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330 Aerodigestive Foreign Bodies in Children

that are not found during endoscopic examination or if migration from
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the airway or oesophagus is suspected.
Management
“Prevention is better than cure”—this proverb holds utmost convic-
tion when it comes to aerodigestive foreign bodies in children. Public
awareness and education are key elements to help foster a culture of
preventive medicine.
In the emergent situation, paediatric life-support algorithms should
be employed in a conscious child presenting with known foreign body
airway obstruction. This involves voluntary coughing in older children
and back blows between the shoulder blades in infants to dislodge
the impacted foreign body. Crucial steps in acute management are the
ABCs: optimisation of Airway, Breathing, and Circulation.
For both tracheobronchial and oesophageal foreign bodies, the
definitive and safest treatment option is endoscopic retrieval under
general anaesthesia. In a few cases, however, a more proximal
foreign body may be removed under local anaesthesia. Risks and
complications (aspiration) due to accidental dislodgement must be
carefully considered before such an undertaking, though.
Some centres have reported success in the retrieval of smooth foreign
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bodies of the airway by using guide wire and angioplasty catheters.
The successful use of a Foley catheter with balloon inflation, with or
without fluoroscopic guidance, to retrieve an oesophageal foreign body
such as a coin, has been reported in older literature and is still practiced
successfully with minimal morbidity in countries where endoscopic
facilities may not be readily available.
Timing of an endoscopy is crucial. It may be required urgently in
Figure 52.1: A retained pen in the stomach. There was no change in the position
the following situations: (1) any suggestion of airway compromise, of the foreign body on a chest radiograph, 10 days after accidental ingestion.
(2) a history of aspiration of dried peas or beans because they have a
hygroscopic potential to swell up and block distal airways, (3) batteries
impacted in the oesophagus because they can cause early caustic
mucosal damage and even perforation, and (4) any suggestions of
oesophageal perforation. 17,18
The success of intervention depends on the experience and skill of
the endoscopist and the local availability of the optimal instruments.
The bronchoscope or oesophagoscope should be carefully sized to the
predicted size of the child’s airway/oesophagus and the foreign body.
Foreign bodies impacted in the pharynx/upper airway are usually
visible during intubation and may be taken out by an anaesthetist using
a Magill’s forceps.
A rigid bronchoscope can be successfully used for removal of
foreign bodies from the trachea or one of the main bronchi. Once
the foreign body is localised, appropriate suction is introduced and
grasping forceps help to engage the body. The endoscope is advanced
to cover the object completely. The endoscope, forceps, and foreign
body are then removed simultaneously. Good anaesthetic support
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is a must for success. More distal foreign bodies need retrieval by
flexible bronchoscopy.
Figure 52.2: The protective sheath through which the different sizes of
Oesophageal foreign bodies are best retrieved by rigid
oesophagoscopy. The same principles as for a flexible broncoscopy endoscopes can be easily guided. Preplacement of the protective sheath
protects the oesophagus from accidental damage during retrieval of a sharp or
apply. Occasionally, if the retrieval looks challenging and the type of pointed object.
foreign body is definitely known to be inert, it may be pushed further
into the stomach. This avoids the risks of aspiration and dislodgement.
Nature can then be allowed to take its course. Disk batteries stuck
in the oesophagus could cause serious harm and should be retrieved
endoscopically as a matter of urgency.
Foreign bodies in the stomach and bowel usually do not need
taking out unless they are harmful (e.g., sharp objects, batteries that
have shown no progression beyond the stomach over a 48-hour period,
or toxic foreign bodies). Long foreign bodies (>6 cm), such as tooth
brushes and pens, and wide foreign bodies (> 2 cm), such as some toys,
are also likely to remain stuck in the stomach. Ingestion of more than
one magnet has been reported to cause necrosis of the intestine trapped