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Foreign Bodies of Air Passages and Food Passage

PREPARED BY : NURUL SYAZWANI RAMLI

Foreign Bodies of Air Passages


A foreign body (FB) aspirated into air passage can

lodge in the larynx, trachea, or bronchi (depend on size and nature of FB). Large FB = cant pass thru glottis lodge in supraglottic area. Smaller FB = pass down thru larynx into trachea or bronchi.

Aetiology
Vegetable Nonvegetable Peanut (most common) Plastic whistle Almond seed Plastic toys Peas Safety pins Beans Nails / Screws Wheat seed Coins Water melon seed Bones Piece of carrot or apple, etc Buttons Hair clips Marble, etc

Nature of Foreign Body


Non-irritating type Eg: plastic, glass, metallic FB symptomless for a long time Irritating type Eg: vegetable (peanuts, beans, seeds, etc) Set up diffuse violent reaction congestion and oedema of tracheobronchial mucosa (vegetal bronchitis) swell up with time causing airway obstruction and later suppuration in the lung.

Clinical Features
Symptomatology of FB is divided into 3 stages: 1) Initial period of choking, gagging and wheezing

Last for a short time FB may be coughed out or it may lodged in the larynx or further down in tracheobronchial tree

2)

Symptomless interval
Resp. mucosa adapts initial symptoms dissappear

3)

Later symptoms
Caused by obstruction to the airway, inflammation or trauma induced by FB and would depend on site of its lodgement.

Cont. Clinical Features


Sites of its lodgement: a) Laryngeal FB

Large FB totally obstruct airway sudden death (unless resuscitative measures urgently). Partial obstructive discomfort, pain in throat, hoarseness of voice, croupy cough, aphonia, dyspnoea, wheezing and haemoptysis.

b)

Tracheal FB
Sharp FB cough, haemoptysis Loose FB move up and down the trachea btwn carina and undersurface of vocal cords audible slap, palpatory thud and asthmatoid wheeze.

c)

Bronchial FB
Right Bronchus (most) becoz wider and more in line with tracheal lumen Totally obstruct lobar or segmental bronchus atelectasis Produce check valve obstruction obstructive emphysema Emphysematous bulla rupture spontaneous pneumothorax Retained FB in lung pneumonitis, bronchiectasis or lung abscess.

Diagnosis
Detailed Hx (FB ingestion)

PE of neck and chest Classical triad


Sudden onset of coughing Wheezing Diminished air entry

Radiology: Plain X-Ray CXR at end of inspiration and expiration Fluoroscopy/videofluoroscopy CT chest

Management
Laryngeal FB First aid measures:
1) 2) 3)

Pounding on the back Turning the patient upside down Heimlichs manoeuvre

shud not be done if pt. partially obstructed

4) 5)

Cricothyrotomy or emergency tracheostomy (if Heimlichs manoeuvre fails) Once emergency over, FB can be removed by direct laryngoscopy or laryngofissure (if found impacted)

Cont. Management
Tracheal and Bronchial FBs Can be removed by bronchoscopy with full preparation and under GA Emergency removal not indicated unless theres airway obstruction or vegetable nature and likely to swell up. Methods to remove tracheobronchial FB:
1) 2) 3) 4)

5)
6) 7)

Conventional rigid bronchoscopy Rigid bronchoscopy with telescopic aid Bronchoscopy with C-arm fluoroscopy Use of Dormia basket or Fogartys balloon for rounded objects Tracheostomy 1st and then bronchoscopy thru the tracheostome Thoracotomy and bronchotomy for peripheral FBs Flexible fibre optic bronchoscopy in selected adult pt.

Foreign Bodies of Food Passage


An ingested FB may lodge in: The tonsil The base of tongue/vallecula The pyriform fossa The oesophagus

Aetiology
Age (children) Loss of protective mechanism Use upper denture (prevents tactile sensation) Loss of consciousness Epileptic seizures Deep sleep Alcoholic intoxication Carelessness Poorly prepared food Improper mastication Hasty eating and drinking Narrowed oesophageal lumen (oesophageal stricture or ca.) Psychotics (attempt to commit suicide)

Site of Lodgement of FB
Just below the cricopharyngeal sphincter

(commonest site) FB which pass the sphincter can be held up at next narrowing at broncho-aortic constriction or at the cardiac end. Sharp or pointed objects lodge anywhere in the oesophagus.

Clinical Features
Symptoms H/O initial choking or gagging Discomfort or pain ( increase on attempts to swallow) Dysphagia Drooling of saliva Respiratory distress Substernal or epigastric pain

Cont. Clinical Features


Signs Tenderness (lower part of neck) Pooling of secretions in pyriform fossa on indirect laryngoscopy and not disappear on swallowing FB may be seen protruding from oesophageal opening in postcricoid region.

Investigation
Plain X-rays

Fluoroscopy

Management
Oesophagoscopic removal (under GA) Cervical oesophagotomy Transthoracic oesophagotomy

FB which has reached stomach may pass thru GIT w/o difficulty; stool shud be carefully examined every day. Operative interference may be required when:

Pain and tenderness in abdomen FB not showing any progress on serial X-rays FB is 5cm or longer in a child belor 2 years Presence of pyloric stenosis

Complication of Oesophageal FB
Respiratory obstruction

Perioesophageal cellulitis and abscess in neck


Perforation Tracheo-oesophageal fistula (rare)

Ulceration and stricture.

Thank You