone
dysphagia because only 17-25% of such cases actually
have a bone present)
The imaging modality of choice if suspected perforation
or abscess (should be done with IV contrast if no
contra-indication)

Workup - 5
Metal detector:
Accurate in determining whether child has swallowed a

coin or not
Unable to determine exact location: cannot differentiate
LES impaction from coin in stomach
Ultrasound:
Bedside ultrasound in unstable patient with suspected

ingestion of drug packets

Treatment - Pre-hospital
care
Transport in comfortable position
Airway compromise Acute airway management
Unable to tolerate secretions Most comfortable in

sitting position
Suction catheter to handle secretions

Treatment - Hospital
care
Unstable condition:

Airway
compromise
Drooling
Inability to tolerate
fluids
Evidence of
sepsis
Perforation
Active bleeding
Ingested button
batteries

Treatment:
Airway management (as
indicated) Urgent
endoscopy

Treatment Button battery - 1

Treatment Button battery - 2

Most commonly in children of average ~ 4 yr. age

Medical emergency because necrosis of esophageal wall

may occur within 2 hours

Cause injury by electric current, electrolyte leakage,

pressure necrosis, or heavy metal poisoning

Important to distinguish between button and battery

7-25 mm size, radio-opaque, appear as round densities on

X-ray, similar to ingested coin (though some demonstrate a
double-contour configuration)

Treatment Button battery - 3

Button battery lodged in esophagus must be removed

immediately

Button battery in stomach:

Is safe
Can be allowed to pass, but must be monitored on X-ray
to observe for disruption of battery
Follow-up X-ray in 24-48 hours: if still in stomach, remove
by endoscopy

Treatment Stable patient - 1

Oropharyngeal foreign body sensation:

Direct oropharyngeal exam
Indirect oropharyngeal exam
Fiberoptic nasopharyngoscopy

History of radio-opaque object X-ray

Endoscopy if object is sharp, elongated (>5 cm in
esophagus, >6 cm in stomach/small intestine), or multiple
in number
If sharp object: urgent endoscopy, because of ~ 35% risk
of perforation, e.g. pin, razor blade, toothpick, chicken
bone
If smooth or blunt object: endoscopy, or Foley catheter
removal, or bougienage, or sphincter relaxation (if lodged
at LES), or Magill forceps removal

Treatment Stable patient - 2

History of non-radio-opaque object CT scan

Endoscopy
E.g. plastic object, toothpick, aluminum soda can tab

Most small bodies which have passed the esophagus will

pass through the gut easily

But do endoscopy for foreign body in stomach or proximal

duodenum if foreign body is:
>2 cm in diameter
>5-7 cm in length
oddly shaped (e.g. open safety pin)

Treatment Stable patient - 3

Meat tenderizer: contra-indicated (risk of esophageal

necrosis)

If workup is negative for foreign body, discharge (with

painkiller as needed) and follow up in 24 hours; if patient is
still symptomatic at follow up, do endoscopy

Treatment Special
cases - 1

Esophageal coin:
May consider watchful waiting if impacted at LES, as
80% coins will pass

Magnet:
1 magnet: treat routinely
2 magnets: may become attached while in different gut
loops risk of necrosis/perforation/peritonitis; so get
surgical consultation

Press-through packing:
Bubble packaging for medication
Especially in elderly or those with dementia
Treat as sharp foreign body: endoscopy

Treatment Special
cases - 2

Razor blades:
Swallowed by prisoners or psychiatric patients
Sharp edge is often taped to avoid injury
Remove if in esophagus or stomach
Allow to pass if past stomach

Body packing:
Admit for observation
Whole-bowel irrigation
Avoid endoscopy (risk of rupture of packet)