FOREIGN BODY ACCIDENTS

Accidental ingestion, inhalation or aspiration of foreign bodies is the commonest accident in toddlers (1-3 years) due to their inquisitive and exploratory behavior, more common in boys (2:1).

While the list of foreign bodies is endless, ~3/4^th of them are organic (peanuts, whole grains) which are not detected on X-rays, unlike inorganic foreign bodies, e.g. coins and buttons.

Clinical presentation and complications of foreign body accidents depend on: (a) type of the body, (b) size and shape, (c) site of lodgement, and (d) duration.

Nasal foreign bodies are most common in toddlers, usually being grains or peanuts. These bodies may present immediately after lodgment with definite history or after many days with unilateral foul-smelling discharge, swelling and noisy breathing. Local trauma, aspiration and rarely tetanus are potential complications in these cases.

Most of these bodies are easily visible with a nasal speculum and may be removed by—(a) forcible blowing of the nose, (b) wet cotton bud, or (c) forceps after local xylocaine and decongestant instillation. Long-standing, sharp, embedded or posteriorly located bodies need removal by an ENT surgeon under rhinoscopic guidance, as blind attempts may push them further down with risk of aspiration.

Ear foreign bodies are common in all groups, usually being insects or left-over cotton buds. These bodies usually present after many days with earache, discharge, tragus swelling, ringing sensation or temporary deafness. Ear-drum injury/perforation and tetanus are important risks of aural foreign bodies.

Due to late presentations, these bodies may be impacted and tend to move deeper on attempted blind removal. Unless visible externally, long-standing bodies should be referred to ENT surgeon for otoscopic or surgical removal.

Pharyngeal foreign bodies are usually fish-bones, presenting with dysphagia or prickly sensation in throat.

Laryngeal foreign bodies are common cause of sudden accidental deaths in preschool children, even if very small in size due to reactive laryngospasm and edema. These cases present with sudden choking, dyspnea, stridor or croup. Whistle sign, i.e. a whistling sound on inspiration and expiration is diagnostic in laryngeal obstruction due to toy whistles—a common foreign body. Considering immediate risk of death, basic first- aid measures, e.g. Back-blows and chest thrust maneuver in infants and Heimlich maneuver in older children may be attempted, provided: (a) foreign body is witnessed or strongly suspected, (b) expert help is not immediately available (Ch 27.1). Spontaneous coughing should be encouraged. As these procedures carry risk of converting partial airway obstruction to complete block and sudden death, expert help must be sought as early as possible.

Diagnosis of laryngeal foreign body may be confirmed on direct laryngoscopy or lateral X-ray of the neck (d/d esophageal foreign body), which then can be removed by endoscopy. Tracheostomy is advisable before laryngoscopy in severe dyspneic children.

Bronchial foreign bodies may be entirely asymptomatic in early stages or present with signs of airway irritation or obstruction, e.g. cough, dyspnea, blood-streaked sputum or recurrent respiratory infections. History of foreign body inhalation is often absent. Bronchial foreign bodies are more common on right side due to straight bronchus.

Clinico-radiological signs depend on the extent of airway obstruction, with two distinct pathologies—(a) incomplete obstruction with ball-valve mechanism, leading to obstructive emphysema, and (b) complete obstruction with distal collapse.

Bronchoscopic removal with a rigid bronchoscope, followed by check X-rays is the treatment of choice in these cases.

While most collapse/emphysema improve rapidly after foreign body removal, persistent lesions may require lobectomy due to risk of recurrent infections.

Esophageal foreign bodies present with dysphagia or retrosternal pain due to esophagitis and tend to rest at one of the three sites of physiological narrowing - below the cricopharynx, at the level of aortic arch and just above the diaphragm. Preliminary diagnosis depend on history and X-ray neck/chest to visualize radio-opaque bodies.

Management of esophageal foreign body depends on its size and shape as well as clinical symptoms. Non-sharp small foreign bodies, e.g. coins, tend to pass

spontaneously, facilitated by ingestion of lubricants, e.g. banana or ghee. Esophagoscopic removal is indicated for sharp, toxic or symptomatic foreign bodies.

27.5.5