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CHAPTER 52

Aerodigestive Foreign Bodies

in Children

Neetu Kumar
Ashish Minocha
With minor contributions by
David Msuya

Introduction older children may be reluctant to divulge the initial details for fear of
Aerodigestive foreign bodies are common causes of morbidity and punishment or due to embarrassment. Such enquiries should therefore
mortality in infants and children worldwide. It is difficult to eradi- be made discreetly and tactfully.
cate the problem, as children, by nature, are curious and exploratory. Tracheobronchial foreign bodies typically present with shortness of
Possibly the only difference from one country to another is in the breath, wheezing, stridor, cough without associated illness, recurrent
nature of foreign bodies commonly encountered. It is important to or migratory pneumonias, and even acute aphonia. When the diagnosis
develop a comprehensive approach to the early recognition and timely is initially missed, children often present with recurrent respiratory
management of aspirated and ingested foreign bodies, as complica- tract infections (pneumonia, empyema, and abscess formation).
tions from delayed diagnosis can have significant health implications. Oesophageal foreign bodies typically present with odynophagia,
Serious complications from aspirated foreign bodies such as severe drooling, spitting, vomiting, or even secondary airway compromise
airway obstruction and death, tend to occur in infants and younger from foreign body impingement. Episodic vomiting may be the only
children due to the small size of their airways. presentation in some cases. 9
Chevalier Jackson’s initial description of endoscopic removal Pathophysiology
1
of foreign bodies in 1936 revolutionised the treatment options Certain characteristics can predispose children to the likelihood of an
2
for management of aerodigestive foreign bodies. Associated aerodigestive mishap. Their underdeveloped posterior dentition, along
developments in radiology have played an important role in the with their immature swallowing mechanism, is no match for their oro-
rationalised and safe management of these cases.
exploratory behaviour.
Epidemiology The process of aspiration or ingestion of foreign bodies can present
10
Foreign body ingestion and aspiration are common childhood adverse in three different stages. The first (or acute) stage characteristically
events. They form the third leading cause of death in children under involves a phase of coughing, choking, and gagging. This history is
the age of 1 year and the fourth leading cause in the age group 1–6 often easily elicited. Typically, an asymptomatic period follows the
years. The maximum prevalence is seen between the ages of 1 and 2 first phase. The diagnosis is potentially missed if the patient presents
years; however, no age group is completely immune. 3–5 during this time. The third phase is a period of chronicity characterised
Children younger than 5 years of age represent the highest risk by failure to thrive, recurrent lung infestations, wheeze, dysphagia, or
6
group. This risk is increased if the child has neurological impairment. even more severe manifestations such as intrathoracic abscesses and
Unfortunately, these children are often not viewed with a high index vascular catastrophes secondary to foreign body fistulation. 11
of suspicion when they present with nonspecific symptoms. Children Investigations
known to have congenital anatomic or physiologic abnormalities of
Nothing can substitute for a high index of clinical suspicion. However,
the oesophagus, such as diffuse oesophageal spasm, oesophageal
clinicians must understand the role and limitations of emergency radi-
atresia, and/or tracheo-oesophageal fistulas, or those who had previous 12,13
bowel surgery are at increased risk of complications. ography. Plain radiographs should be assessed in two dimensions.
Radio-opaque foreign bodies are often easily seen, but more impor-
The commonly encountered foreign bodies vary geographically.
tant is accurate anatomical localisation to assist retrieval. Follow-up
7
Coin ingestion seems to be the commonest worldwide problem.
radiographs are often essential if the preliminary studies have been
Other common nonfood items are school stationery, balloons, and
negative. If a foreign body has not been visualised in the cervical
toys. Pharyngeal fish bones are well reported from countries where
or thoracic regions, it may well have passed into the small and large
fish forms a part of the staple diet. Over the years, there has been a
bowel; such relevant body parts may also need imaging. At times,
rise in the incidence of disk-type battery ingestion in the paediatric
there are indirect signs that assist in making a diagnosis. For example,
population, which can lead to serious consequences.
8
air trapping on expiratory chest radiographs may be indicative of an
Seeds and nuts are frequent causes of tracheobronchial obstruc-
obstructing foreign body not otherwise visible. In a considerable num-
tion worldwide. Accidental aspiration of peanuts is commonly
ber of cases, plain radiography is unrevealing and secondary signs are
responsible for airway obstruction in children in Southeast Asia and
not convincing enough to make a confirmed diagnosis. Some children
Africa, and kola nuts, which are traditionally used in Africa, may
may need urgent fluoroscopy to look for “filling defects” in the diges-
be inhaled accidentally.
tive tract. 14
Clinical Presentation Bronchoscopy can be both diagnostic and therapeutic. Foreign
Children present in myriad fashions, both with typical and not so typi- bodies more distally located in the respiratory tree may warrant an
cal or convincing stories. The problem is worse when no witness is urgent bronchogram. Computed tomography (CT) and even magnetic
available or parents are unsure of the sequence of events. In addition, resonance imaging (MRI) may be employed to detect foreign bodies