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Aerodigestive Tract Foreign Bodies

Overview
Foreign body (FB) impaction or aspiration requiring otolaryngology consultation is most common in the pediatric age group and most frequently involves organic material in the airway and inorganic material in esophageal impactions. All cases require airway evaluation for patency as FBs can lodge in the pharynx or larynx, and esophageal FBs can illicit pressure and edema that encroach on the posterior trachea leading to airway obstruction, or even erosion into the airway. Furthermore, a co-existing airway FB is not uncommon in the setting of a seemingly isolated esophageal FB. Most aspiration events lodge the aspirated material in the primary bronchi (R>L) unless they are larger in size and obstruct more proximally in the trachea or upper airway. After removal of the FB, checking for a second FB or secondary aerodigestive injury is one of the most important steps in these patients.

Foreign bodies of the aerodigestive tract are a relatively common otolaryngology consult request. Consider these by the suspected site afflicted: oral cavity, oropharynx, base of tongue, vallecula, glottis, piriform sinus, subglottis/trachea, lower airway, and esophagus. A thorough history, that explores the mechanism and nature of the FB is important in these cases. If the patient or family member can provide an identical item for study, that can be helpful in instrument selection for removal. Diagnosis is primarily clinical; however, radiographs should be obtained if the patient is clinically stable as they may help localize the FB even if it is radiolucent. In many cases the FB may be radiopaque (e.g., coin, watch battery, chicken bone); however, a “negative scan” does not rule out the presence of a FB since radiolucent material may be missed. It is also prudent to look for indirect signs of FB including unilateral lung hyperinflation, atelectasis, focal consolidation, surrounding edema, or air in soft tissue surrounding the esophagus or trachea. Persistent sensation of a FB that is not visualized by viewing the surface of the mucosa may require a CT scan to evaluate for embedded fish bone, glass, etc.; this sensation may persist even after the FB migrates or is removed. More proximal foreign bodies in the cooperative older patient may be managed in the ER setting; however, those near or below the glottis or at or below the cricopharyngeus will likely require treatment in the operating room setting.

Key Supplies for Aerodigestive Tract Consultation

  • Appropriate PPE including masks, eye protection, gloves, gown

  • Headlight

  • Rigid or flexible endoscope and tower for recording

  • If available, flexible bronchoscope with grasping instruments

  • Antifog (FRED) solution

  • Yankauer suction

  • McGIll forceps, carmalt, curved Kelly clamp

  • Topical anesthetic spray (e.g., Oxymetazoline/lidocaine spray)

  • Ensure airway cart is immediately available with supplies for bag valve mask, and surgical airway

Management By Subsites

  • Oral Cavity/Oropharynx

    • Oral cavity and oropharynx FBs are often successfully removed by the patient prior to presentation or by the ER provider. In some cases, focal mucosal injury from a prior FB that has since migrated distally or has been expelled may induce symptoms that make the patient and provider concerned that it is still present. Small and sharp items, such as fish bones, may also firmly lodge in the oral cavity or oropharynx mucosa making them difficult to immediately visualize. Common areas of the oral cavity and oropharynx that are not easily visualized by other providers include the retromolar trigone, tonsillar fossa, glossotonsillar sulcus, posterior pharyngeal wall, and tongue base/ vallecula. In these areas, it is important to examine the painful area as well as the opposing mucosal surface for a potential FB. Occasionally, the FB will be on the opposite surface from where the patient is experiencing pain. Loupes can be useful to visualize small, difficult to see items, and reflections from a headlight may indicate the location of small FBs.

  • Tongue base/Vallecula

    • Foreign bodies at the base of tongue/vallecula can sometimes be taken care of in the ED (patient tolerance dependent, with great care not to dislodge more distally); however more distal FBs require operative intervention. Mucosal irritation can sometimes be mistaken for a FB up to 72 hours after injury; however, in all cases a FB must be ruled out. Fish bones, toothpicks, wire brush bristles etc. are very common FBs at the tongue base/vallecula. The vallecula is optimally visualized by having the patient maximally protrude the tongue while using a flexible nasopharyngoscope through the nose. “Helping” the patient by gently pulling their tongue forward with gauze may enhance visualization. Depending on the patient’s anatomy, you can also assess the tongue base and vallecula transorally with a good headlight, or more commonly use a flexible scope either through nose or mouth. One to 2 puffs of hurricane spray can help with patient tolerance, but remember it can cause methemoglobinemia! If there is no concern for airway distress, a lidocaine nebulizer can also be very effective at topically anesthetizing the upper aerodigestive tract to allow for good examination and FB removal, especially in patients with a strong gag reflex. Foreign bodies that are easily accessible in the tolerant adult patient may be removed in the ER setting; however, adults who are not tolerant of examination and instrumentation, or when concern for impending airway compromise is present, management in the OR setting is recommended. A portable rigid scope or taping a flexible scope to the McGill forceps can be helpful to both visualize and grasp the FB.  For children, OR removal is strongly recommended. For all patients, avoid use of blind finger sweep as FBs can be pushed distally, and because sharp edges may injure you.

  • Piriform Sinus/Supraglottis/Glottis/Subglottis/Trachea/Bronchi

    • Foreign bodies located more distally are more difficult for the patient to localize, are more challenging to visualize with awake endoscopy, and are more concerning from an airway perspective. Cases of suspected or confirmed FBs involving the supraglottis, glottis, subglottis, or trachea generally require acute intervention. In the stable patient, AP and lateral neck and chest x-rays may be very useful to help localize the FB. In many cases, flexible nasopharyngoscopy can visualize a FB involving the hypopharynx, glottis, immediate subglottis or esophageal introitus; however, removal in the ER is difficult and the likelihood that the FB could be dislodged and move distally is high with manipulation and therefore is generally not advisable. For smaller, biodegradable FBs in adults, time and plenty of fluids may dislodge the FB and the patient will swallow it. For larger (or compositionally harmful) FBs, you will likely have to take the patient to the OR. Contact your senior resident, the attending on call, OR staff, and Anesthesia team as quickly as possible. Regardless of whether an object is visualized on plain film or endoscopy, stories concerning for FB aspiration in children necessitate an examination in the OR. Assessing these patients quickly when consulted is highly important, as clinical status can rapidly change if the object is obstructing the airway or changes position to cause more complete airway obstruction.

Operating Room Setup
No matter if a child or adult, when proceeding to the operating room for airway examination and potential FB removal, it is important to ensure that you are setup with all supplies needed to ventilate, expose, examine, and retrieve the FB, prior to starting the case. When contacting the OR, communicate that you will be performing a microlaryngoscopy, rigid bronchoscopy, esophagoscopy, retrieval FB, proceed as indicated. If there is a possibility that the FB has fragmented, you should also request a flexible bronchoscope to allow inspection of the more distal airways. Depending on the clinical status of the patient, you may want to have a tracheostomy tray in the room as well. You will need your institution’s airway/microlaryngoscopy/laryngoscopy cart or instrument pans, appropriate laryngoscopes, the endoscopy tower, topical lidocaine, the 0-degree 4mm Hopkins rod telescope, the McGill forceps, a range of age appropriate bronchoscopes and esophagoscopes (chart below), the FB graspers, the peanut graspers, the coin graspers, suction etc. If the patient is an infant, consider having tracheoscopes available as well. Have suspension ready if the FB is at or above the glottis. Make sure that you check the lenses and light prisms in essentially everything that has a lens to ensure nothing is broken before you need it, and do not forget to focus and white balance your scopes. Make sure your telescopes, suctions, FB instruments, and bronchoscopes match in terms of length and diameter. Keep in mind that bronchoscope/tracheoscope must be size 3.5 or larger to fit FB forceps. If the child is too small to use a 3.5 rigid scope, consider using the laryngoscope and optical FB instruments by themselves. Ensure accordion ventilation connectors are available for the bronchoscope. Make sure to communicate with the Anesthesia team that the patient’s respiratory status could change quickly and dramatically and ask them to keep the patient breathing spontaneously and to avoid paralysis. Discuss timing of IV access, communicate that the Otolaryngology team will be managing the airway and again, ensure that you are setup with all supplies needed to expose, examine, ventilate, and retrieve the FB, prior to starting the case.  It is helpful to run through the case in your head, imagining all the instruments and tools you will need, verifying that you have them in working order before the case. Calculate max lidocaine dosage and inform the circulating nurse and surgical tech of this volume, as well as recording it somewhere in the OR. If you are confident the FB is esophageal, discuss with the anesthesiology team the option to intubate before retrieving the FB.

Bronch-Esophagoscope+size+chart.jpg

Table 1. Age Appropriate Bronchoscope/Esophagoscope Sizing (individualized patient sizing must be considered)

Operative Procedure

  • Patient masked down by anesthesia and handed off to Otolaryngology team, bed generally turned 90 degrees. IV access either before or after mask induction depending on preop discussion

  • Size appropriate Phillips, MAC, Miller blade or Parsons laryngoscope used to visualize pharynx, larynx, esophageal inlet with tooth guard

  • Many foreign bodies will lodge post cricoid and can be removed with McGill’s at this point

  • Anesthetize glottis with topical lidocaine

  • Pause to allow for lidocaine to take effect, mask ventilate

  • Re-expose larynx, advance rigid bronch through cords with care to avoid injury to vocal cords. Remove laryngoscope once rigid bronch is through the cords. Connect circuit to bronch, can provide some ventilation during exam

  • Can also place small cuffless ETT transnasally or transorally, positioned just above glottis to aid in oxygenation. This will not be useful once the bronchoscope is through the cords

  • Examine subglottis, trachea, carina, and as far into bronchi as safely possible. If FB is visualized, record images, and prepare optical forceps to retrieve object. Turn the head to the right to visualize the left mainstem,and vice versa

  • With the appropriate optical forceps (peanut, coin, etc.), the object is grasped and the entire rigid bronchoscope, forceps, object are removed as a single unit

  • After removal, examine for a “second FB” in the trachea/bronchi and entire esophagus, suction any secretions/blood, look for any aerodigestive tract injuries secondary to the FB or its removal, and record images of the airway and esophagus

Esophageal Foreign Bodies
As a general rule, non-food FBs located in the proximal esophagus are frequently managed by Otolaryngology while food boluses impacted in the esophagus are generally treated by GI unless there are airway issues; however, this division of labor varies by institution. For FBs that are located in the esophagus, make sure to evaluate for airway symptoms, as anterior pressure on the trachea and associated edema can cause airway issues. As alluded to earlier, a second FB is also possible. Radiographs are particularly important for esophageal FBs. In children, esophageal FBs are frequently inorganic objects (e.g., coins) and usually no underlying esophageal dysfunction is present. Common locations for the FB to come to rest include at or just below the cricopharyngeus, at the aortic arch, at the level of the left mainstem bronchus, and at the lower esophageal sphincter. It is particularly important to evaluate for possible signs of disk battery ingestion. In contrast to coins, a disc battery will have a “step off” sign on lateral projection and “halo” sign on AP that generally indicates a button battery. Button battery ingestion is considered an operative emergency and generally requires expeditious removal, as coagulative necrosis begins soon after mucosal contact.  

In contrast to children, adult esophageal FBs are more likely to be food matter and are more likely to occur in the setting of anatomic abnormality or dysmotility that makes the patient susceptible. In both age groups, the cervical esophagus just distal to the cricopharyngeus muscle is the most common location for the object to become lodged; however, the compression site of the aorta and left main bronchus are all possible locations. Sharp objects such as animal bones and safety pins represent unique situations where timely treatment and removal can prevent serious morbidity. Finally, if there is concern for esophageal perforation, appropriate antibiotics, serial chest films, possible water-soluble oral contrast study, thoracic surgery consult, CT scan of the chest, and early intervention are generally necessary.

Operating Room Setup
Essentially the same as above, with the addition of rigid esophagoscopes, which are necessary for FB removal beyond the CP muscle.

Operative Procedure
If a known proximal esophageal FB is present, this is addressed in the same fashion as an airway FB, with attention on the proximal esophagus upon initial exposure. If the location of the object is unknown, it is prudent to first examine the airway thoroughly. This not only allows for airway FBs to be addressed first, but often, the patient can be intubated after the airway is cleared and focus is turned to the esophagus.

Example Operative Note
Direct Laryngoscopy/Esophagoscopy with Foreign Body Removal

PREOPERATIVE DIAGNOSIS: ___
POSTOPERATIVE DIAGNOSIS: ___
PROCEDURE: ___
SURGEON: ___
ASSISTANT: ___
ANESTHESIA: ___ (e.g. GETA, general mask, local)
ESTIMATED BLOOD LOSS: ___
SPECIMENS: ___
INDICATION: ___
KEY FINDINGS: ___
COMPLICATIONS: ___

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. The patient was induced with inhaled anesthetic, remained spontaneously breathing, paralysis was avoided, and mask ventilation was conducted easily.  The patient was then rotated 90° for direct laryngoscopy. A Dedo laryngoscope was used to perform a standard direct laryngoscopy, taking care to avoid damage to the teeth, lips, and gums. The patient's bilateral tonsils, tongue, and the remainder of the oral cavity exam were normal. The supraglottic and glottic structures were visualized with a grade 1 view with no evidence of damage or foreign body presence. The vocal cords were anesthetized with __cc of 1% lidocaine. An uncuffed endotracheal tube was inserted through the nose, positioned above the glottis, and connected to oxygen. The rigid bronchoscope was introduced and brought through the vocal cords. The immediate subglottis and trachea were without lesion and normal in appearance. The carina and the primary bronchi were also well appearing, and no foreign body was identified in the visualized airway. At this time, the patient was intubated with a cuffed/uncuffed ___ ETT. Attention was then turned to the esophagus where, after examination of the upper esophagus with a rigid cervical esophagoscope, a fish bone was noted lodged in the inferior portion of the cricopharyngeus muscle/upper esophagus. The bone was removed with graspers with minimal bleeding. The esophagus was inspected distally to the lower esophageal sphincter with a thoracic esophagoscope following removal with no additional foreign bodies visualized and no additional damage. The esophagoscope was withdrawn atraumatically. This marked the end of the procedure.  The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.


Button Batteries

Overview
Button or disk battery ingestion or intranasal placement occurs most commonly in toddlers and most commonly involves hearing aid batteries or toy batteries. Smaller hearing aid batteries often pass through the gastrointestinal tract without causing substantial damage due to their small size. Larger disk batteries on the other hand, most commonly become lodged in the upper cervical esophagus. Severe mucosal damage can occur in as little as 1 hour and esophageal perforation in as little at 6 hours with potentially fatal sequelae. Erosion adjacent to major vessels such as the aortic arch may also lead to fatal aorto-enteric fistulae. Identification and localization can usually be achieved with plain film radiography and differentiated from coins by carefully looking for a subtle step off on lateral view or potentially a double-ring or halo sign on AP, reflecting the battery’s bilaminar construction. The damage from a battery is due primarily to electrical discharge and the formation of a basic environment around the anode. Spent or “dead” batteries still frequently retain enough charge to cause electrical damage and independently can cause pressure necrosis, mercury poisoning, or leakage of alkaline contents leading to a liquefactive necrosis in the gastrointestinal system. Current evidence suggests that ingestion of honey or sucralfate in the field may buffer the battery and reduce injury. Intraoperatively, the site should be copiously irrigated with dilute acetic acid. Battery ingestions should be reported to the National Battery Ingestion Hotline at 800-498-8666.

References

  1. Schoem SR, Rosbe KW, Bearelly S. Aerodigestive Foreign Bodies and Caustic Ingestions. In P.W. Flint, et al (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 3184-3194). Philadelphia, PA: Elsevier

  2. Cohen S, Avital, A, Godfrey S, Gross M, Kerem E, Springer C. Suspected foreign body inhalation in children: what are the indications for bronchoscopy?. J Pediatr. 2009;155(2):276-280. doi:10.1016/j.jpeds.2009.02.04

  3. Fidkowski, CW, Zheng H, Firth PG. The anesthetic considerations of tracheobronchial foreign bodies in children: a literature review of 12,979 cases. Anesth Analg. 2010;111(4):1016-1025. doi:10.1213/ANE.0b013e3181ef3e9c

  4. Kimball SJ, Park AH, Rollins MD 2nd, Grimmer JF, Muntz H. A review of esophageal disc battery ingestions and a protocol for management. Arch Otolaryngol Head Neck Surg. 2010;136(9):866-871. doi:10.1001/archoto.2010.146

  5. Lerner DG, Brumbaugh D, Lightdae JR, Jatana KR, Jacobs IN, Mamula P. Mitigating risks of swallowed button batteries: new strategies before and after removal. J Pediatr Gastroenterol Nutr. 2020;70(5): 542-546.