Milton Tenenbein
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 dogs4comprising 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.2For 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.
FIGURE 11-1. 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.
INGESTED FOREIGN BODIES
Ingestion of a foreign body is a common emergency department problem. Esophageal foreign bodies are twice as common as endobronchial foreign bodies.1 However, spontaneous passage occurs in 80% to 90% of patients, whereas 10% to 20% require endoscopic removal and less than 1% require surgical intervention.7 Most esophageal foreign bodies are coins, 88% in one series.8 They typically lodge in one of three locations (Fig. 11-2), 60% to 70% at the thoracic inlet, 10% to 20% in the mid-esophagus at the level of the aortic notch, and 20% at the lower esophageal sphincter.7
FIGURE 11-2. The three most common sites for esophageal foreign body: A. thoracic inlet (60%–70%); B. mid-esophagus (10%–20%); C. lower esophageal sphincter (20%).
Esophageal foreign bodies, like their endobronchial counterparts, may manifest three clinical stages.1 The initial symptoms are typically abrupt and dramatic. They include choking, gagging, drooling, vomiting, odynophagia, dysphagia, and chest pain. If the foreign body is large enough, pressure upon the airway may produce paroxysms of coughing.1 Symptoms diminish over time, much like endobronchial foreign bodies.1 Prolonged presence within the esophagus can lead to perforation and infection, tracheoesophageal fistula, and aortic-esophageal fistula.9
Most children presenting with a history of foreign-body ingestion are asymptomatic because of passage into stomach. It is important to determine whether there were any symptoms at the time of event, such as gagging, choking, or apparent discomfort. Obtain x-ray of the cervical, thoracic, and abdominal regions if the object is radiopaque and large enough to lodge within the esophagus (coin-sized) (Fig. 11-2). In a prospective study, 9 of 30 children with esophageal coins were asymptomatic at the time of assessment in the emergency department. It is unclear whether these children had symptoms at the time of ingestion. The presence of symptoms in the emergency department had a sensitivity of 70%, a specificity of 77%, a positive predictive value of 81%, and a negative predictive value of 65% for the presence of a coin in the esophagus.9
Refer all children with significant symptoms, such as respiratory difficulty, pain or inability to swallow their oral secretions, for immediate endoscopic removal. For children with esophageal coins and mild or no symptoms, consider a watch-and-wait approach for 8 to 16 hours.10 During this observation period, approximately 25% to 30% of esophageal coins pass spontaneously into the stomach.10 While under observation, ensure no oral intake to prepare for endoscopy under general anesthesia.
Another method for esophageal foreign-body removal is balloon (Foley) catheter extraction with fluoroscopy.8,11 “The patient is typically placed prone and oblique position on a horizontal table and often restrained. No sedation or analgesia is utilized. A Foley catheter (8–10 French) is placed, usually through the nose, and under fluoroscopic guidance is passed distal to the foreign body. The balloon is inflated using a radiopaque contract material (3–5 cm3 of barium), the syringe is left on the balloon port, and gentle traction is applied pulling the foreign body into the oropharynx where it is expectorated or removed manually.”11 In two large series of 4688 and 41511 children, there were high success rates of 88% and 91%, respectively. Epistaxis occurred in several patients. There were no significant complications in one series8 and a 1% rate in the other.11 Despite these high success and low complication rates, this technique is often criticized. Criticisms include inadequate visualization, the possibility of missing underlying pathology, injury or additional foreign bodies, absence of airway protection with the possible risk of aspiration of the foreign body, and discomfort to the patient.11 In most institutions, endoscopic removal under anesthesia is the procedure of choice.
Another treatment strategy for esophageal coins is bougienage using a Hurst esophageal dilator.12 Measure the distance between the tip of the nose and the epigastrium which is used as the insertion depth of the dilator. Place the child on the caretaker’s lap and achieve restraint using a “bear hug.” There is no anesthetic administration. The dilator is passed through the mouth to the measured depth and immediately removed. Order an x-ray after the procedure to confirm coin location. The success rate was 95% in 372 children and there were no significant complications.12
Intravenous glucagon has been recommended as a treatment for esophageal foreign bodies. However, this was shown to be ineffective in a placebo-controlled trial of children with esophageal coins.13
NASAL FOREIGN BODIES
Nasal foreign bodies in children are a frequent problem.14–16 The array of objects is broad with beads, pebbles, plastic toys, nuts, and seeds being the most common.14–16 The emergency physician can remove most of these.16 The typical patient is a 3 to 4 years old child who is brought to the emergency department with a chief complaint of nasal foreign body and is asymptomatic. Possible symptoms are discomfort and difficult breathing. A less-frequent presentation is a child with a unilateral foul nasal discharge without a history of nasal foreign body.
There are several techniques for removal of foreign bodies from the nose. The choice is dependent upon the type of foreign body and its location in the nostril (Table 11-1).
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TABLE 11-1 |
Techniques for Removal of Foreign Bodies from the Nose or Ear |
There are several positive-pressure techniques. The parent’s kiss entails the parent placing his or her mouth over the child’s open mouth forming a seal. Occlude the unaffected nostril and the parent forcibly blows into the child’s mouth expelling the foreign body. A 60% success rate has been reported.17 An alternative source of positive pressure is a bag-valve-mask resuscitator.18 Applying positive pressure to the contralateral nostril through a catheter connected to wall oxygen or air outlet (Beamsley Blaster) has been described.19 However, barotrauma resulting in subcutaneous facial emphysema has been reported as a complication of this technique.20 It should probably be avoided.
Consider forceps for soft easily grasped foreign bodies. There is a variety to choose from, including alligator, bayonet, and conventional forceps. Hard spherical foreign bodies are not amenable to extraction with forceps. They can be removed with a size 5 to 6 French Foley balloon catheter.16 Alternatively, one can use a commercially marketed device, the Katz Extractor®.21 It is a small-bore balloon catheter attached to a syringe (Fig. 11-3). Balloon catheter extraction is particularly useful for posteriorly sited nasal foreign bodies. More anteriorly sited ones can also be extracted with a right angle or hooked probe or as an ear cerumen curette. Other alternatives for anterior spherical foreign bodies are cyanoacrylate tissue glue placed on the end of cotton-tipped applicator,22 a small magnet attached to the end of cotton-tipped applicator for metallic foreign bodies, and a suction catheter.
FIGURE 11-3. The Katz Extractor® for removal of intranasal foreign bodies with and without balloon inflated.
EAR FOREIGN BODIES
A child with a foreign body in the external auditory canal is a frequent emergency department problem.23–25 Beads, pebbles, paper, and insects are common, but a wide array of objects is seen.23–25 Most can be removed by the emergency physician, with one series reporting 80% success.25 Success rates are related to several factors including size, shape, and texture of the foreign body, patient cooperation, trauma to the ear related to previous removal attempts, available equipment, and skills of the operator.24 Table 11-2 lists factors that are related to failure of foreign body removal or the development of complications.24 These are potential considerations for referral to an otolaryngologist.
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TABLE 11-2 |
Factors Related to Failure of Removal of a Foreign Body from the External Auditory Canal or the Development of Complications |
1. Foreign-body type: spherical or sharp-edged shape
2. Foreign-body location: proximal portion of the canal
3. Duration in canal: >24 h
4. Patient age: <4 y, uncooperative
5. History: previous removal attempts
Techniques for removal of foreign bodies from the external auditory canal can be grouped into irrigation, mechanical extraction, and suction. Irrigation is unique to ear foreign bodies. However, extraction and suction are used for removal of foreign bodies from the nose as well (Table 11-1). The choice of technique is governed by foreign-body type and location.
Consider irrigation as the primary removal technique for most aural foreign bodies. Exceptions are organic foreign bodies such as peas or beans because of the potential for swelling. Do not use irrigation in patients with known tympanic membrane perforation or tympanostomy tubes. Irrigation is easily done even in a relatively uncooperative child and is the procedure least likely to produce complications. Procedural sedation is unnecessary. Equipment includes a 60-mL syringe, a 20 G angiocath, and a basin to collect run-off. The patient may be sitting or lying. The water temperature should be close to body temperature to avoid vertiginous symptoms. Place the angiocath tip into the auditory canal and irrigate until the foreign body is washed out. Always perform otoscopy to ensure that there is no additional foreign body and that there are no complications of the procedure. Expect to find a pink-red tympanic membrane as a consequence of the irrigation.
Other removal techniques involve instrumentation of the canal, have similar indications, and employ similar equipment as for intranasal foreign bodies (Table 11-1). It is best to perform all of these through an ENT speculum with adequate illumination such as a headlamp. Patient cooperation is critical and consider procedural sedation for patients who are not easily restrained. Complications are related to patient cooperation and skills of the operator. The most common are bleeding due to canal abrasion or laceration or displacing the foreign body proximally.
Forceps can easily grasp soft anterior foreign bodies. Hard spherical objects can be pulled out with a right-angle hook or a cerumen loop. Although the Katz Extractor (described in the previous section) was designed for intranasal foreign bodies, some physicians have used it for selected ear foreign bodies. Other alternatives for hard spherical foreign bodies are as for their intranasal counterparts. These include cyanoacrylate glue,22 magnets if metallic, and suction. For suction removal, it is best to use a small-caliber soft-tipped catheter. The Schuknecht foreign-body remover23 is a suction device designed for this purpose. It is similar to a tonsil suction but is much smaller and has a funnel-shaped tip that conforms to the surface of spherical foreign bodies.
Live insects should first be killed prior to removal attempts. Instilling mineral oil or 2% to 4% lidocaine into the external auditory canal usually achieves that goal. Then, irrigation, suction, or forceps can be used to remove the dead insect.
OCULAR FOREIGN BODIES
Patients with foreign bodies on the surface of the eye typically present with a history of an abrupt onset of foreign-body sensation, blepharospasm, and lacrimation without a history of significant ocular trauma. If there is a history of trauma, an intraocular foreign body is a possibility. Regardless, the physician should assess whether the globe has been penetrated. A complete eye examination achieves that goal. A patient with an intra-ocular foreign body requires immediate referral to an ophthalmologist.
Management of a patient with a suspected superficial ocular foreign body is straightforward.26 It is best to instill a local anesthetic to facilitate a complete examination. This enables inspection of the globe. Evert the eyelids to inspect the superior and inferior fornices. This is followed by a fluorescein examination to assess for a corneal abrasion that could be the cause for the patient’s symptoms or could be secondary to the foreign body.
If a superficial foreign body is found, it may be removed by irrigation with normal saline or by rolling the tip of a moistened cotton-tipped applicator over the foreign body. If a foreign body is not seen and no corneal abrasion is found, it is often beneficial to irrigate the eye thoroughly with a stream of saline directed from the sclera to the cornea. Both lids should be everted to irrigate the fornices. Sweeping the palpebral conjunctiva with a cotton-tipped applicator may relieve symptoms even if a foreign body is not seen.
ZIPPERS
Body tissue can be trapped within a zipper. The most common scenario is entrapment of the foreskin. In a children’s hospital in Edinburgh, this injury accounted for 1 in 4068 emergency department visits.27In most instances, the foreskin is trapped between the undersurface of the zipper and the inferior plate of the slider. Less commonly, it is trapped between the teeth of the zipper.27
A simple and painless management first described in 197728 is cutting the median bar of the slider with a sturdy bone cutter (Fig. 11-4). The zipper falls apart and the trapped foreskin is freed. For the less common scenario of entrapment between the zipper teeth, cut horizontally across the zipper below the trapped foreskin. The zipper will fall apart.
FIGURE 11-4. Method of zipper removal by cutting the median bar of the zipper.
Cutting the median bar has been criticized as an ineffective technique.29 However, this may be due to choosing a cutter that is not sturdy enough for the task. An alternative method is inserting a flat-edged screwdriver between the two faceplates of the slider and twisting it toward the median bar. This widens the gap between the two faceplates and frees the foreskin.30 However, the torque required for this method may produce traction of the injured foreskin resulting in pain. Therefore, this method should be reserved for failed median bar cutting.
FISH HOOKS
Withdrawal of fish hooks imbedded in subcutaneous tissue is impeded by the hook’s barb. An easy method of removal is advancing the hook forward with a needle driver after anesthetizing the exit point with local anesthetic. The barbed point is then cut with a wire cutter and the remaining portion of the hook is easily withdrawn from its original entry point (Fig. 11-5).
FIGURE 11-5. Fish hook removal by advancing the point through the skin, cutting off the barbed end and withdrawing the proximal portion from the entrance site.
RINGS
A child may present for care because of a ring trapped on a finger. Usual home remedies such as ice and lubricants were unsuccessful. At the time of presentation, the finger is typically swollen, tender, and discolored. Removal can be challenging. Several methods employing string and the finger portion of latex gloves being placed under the ring followed by downward traction have been described. However, these are painful and often unsuccessful. Commercial ring cutters, both manual and powered, are often ineffective but are worth a try. A sturdy bone cutter is usually effective. Procedural sedation may be required.
HAIR-THREAD TOURNIQUET SYNDROME
The hair-thread tourniquet syndrome is a consequence of a hair or thread becoming tightly wrapped around an infant’s finger, toe, or genitals.31 The mechanism of injury is thought to be a consequence of initial impedance of lymphatic drainage resulting in lymphedema, venous outflow obstruction, and eventually arterial inflow obstruction.
The infant presents with a tender, swollen, and discolored digit with a proximal sharp circumferential border that is often indented. Management entails a search for the hair or thread. If visualized, it may be cut or unwrapped. Use of depilatory agents to dissolve the hair has been described.32 If the constricting foreign material is not visible or has eroded into the subcutaneous tissue referral to a surgeon is indicated.
BUTTON BATTERIES
Button battery–powered devices are ubiquitous. Thus, there are numerous opportunities for young children to play with them and to place them in various body orifices. They are unique foreign bodies because of the potential for electrolytic generation of hydroxyl ion in an aqueous media thus creating a risk for caustic tissue injury.33 Even spent batteries have this potential. The generated dose of hydroxyl ion is relatively small and easily diluted by the gastrointestinal contents. However, local tissue injury can occur within a few hours if the battery is lodged or impacted. The chief areas of concern are the esophagus,34the external auditory canal,35 and the nostrils.35 Esophageal button batteries have significant morbidity and the potential for mortality.34 An immobile battery anywhere in the body requires emergent removal.
It was shown decades ago that most ingested button batteries pass harmlessly through the gastrointestinal tract.36 This is because they were too small to become lodged within the esophagus. However, this changed over the past decade coincident with the increased prevalence of larger lithium button batteries. They are more powerful than their predecessors (3.0 vs. 1.5 V) and are the size of coins. Not surprisingly, they have the potential to become lodged within the esophagus. The battery diameter of concern is 20 mm or greater.33 Severe and potential fatal complications of esophageal button batteries include esophageal perforation, mediastinitis, tracheal esophageal fistula, and aortic esophageal fistula resulting in exsanguination.34
A button battery lodged in the ear can result in tympanic membrane perforation or destruction, necrosis of the epidermis of the external auditory canal, hearing impairment, destruction of ossicles, and facial nerve paralysis.25Intranasal button batteries can produce chondritis, nasal septal perforation, and superficial burns of the nasal mucosa.35
The most recent guideline for the management of button battery ingestion was published in 2010.34 The key features are that all young children should have an immediate x-ray to locate the battery. If it is in the esophagus, refer for immediate endoscopic removal. If it is in the stomach, and the patient has symptoms or signs related to its presence, refer immediately for its removal. Children with symptoms and signs of an esophageal foreign body but no history of battery ingestion may nevertheless have an esophageal battery. Differentiation from an esophageal coin is based upon its radiologic appearance—the presence of a double rim or halo effect is characteristic of a battery (Fig. 11-6).
FIGURE 11-6. Button battery in the proximal esophagus of a 13-month-old boy. Note the double rim or halo effect which differentiates a battery from a coin.
A child with a button battery in his nose or external auditory canal should be immediately referred to an otolaryngologist for its removal. If its instillation was recent, for example, less than 1 to 2 hours, the emergency physician may consider an attempt of removal.
MAGNETS
Magnets have become a significant cause of foreign-body morbidity in children over the past decade.37,38 There are two scenarios, ingesting resulting in damage to the gastrointestinal tract and intranasal insertion resulting in nasal septal damage.39,40 The former is typically seen in preschoolers, whereas the latter in pre-adolescents who are using these magnets to mimic body piercing of the ear lobes, tongue, and nose. The magnets responsible for this morbidity are small rare-earth magnets also known as neodymium magnets. They are 5 to 10 times more powerful than conventional magnets. They are typically marketed as desk toys, puzzles, and stress relievers for adults. They are typically spherical and less than 1.0 cm in diameter.
Morbidity is a consequence of exposure to at least two magnets that subsequently attach to each other with intervening trapped body tissue. The trapped tissue erodes. Within the alimentary canal, magnets in adjacent intestinal loops affix to each other. The bowel wall is compressed between the magnets and the tissues become necrotic. Intestinal perforation, fistula formation, peritonitis, small bowel perforation, volvulus, massive intestinal resection resulting in short bowel syndrome and death have been reported.37,38
Nasal septal injury is typically a consequence of imitation jewelry studs that give the appearance of decorative piercing of the ala nasi. These imitation studs consist of an ornamental portion which is placed on the external surface of the nostril and a rare-earth magnet disk that is placed intranasally against the lateral wall of the nostril. If these are applied bilaterally, the inner disks can displace medially and affix together, thereby trapping nasal septum. Thus, erosion of the septum can occur within hours.3,9,40
The North American Society of Pediatric Gastroenterology, Hepatology and Nutrition has identified more than 80 patients with magnet-induced morbidity.41 Included are 39 endoscopies, 26 surgeries, 26 bowel perforations, and 3 bowel resections. They have published a management algorithm.41 Key features are to obtain an abdominal x-ray in children with a history of rare-earth magnetic ingestion. Obtain a lateral view if present to ascertain whether there is more than one magnet. If a single magnet is present, discharge the patient and counsel parents to ensure no further contact with additional magnets or small metallic foreign bodies including clothes with metallic buttons or ornaments. Consider serial x-rays to document passage. If multiple magnets have been ingested, immediate referral is indicated. Refer for endoscopy if in the stomach and to a surgeon if in the intestines.
For patients with magnets in both nostrils, removal can be quite difficult. One report suggests using a hook fashioned from a nonferromagnetic blunt probe.42 If unsuccessful, immediately refer to an otolaryngologist.
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