Airway and esophageal foreign bodies: Update Course 2015
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Aerodigestive foreign bodies present training challenges due to unstandardized treatment, intersection of multiple specialties (pediatric surgery, gastroenterology, ENT), and variable equipment familiarity.
Plain radiography for airway foreign bodies is neither sensitive nor specific; hyperinflation on decubitus films may indicate foreign body but can also be mucus plug or congenital stenosis.
If clinical suspicion for airway foreign body is high, bronchoscopy is indicated even with normal or equivocal imaging.
Flexible bronchoscopy via LMA is less invasive than rigid bronchoscopy and appropriate for low-suspicion cases; if foreign body is found, can convert to rigid instrumentation.
The double-disc sign on AP radiograph (two concentric circles) is pathognomonic for button battery; lateral X-ray is not required for diagnosis.
After button battery removal from esophagus, bronchoscopy should be performed to assess for tracheal erosion before assuming the airway is intact.
Post-removal management of esophageal battery injury may include esophagography, NG tube placement, and surveillance endoscopy for stricture; steroids peri- and post-operatively may reduce airway swelling.
Endovascular repair (stent) is the treatment for aorto-enteric fistula in pediatric patients; angiography is performed first to localize the fistula.
Even if a battery reaches the stomach, esophageal evaluation (endoscopy or esophagography) may be warranted because transient esophageal lodgment can cause delayed perforation or fistula.
Once a battery is in the stomach, it is electrically shorted out and poses less immediate risk than in the esophagus.
Single magnet ingestions can be observed; the child should avoid MRI.
Multiple magnets in the stomach that are clearly joined on X-ray can be observed with serial imaging to confirm they pass as a pair.
Multiple magnets in different bowel segments (e.g., one in RUQ, one in LLQ) should be removed operatively due to risk of pressure necrosis and entero-enteric fistula.
Magnets can cause gastro-splenic flexure colonic anastomosis or duodeno-mesenteric anastomosis by eroding through bowel walls.
Foley catheter extraction of esophageal coins is performed under fluoroscopy: catheter is passed beyond the coin, balloon inflated with contrast, and coin flipped out.
Foley extraction is generally limited to coins lodged <24 hours; if duration is unknown, endoscopic retrieval in OR is preferred.
Sharp objects (e.g., safety pins) in the esophagus often flip in the stomach and pass with the sharp edge trailing; many can be observed rather than retrieved.
Post-bronchoscopy tracheal tears with persistent air leak can be managed conservatively with chest tube, selective main-stem intubation past the tear, fibrin glue, or airway stent if leak persists beyond one week.
There are tens of thousands of ED visits annually for foreign body ingestions; magnet injuries are on the rise, possibly peaking.
Peak age for foreign body ingestion is 2-3 years, due to distraction while eating, incomplete dentition, and poor swallowing coordination.
Virtual bronchoscopy by high-resolution CT is emerging for foreign body detection; it is quick but carries radiation exposure.
The 3-volt 20mm button battery is the key offender in esophageal injuries; higher voltage causes higher rates of electrochemical damage.
Esophageal tissue damage from button batteries begins within one hour; immediate retrieval is mandatory.
Aorto-esophageal fistula can occur days to weeks after button battery removal, presenting as sentinel bleed or sudden death; advanced imaging (MRI/CT) may be warranted in high-risk cases.
The negative (smaller disc) side of a button battery causes the necrosis; the outer disc with the plus sign is the positive terminal.
For button batteries that reach the stomach: AAP algorithm recommends endoscopic removal if diameter >2.5cm or length >6cm; smaller batteries can be observed.
There is a case report of a battery found in the stomach, observed, and the child later died of aorto-esophageal fistula from erosion at the lower esophageal sphincter.
Magnet ingestions have increased nine-fold in the last 10 years.
Thirty percent of coins lodged in the upper esophagus will pass spontaneously within 6-19 hours; 60% of coins in the lower esophagus will pass spontaneously.
Milwaukee Children's Hospital reported 1200 cases of esophageal coin extraction over 20 years using Foley catheter in the ED by senior residents/fellows, with high success rate, no major complications, and 10-fold cost savings vs. OR.
Rare catastrophic complications of Foley extraction include esophageal or tracheal tear, massive hemoptysis, and need for ECMO.
Alabama and Indiana groups implemented level-1 trauma activation protocol for button battery ingestions, reducing door-to-OR time from 3 hours to 30 minutes.