A child suspected to have aspirated a foreign body is a common emergency department problem. This occurs most commonly in children less than 3 years old1 with a peak incidence in the 10- to 24-month age group.2 The vast majority, 80% to 90% is endobronchial with the remainder being laryngeal and tracheal.1 Deaths are more likely for laryngeal and tracheal foreign bodies with toy balloons3 and hot dogs4 comprising a large proportion of this group. The most common endobronchial foreign bodies are nuts and seeds.5
Patients with a laryngeal or tracheal foreign body typically present with dramatic symptoms and signs: obstructive (cough, stridor, dyspnea, retractions, cyanosis) and voice alteration (hoarseness, dysphonia, or aphonia).
Typical laryngeal and tracheal foreign bodies are fish bones, eggshells, and grapes.1 These require immediate removal. Laryngeal foreign bodies may be amenable to removal in the emergency department using McGill forceps with direct visualization. Children with tracheal foreign bodies require emergent referral for endoscopic removal.
Endobronchial foreign bodies are marked by three clinical stages.1 The initial stage, impaction of the foreign body, is marked by choking, gagging, coughing, and respiratory difficulty. This is followed by a relatively asymptomatic phase (tolerance of the foreign body), which may last for hours or days. The third stage, the complication stage, is a consequence of obstruction and infection. The child may have atelectasis, pneumonia, or abscess.
Diagnosis of foreign-body aspiration is often challenging. Frequently, the caregiver is unaware of the event. Both the caregiver and the clinician may not relate the child's symptoms to a foreign body. Physical examination findings can vary from none to unilateral decreased air entry or wheezing. The sensitivity and specificity of the history for foreign-body aspiration are 75% to 91% and 10% to 92%, respectively.2 For physical examination, they are 57% to 86% and 26% to 72%, respectively.2 Because the history and physical examination have unsatisfactory sensitivity and specificity, investigations play an essential role in the diagnosis of endobronchial foreign body.
The gold standard for the diagnosis of an endobronchial foreign body is endoscopy.6 Thus, negative endoscopies are unavoidable. The chest x-ray may not be helpful unless a radiopaque foreign body was aspirated. However, 80% to 96% of airway foreign bodies are radiolucent.2 Obstructive emphysema with air trapping is the most common chest x-ray abnormality, seen in 17% to 69%.2 Atelectasis is seen in 12% to 41% and the chest x-ray is normal in 14% to 37%.2
Chest x-rays taken during inspiration and expiration (Fig. 11-1) have a 65% sensitivity in patients who do not have a clinically obvious foreign-body aspiration. For a patient with a right-sided endobronchial foreign body, the expiratory view would show a shift of the mediastinum to the left and hyperaeration of the right lung. Fluoroscopy showing the same mediastinal shift and decreased diaphragmatic excursion of the affected side supports the diagnosis.
Inspiration and expiration views of the chest demonstrate air trapping within the right hemithorax suspicious for an obstructing foreign body.
Recently, multidetector computed tomography of the chest has shown high sensitivity (94%) and specificity (95%) for foreign-body aspiration in children.6 Exposure times are brief (2–7 seconds) and radiation exposure is modest. However, a retained endobronchial foreign-body risks chronic morbidity. Thus, a negative CT does not rule out the need for endoscopy.
Management of a child with a suspected foreign-body aspiration consists of addressing respiratory distress or failure if present. For children with an obvious aspiration, for example, those with a clear history of placing a foreign body in the mouth, followed by an abrupt onset of coughing, gagging or choking and with unilateral wheezing, obtain a chest x-ray and immediately refer for endoscopy. In less obvious cases, consider inspiratory and expiratory radiographs, fluoroscopy, and multidetector computed tomography of the chest if available. In most cases, referral to an endoscopist is indicated for those children with a history of a foreign body in the mouth and a choking paroxysm.