An approach to the diagnosis and management of FB throat.

1. Removal of Foreign Body from
Aerodigestive Tract
Dr. Basit Ali khan
House officer, ENT dep, HFH.

2.  Though medical recorded histories are
not available, FB in ENT are as old as
mankind.
 The well known Greek fabulist Aesop
(560 BC) tells the story of a wolf with
an impacted bone which was skillfully
removed by a crane.

3. FACT!
 According to the American Academy of Pediatrics (AAP), one child dies
every five days from choking on food, making it the leading cause of
death in children ages 14 and under.

4. Case 1
 A 39-year-old male presented to OPD with a 9-year history of intermittent
odynophagia and hoarseness, associated with noisy breathing. He recalled that
his symptoms began in a certain day after work; however, he did not seek
medical attention. He presented in the OPD 9 years later with mild biphasic
stridor and IDL revealed a subglottic proliferative growth.
 X-ray neck lateral view revealed a subglottic narrowing at C6-C7 level.
 CT neck showed a circumferential wall thickening involving the subglottic
region and adjoining trachea.

5. Case 1
 A working diagnosis of subglottic growth/idiopathic subglottic stenosis was
made.
 Tracheostomy was done prior to examination under anesthesia. A zero degree
telescopic assessment of the larynx was done and a single tablet foil was noted
at the level of the first and the second tracheal ring surrounded by thick
granulation tissue.
 The foil was removed and the adjacent granulation tissue was excised by cold
steel excision. Histopathology of the granulation tissue revealed fibro
collagenous tissue.
Ref: Philip A, Rajan Sundaresan V, George P, et al. A reclusive foreign body in the airway: a case report and a
literature review. Case Rep Otolaryngol. 2013;2013:347325. doi:10.1155/2013/347325

6. Case 2
 A 7 years old boy, presented in OPD with recurrent unresolved pneumonia.
Due to the long history of the patient and abnormal X-ray findings (not
shown) CT was requested.
 CT revealed a partially calcified mass at the region of right hilum, causing
complete obstruction of bronchus intermedius and subsequent collapse of
right middle and lower lobes
 The possibility of tuberculous lymphadenopathy was considered; but all
laboratory investigations for TB were negative.

7. Case 2
 Rigid Bronchoscopy revealed a localized, vascular, easily bleeding, non
infiltrating mass lesion occluding the bronchius intermedius. A biopsy was
taken from this mass.
 The result of biopsy revealed inflammatory granulation tissue.
 This is at that time that the patient’s father revealed a history of aspiration of
a crackable plant seed wherein the boy suffered severe chocking before
aspirating this seed.
Ref: Bahnassy AA, Diab AB. Neglected bronchial foreign body in a child simulating a calcified
mass lesion: challenging computed tomography diagnosis. Int J Health Sci (Qassim).
2007;1(1):107‐109.

8. Foreign body
Aspiration

9. Foreign body Aspiration
 More common in children below 5 years.
 A foreign body aspirated into air passage can lodge in the:
 larynx,
 trachea or
 Bronchi ( rt. main bronchus is the commonest)

10. Etiology
1. Children:
• Poor airway reflexes
• Lack of Molar teeth ,poor mastication
• Natural tendency to put objects in mouth.
2. Repeated aspiration may suggest neglect
3. Failure of protective mechanisms during coma, deep sleep or
alcoholic intoxication.

11. Types of foreign Body
 Nonirritating type.
• Plastic, glass or metallic foreign bodies
 Irritating type.
• Organic FB like Vegetables, peanuts, beans, seeds, etc.
• Congestion and oedema of the tracheobronchial mucosa—
“vegetal bronchitis.”
• They also swell up with time causing airway obstruction and
later suppuration in the lung.

12. Clinical features
 Initial Period of choking, gagging and wheezing.
 Symptomless interval:
 Varies with the nature and size of the FB.
 Later symptoms due to airway obstruction

13. Clinical features

14. Clinical features
Acute aspiration Chronic aspiration
Neck/throat pain Fever
Choking Persistent cough
Cough Hemoptysis
Stridor Dyspnea
Dyspnea Wheezing
Wheezing Asymmetric lung
sounds

15. Diagnosis/ clinical assessment
1. History
• Circumstances of ingestion,
• The related symptoms,
• The size, shape and nature of the FB must be investigated.
2. Examination
• Look for the signs of FB aspiration.
• Examination of chest esp. auscultation.

16. Investigations
 X-ray Neck and Chest
 PA and Lateral Views
 Inspiratory and expiratory films
 To investigate the indirect signs of a radiolucent object: during inspiration a reduced air
entry in the affected lung with deviation of the mediastinum towards the ipsilateral side. In
the expiratory phase, the air emission from the obstructed lung is reduced, giving rise to
obstructive emphysema (so-called “air trapping”) in this case the mediastinum is shifted
towards the contralateral side

17. Investigations
 Atelectasis (complete obstruction by foreign body).
 Pneumomediastinum or pneumothorax.
 Pneumonitis/bronchiectasis
 Fluoroscopy/videofluoroscopy.
 Radiolucent FB
 CT chest.

18. FB in rt. main bronchus.

20. Management
 Laryngeal foreign body

22. Management
 Cricothyrotomy or emergency tracheostomy
 Once acute respiratory emergency is over, foreign body can be
removed by D/L or by laryngofissure, if impacted

23. Management
 Tracheal and bronchial foreign bodies
 Can be removed by bronchoscopy with full preparation and under
general anaesthesia.
 Emergency removal of these foreign bodies is not indicated unless
there is airway obstruction or they are of organic nature.
 A failure to perform bronchoscopy may be much more disastrous
than the risk involved in bronchoscopy (Jackson’s dictum)

25. Management
 Methods to remove tracheobronchial foreign body:
1. Conventional rigid bronchoscopy.
2. Rigid bronchoscopy with telescopic aid.
3. Bronchoscopy with C-arm fluoroscopy.
4. Use of Dormia basket or Fogarty’s balloon for rounded objects.
5. Tracheostomy first and then bronchoscopy through the tracheostome. (large
FB in sub glottis)
6. Thoracotomy and bronchotomy for peripheral foreign bodies.
7. Flexible fibreoptic bronchoscopy in selected adult patients.

26. Foreign body
ingestion

27. Foreign Body ingestion
 Etiology
1. Age.
 Children are most often affected.
2. Loss of protective mechanism.
 Loss of consciousness, epileptic seizures, deep sleep or alcoholic intoxication are other
factors.
3. Carelessness.
• Poorly prepared food, improper mastication, hasty eating and drinking.

28. Etiology
4. Narrowed oesophageal lumen.
 oesophageal stricture or carcinoma.
5. Psychotics.

29. Types of FB
 Coins: Commonest in children
 Household items, Pen cap, Small Toys
 Meat Bone: Commonest in Adults

30. Site of Lodgement
 The tonsils.
 The base of tongue/vallecula.
 Posterior pharyngeal wall
 The pyriform fossa.
 The oesophagus.

32. Site of Lodgement

33. Site of Lodgement
 Once object passes the oesophagus it is likely to pass per rectum but
sometimes it gets obstructed at pylorus, duodenum, terminal ileum,
ileocaecal junction, caecum, sigmoid colon or even at the rectum.

34. Acute chronic
Asymptomatic Fever
Neck/throat pain Emesis
Foreign body sensation Hematemesis
Choking Abdominal pain
Drooling Distention
Respiratory distress Abdominal rebound tenderness/guarding
Wheezing Hematochezia
Chest pain Failure to thrive
Emesis Weight loss
Food refusal

35. Diagnosis
 History and examination
 Xray neck and chest (PA and lateral view)

38. Management
1. Observation
 Usually for 24 hours
 Immediate presentation
 Blunt foreign body below the cricopharynx
 Pt. is Stable
 Spontaneous passage of foreign body into the stomach is expected
 If it doesn’t pass into stomach, endoscopy is done
 C/I: Disc Battery Ingestion: emergency removal

39. Management
2. Endoscopic removal
 Most of the foreign bodies in oesophagus can be removed by
oesophagoscopy under general anaesthesia.

40. 2

41. Management
3. Cervical oesophagotomy.
 Impacted foreign bodies above thoracic inlet
4. Transthoracic oesophagotomy.
 For impacted foreign bodies of thoracic oesophagus, chest is opened at the
appropriate level.

42. FB that has reached the stomach
 It may pass through rest of gastrointestinal tract without difficulty
 Stool should be examined daily.
 Patient should take a normal diet.

43. FB that has reached the stomach
 Operative interference is required when:
a) Patient complains of pain and tenderness in abdomen.
b) Foreign body is not showing any progress on periodic X-rays.
c) Objects are sharp and likely to penetrate or get obstructed, e.g. nails, pins,
needles, sharp bones.
d) Foreign body is 5 cm or longer (e.g. hair pin) in a child of 2 years; it is
unlikely to pass through turns of duodenum. A disc battery larger than 1.5
cm in a child of 6 years and remaining in stomach for 48 h.
e) There is pyloric stenosis.

44. Complications of FB inhalation
1. Respiratory obstruction.
2. Perioesophageal cellulitis and abscess.
3. Perforation..
4. Tracheo-oesophageal fistula.
5. Ulceration and stricture.

45. Don’ts of esophageal FB
 It is not recommended to remove oesophageal foreign bodies by Foley’s or
balloon catheter, as they can be aspirated when pulled up into the pharynx.
 Do not try to push foreign bodies down into the stomach .
 Use of papain, a meat tenderizer, is not recommended if a bolus of meat is
stuck up. It can digest the oesophageal wall.
 Do not use glucagon to relax lower oesophageal sphincter for foreign body to
pass. It does not relax a stricture or oesophageal ring if foreign body is held
due to that.

46. THANK YOU!