Chapter 11: Foreign Bodies

High-Yield Facts

• Endobronchial and esophageal foreign bodies are marked by three clinical stages—an initial symptomatic stage of coughing, choking, and discomfort; a stage of relative amelioration of symptoms; followed by a stage of complications due to obstruction and infection.

• The gold standard for the diagnosis of an endobronchial foreign body is bronchoscopy.

• An asymptomatic or mildly symptomatic child with a coin in the esophagus can be observed for 8 to 16 hours because the coin will spontaneously pass into the stomach in 25% to 30% of these children.

• A useful method for removal of most intranasal foreign bodies is a positive-pressure technique such as the parent's kiss or a bag-valve-mask resuscitator.

• A useful initial method for removal of most foreign bodies from the external auditory canal is irrigation. This technique requires very little patient cooperation.

• An immobile battery, for example, in the esophagus, nose or ear, requires emergent removal to prevent perforation at the site of impaction and subsequent infection.

• Two or more rare-earth magnets in the gastrointestinal tract or on both sides of the nasal septum require emergent removal because of the potential of erosion and perforation of the tissue between the two adherent magnets.

Children with foreign bodies are certainly not foreign to the emergency department. Through natural curiosity, a child may place a foreign object into various body orifices. It may be aspirated into the respiratory tract, swallowed into the alimentary canal, lodged in an external auditory canal, a nostril, or an eye. Others may become firmly attached to various parts of the body with examples being zippers, fish hooks, rings, and constricting hairs or threads. Button batteries and magnets are unique hazards and will be discussed separately.

Airway Foreign Bodies

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 ...