Presentation on theme: "Foreign Bodies of the Airway, Esophagus and Ear"— Presentation transcript:
1Foreign Bodies of the Airway, Esophagus and Ear Presented byNannaphat pradutdecha
2ReferencesLauren DH, Sheri AP. Foreign bodies of te airway and esophagus. Cummings otolayngology Head & neck surgery. 5th ed. Philadelphia : Elsevier, 2010 :Nancy Sculerati. Foreign body of the nose. Pediatric otolaryngology. 4th ed. Philadelphia : WB Saunders Co, 2002 :
3EpidemiologyFB result in approximately 150 deaths per year in children secondary to asphyxiation.Most deaths occur before hospital interventionMost aerodigestive foreign bodies are esophageal—85%The highest incidence occurs between 1 and 3 years of age25% of patients are younger than 1 year.
4ToddlersLack posterior dentition (molars - necessary for proper grinding of food)Less-controlled coordination of swallowing, and immaturity in laryngeal elevation and glottic closureOral exploration (age-related tendency to explore the environment by placing objects in the mouth)Easy distractibility (often running or playing at the time of ingestion)
5Epidemiology The most common esophageal FB are coins ,75% Round objects, trinkets, disk batteries, and sharp objects constitute less than 20% of impacted esophageal FBMultiple esophageal FB impactions, 80% have an esophageal anomalyRecurrent esophageal FB, 19% have esophageal anomalies that previously required surgical repair
6EpidemiologyVegetable matter is seen in 70-80% of airway FB ingestionsthe most commonpeanuts in the United Stateswatermelon seeds in Egyptpumpkin seeds in GreecePlastic pieces constitute approximately 5- 15% of airway FB -tend to remain longer because they are inert and radiolucent.
7Location Most airway FB lodged in bronchi common in the right main bronchus in adultsposition of the carina to the left of the midlinelesser angle of divergence from the tracheal axischildren : right = left main bronchi (no clear explanation)
8LocationMost esophageal FB impact in cervical esophagus just below cricopharyngeus muscleAnother 4% to 5% of esophageal foreign bodies become lodged atmidesophagusdistal esophagusoften caused by extraluminal compression --aortic arch or left main bronchus
9Figure 72-1. Schematic view of the esophagus and its relationship to neighboring structures. LES, Lower esophageal sphincter; UES, upper esophageal sphincter. (Reprinted with the permission of the Cleveland Clinic Foundation.)
10Management of choking victims Infantsrescue breaths and chest compressionsChildren > 1 yearrequire gentle abdominal thrusts while supineOlder children and adultsHeimlich maneuver(standing, sitting, or recumbent)Note : Back blows or abdominal thrusts in individuals with only partial obstructions could lead to complete obstruction and are not recommended.
12Symptoms Three clinical phases of FB aspiration Initial phase occur at the moment of during aspiration--choking, gagging, and paroxysms of coughing or airway obstructionAsymptomatic phase when FB becomes lodged, and the reflexes fatigue --choking, gagging, and coughing are subside, can last hours to weeksThird phase--complications from obstruction, erosion, or infection causes hemoptysis, pneumonia, atelectasis, abscess, or fever
13Site of the obstruction SymptomsLaryngIrregular FB or orientation in sagittal plane may produce only partial obstruction, allow air flow but laryngeal edema can lead to complete obstruction.Typical: symptoms of obstruction and hoarseness, some mimic croupTracheaTypically do not have hoarsenessThree signs associated with tracheal FB: asthmatoid wheeze, audible slap and palpable thudBronchusairway foreign bodies, 80-90% are found in the bronchiTriad of cough, wheezing, and decreased breath sounds. One large series reported that 65% have the classic triad but 95% have at least one finding.Esophagusvomiting, odynophagia, dysphagia, ptyalismA large FB may cause symptoms of airway obstruction and cough (compression or irritation of upper airway)In long-standing impaction, fever and other symptoms of respiratory infection may be present
14Daksheh H. pahrik. Paediatic thoracic surgery. P 359
15Laryngotracheal Foreign Bodies patient was taken to the operating room for bronchoscopy. At bronchoscopy, about pieces of nut particles in the lower trachea and in both major bronchi were found. They were somewhat difficult to remove because of their small size. Most were removed with grasping forceps and suction. He did well postoperatively.A 17 month old male presents to the ED in the evening with a one-hour history of noisy and abnormal breathing after a choking episode while he was eating a chocolate and almond bar. He was able to speak and drink fluids without difficulty VS T36.8, P200 (crying), R28 (crying), oxygen saturation 99% in room air. He appeared alert, with no signs of respiratory distress. He was able to speak, had no cyanosis, no drooling, and no dyspnea. His lung sounds showed mild wheezing with possible mild inspiratory stridor. An albuterol aerosol was administered but no improvement was noted. A chest radiograph was ordered
16Bronchial Foreign Bodies check-valve effect : expiration ,resulting in hyperinflation of the affected side and mediastinal shift to the opposite side
17Bronchial Foreign Bodies ball-valve effect is produced later when FB obstruct on inspiration and open on expiration, producing atelectasis on the affected side and a mediastinal shift toward the affected side
18Esophageal Foreign Bodies Food or true foreign bodiesChicken bones (opaque), fish bones (non-opaque)Coins, toy trucksMost often they impact just below cricopharyngeous (70%)Another 20% impact at the level of the aortic archAnother 10% at EG junction
19Management Airway History taking standard radiographic : posteroanterior and lateral airway and chest filmsNPO for 6 hours, and adequately hydratedAge-appropriate equipment for endoscopic foreign body removalIf a suspected esophageal foreign body is radiolucent, a barium contrast study should be avoided because it would delay endoscopy in that the patient can no longer take anything by mouth, and the foreign object may be obscured by the material swallowed
20Guidelines for Selection of Bronchoscope, Esophagoscope, and Laryngoscope for Diagnostic Endoscopy by Age
21Anesthesiaunder GA : provide optimal airway control and patient comfortmethod of evaluation and removal of FB should be communicate with anesthesiologistPatients are placed supine for mask induction using volatile inhalational agentsEye protection prevents corneal abrasionsTopically anesthetized with 1% to 4% lidocaine to inhibit laryngeal reflexes and to reduce the incidence of laryngospasm.
22Anesthesia Laryngeal FB Tracheobronchial FB removal Preoxygenated then mask inductionanesthesia is maintained with an insufflation catheter through the nares into the hypopharynxTracheobronchial FB removallaryngoscope tip is placed in the vallecula to expose the larynx for passage of the bronchoscopebreathes through bronchoscope until finish
23Anesthesia Esophageal FB patient undergoes ETT ETT prevents inadvertent aspiration of FB into the airway during attempted removalminimizes any tracheal compression caused by a rigid esophagoscope
24Technique Bronchial FB Healthy bronchus is examined first Bronchoscope is positioned above the foreign body, and secretions are gently suctioned to expose the object fullyPreoxygenated before the attempt at removalBronchoscope, forceps, FB are removed as a unitBronchoscope is returned immediately to the airway for ventilation and assessment for other FBsimultaneous biplane fluoroscopy can be used for extraction of radiopaque foreign bodies in the lung periphery
25Technique esophageal FB Esophagoscope is passed through right side of mouth and directed toward pyriform sinus, angled toward sternal notchEsophageal lumen is kept in view at all times while gently advanced until FB is visualizedFB is engaged with the forceps; esophagoscope is advanced toward the object and removed as a single unitEsophagoscope is reinserted to assess esophageal mucosa and to identify additional FB below the primary one. (Multiple foreign bodies are found in 5% of pt.)Coins generally can be removed safely with an optical forcepsthrough a rod-lens esophagoscope or with a grasping forcepsthrough an esophageal speculum.♦ Round objects generally are removed easily with the bead-graspingforceps through a Jackson esophagoscope.♦ Sharp objects are sheathed into the esophagoscope by using a graspingforceps through a rod-lens esophagoscope.♦ Jackstones are difficult to remove because of their size and sharppoints. Figure 25–21 illustrates how the sharp point is rotated intoa Jackson esophagoscope and the jackstone is removed using agrasping forceps. Mucosal tears are common and may result inpneumomediastinitis and esophageal perforation.
26Technique Removal of Sharp Objects Tip of a pointed object engages mucosa, causing point trailingSafety pins : Two methods of removal are suggested1) sheathing the point within the endoscope while locking the forceps closed to hold the keeper against the outside of the tube particularly during extraction through the larynx2) gastric version (under fluoroscopic guidance) of esophageal safety pins, using rotation forceps to flip the safety pin point down within the stomach
27Safety pins have rarely been seen at our institution during the past two decades. The original techniques described by Jackson are presentedKenny H. Chan, et al.Endoscopy of the Aerodigestive Tract. In : Bluesone CD. Surgical Atlas of Pediatric otolaryngology :581
28Technique Removal of Sharp Objects Severely impacted or embedded sharp object , open surgical approach may be the safest method of FB removalLong or large objects in children younger than 2 years may not pass through the duodenum, remove these objects from the stomach endoscopically before they migrate further or perforate a bowel wall
29Technique Disk batteries are commonly used in hearing aids, calculators, watches, and other portable electronic devicesPeak incidence of ingestion occurs at age 1 to 2 years33% of cases, the ingested battery is from the child's hearing aidMercuric oxide–containing batteries can cause systemic mercury poisoning if they open in the gastrointestinal tract
30Technique Disk batteries In 1 hour, esophageal mucosa damaged In 4 hours, leakage of caustic battery contents cause erosion muscular wall of esophagusWithin 6 or more hours, esophageal perforation leading to mediastinitis, tracheoesophageal fistula, or death may occur
31From: Foreign body of the pharynx and esophagus From: Foreign body of the pharynx and esophagus. Pediatric otolaryngology. 4th ed. Philadelphia : WB Saunders Co, 2002 : 1327
32TechniqueEsophageal PerforationCaused by the object itself, length of time that lodged, attempts to retrieve objectPreoperatively esophageal perforation may be diagnosed on preoperative radiographic, cervical subcutaneous emphysema, retroesophageal abscess or obvious extraluminal portion of the esophageal FBEarly signs of a perforation: fever + tachycardia, tachypnea, increased pain
33TechniqueEsophageal PerforationEarly recognition and management, decreased mortality rate for esophageal perforation has from 60% to 9%NPO and broad-spectrum ATB,necessary in pharyngoesophageal perforations (the most common area injured in endoscopic removal of esophageal FB)In more severe injuries, drainage, closure, or more complex surgical repairs may be necessary
34Postoperative Management After esophagoscopyNPO for 4 hoursmonitored signs of perforation: fever, tachycardia, and tachypneaATB are not routinely given unless significant esophageal injury
35Postoperative Management After bronchoscopyWhen appropriate-sized bronchoscopes are used for brief procedures, epinephrine or corticosteroids are not given.Chest physiotherapy may help to clear inspissated secretionsRoutine postoperative radiograph is unnecessary unless the patient's symptoms persist or progress.
36Postoperative Management After bronchoscopyFail extraction or incomplete, patients are rested for several days, and then returned to the OR for repeat endoscopyRecovery time of more than 1 week was associated with preoperative inflammatory findings by radiologic study, procedure time greater than 50 minutes, and worsening postoperative radiologic findings
37ComplicationsPneumonia and atelectasis are the most common complications after bronchial FB removal.Pt. usually respond to intravenous ATB and chest physiotherapyBleeding can occur because of granulation tissue or erosion into a major vesselPneumothorax and pneumomediastinum can result from an airway tear.Laryngeal inflammation and edema have decreased significantly with the use of appropriate-sized endoscopic
38ComplicationsLong-term complications : granulation tissue, stricture formation occur at site of lodgedDuring esophagoscopy, ETT may be dislodged, and the patient may have cricopharyngeal spasm, esophageal mucosal injury, or perforationAfter esophagoscopy, vomiting, aspiration, a second missed FB and fever are the most common complicationsEsophageal perforation, retroesophageal abscess, mediastinitis, and death are rare
39Controversies in Management Flexible bronchoscopic removal is not recommended, especially in small children- -poor control airway and FBImpacted esophageal FB, nasogastric tube has been proposed to push FB into stomach, blind technique may cause esophageal injury (not universally accepted)
40Controversies in Management Foley catheter removal with fluoroscopic control of blunt radiopaque esophageal FB, recommended for a single object lodged below cricopharyngeus for a short durationAdvantages : reduced cost and avoidance of general anesthesia.Disadvatage: not allow a postretrieval assessment of esophageal mucosa or identification of a nonradiopaque second FBcoin is not grasped using this technique, loss of control of coin at the level of posterior pharynx can result in an airway emergencyrisk of vomiting and aspiration with an unprotected airway, emotional traumaand (awake and restrained in a steep head- down position)
41Controversies in Management Papain (meat tenderizer) has been used in impacted esophageal meat bolusesPapain was given as a 5% solution to adult patients, with the meat passing in most instances.at least two cases of mediastinitis and death in these patients caused by necrosis of the esophagus and perforation.Glucagon produces relaxation of the smooth muscle of the esophagus, promoting passage into the stomach. One open-label study in pediatric patients failed to show a higher incidence of passage in patients who received glucagon versus placebo. Sumatriptan prolongs fundic relaxation and delays gastric emptying. Studies conducted so far have revealed an increase in the rate of gastroesophageal reflux and the number of esophageal mother waves
42Controversies in Management Flexible esophagoscopy has been used for removal of blunt objects or meat impaction. Sharp objects pose a greater risk because of inability to sheath the object as with a rigid esophagoscopeGlucagon produces relaxation of the smooth muscle of the esophagus, promoting passage into the stomach. One open-label study in pediatric patients failed to show a higher incidence of passage in patients who received glucagon versus placebo. Sumatriptan prolongs fundic relaxation and delays gastric emptying. Studies conducted so far have revealed an increase in the rate of gastroesophageal reflux and the number of esophageal mother waves
43Foreign body of the nose PresentationPersistent rhinitis, unilateral purulent rhinorrheaAdenoiditissinusitisAdult witness child putting something in nose
44Foreign body of the nose SequelaeSeeds swell when moisted by nasal secretion , Increase impact overtimeFoam rubber increase irritation with oxidation and breakdown materialPlastic or other inert material gradual formation of granulation obscure FB cause pressure erosion of surrounding boneButton batterries rapidly cause severe mucosal burn septal perforation , saddle nose deformities
45Foreign body of the nose ManagementDecongestantAnterior rhinoscope : nasal speculum, otoscopeFrazier suction tubeเตรียมRight angle hook, flexible cerumencurette and alligator forcepsRestrain or sedate or under brief GA
46Foreign body of the nose Managementใส่guazeชุบadrenaline or antibiotic oinmentให้ATBให้ยาแก้ปวด
47RhinolithFormed from intranasal FB that encrusted with mineral salt ( Calcium, Magnesium)Treatment : remove