foreign bodies in aero-digestive tracts

13/04/23Prof. Abdulsalam Y Taha1

Let me take you all to your childhood. I am sure you must have heard the story

of snow white and seven dwarfs,

in which an apple piece lodges in the throat of princess due to the evil works of the witch, and princess comes back to

life only when that apple piece is dislodged from the throat by the prince.

I think that if that prince wouldn’t have been a prince, he would definitely have

been a very good bronchoscopist .

Foreign Bodies in Aero-digestive Tract

Foreign Bodies in the Airo-Foreign Bodies in the Airo-Digestive TractDigestive Tract

ByBy Prof. Abdulsalam Y TahaProf. Abdulsalam Y Taha

https://sulaimaniu.academia.edu/AbdulsalamTaha

•Unit of Thoracic SurgeryUnit of Thoracic Surgery•Sulaimania Teaching HospitalSulaimania Teaching Hospital


https://sulaimaniu.academia.edu/AbdulsalamTaha

NOTE!

• I have presented this lecture at October 7th 2004 in the Ministry of Health/ lecture hall few months after establishment of our Broncho-Esophagoscopy Unit in Sulaimania Teaching Hospital/Sulaimania/Region of Kurdistan/Iraq. It has, therefore, both a scientific and historical values.

13/04/233 Prof. Abdulsalam Y Taha

INTRODUCTIONThoracic and cardiovascular surgical department in Suleimani Teaching Hospital is about to complete its first year. Thus it is in its infancy.However, it has become one of the very active and busy departments inthe hospital.

Our bronchoscopy unit began in December 2003.

By now, more than 125 flexible bronchoscopies and more than 60 rigidBronchoscopies and oesophagoscopies have been performed for differentindications.

We have faced many difficulties to obtain the necessary instruments forpaediatric bronchoscopy .

Once these equipments were obtained, paediatric bronchoscopy and oesophagoscopy began in May 2004.


Patients (children and adults) were referredto our unit with aspirated or ingested foreignbodies.

Over 4 month period at least 40 patients withdifferent foreign bodies were managed in ourunit with excellent outcome.

Many patients unfortunately were not registeredas they returned back to their referring doctorafter endoscopy.

In this seminar, some of these cases will bepresented for the sake of demonstration.


Males 17Females 12Children 28< 1 year 9 1- 5 year 14 6 year and above 5 Adult (50 year old) 1Positive bronchoscopy 18Negative bronchoscopy 11Site of ImpactionLarynx 1Trachea 2Right bronchial tree 9Left bronchial tree 6Type of FBPeanut 5Watermelon seed 5Rubber piece 1Sunflower seed 5Denture 1Plastic whitsel 1Duration of InhalationFew hours 1Few days 7Weeks to months 10Outcome ExcellentTotal 29

AspiratedForeignBodies


Foreign Bodies in Oesophagus Males 13Females 4Adults 12Children 5 Positive oesophagoscopy 11Negative oesophagoscopy 6Site of ImpactionHypopharynx 1Upper oesophagus 8Mid- thoracic oesophagus 1Lower thoracic oesophagus 1Type of FBMetalic 4Bone 4Meat 1Denture 1Plastic material 1 Total 17Outcome Excellent


Arrangements should be made for early removal in OT as edema and mucosal swelling will make retrieval more difficult. As is often the case in medicine, the decision to use flexible or rigid

instrumentation depends on a variety of things including the availability of equipment, experience of personnel, the age and medical status of the child, nature of the object and length of time since

impaction. Ideally, a coordinated team of surgeons and physicians trained in both rigid and flexible endoscopy, who can perform the removal the foreign body in one procedure should undertake this

work.


• For removal of foreign body with fibreoptic bronchoscope, a fogarty balloon catheter can be used. This is a schematic drawing showing the fogarty catheter passing through a hole in the foreign body.Once it passes through the fb, the balloon is inflated and the foreign body is then dragged out.


• Flexible bronchoscopic view of a large foreign body (mini light bulb lodged in the right main bronchus of a 7-year-old boy (left, A).

• The ureteral stone basket inserted through the 1.2-mm working channel of the bronchoscope has grasped the foreign body (right, B),

• Proximal portion of the foreign body is pulled in to distal end of the endotracheal tube by the flexible bronchoscope (right, C).

• Once the foreign body is thus secured,the entire apparatus (endotracheal tube, flexible bronchoscope, and basket with the foreign body in it) is removed en masse from the airways.


• The flexible bronchoscope is introduced through an aid adapter and a laryngeal mask airway. Forceps are introduced through the flexible bronchoscope channel. The ambu bag supplied with oxygen, helps ventilate the patient during the procedure.


• The newer optical grabbing forceps contain an integrated telescope and can be passed through most rigid ventilating bronchoscopes (size 3.5 & above). They give a supeb view of trachea and the main stem bronchi. This enables the operator to grasp an object such as a peanut under direct vision. These optical instruments will make the management of tracheobronchial foreign bodies much easier and safer, although presently very few institutions have this instrument.


M. N. F. A 78 YR EDENTULOUS MAN


A MAN OF 35


A BOY OF 17 MONTHS


D.Y.K: two and a half yr old boyIngestion of metallic foreign body


A. M. H. A BOY OF 2


M. F. AN EDENTULOUS MAN OF 82: INGESTION OF A BIG MEAT BOLOUS


A TEENAGER INJESTED A BONE BUT REFUSED OESOPHAGOSCOPY


AN EDENTULOUS LADY OF 70: SUSPISION OF CHICKEN BONE INJESTION.


A GIRL OF 17 COMMITTED A SUCIDE BY INGESTION OF 7 RAZORS !


One and a half yr old boy with respiratory distress


Pectus Excavatum


19 months old girl with aspirated sunflower seed


A 2 yr old boy: watermelon seed inhalation of few days duration


A 4 yr old boy suspected to have aspirated FB


A five and a half yr old boy: non-resolved coughof 40 days duration


19 months old girl


A. A: a 20 months oldgirl with RLL atelectasis due to

aspirated sunflower seed of 2 m duration


Post-bronchoscopy chest radiograph


A. M: a 50 yr old man

with intra-laryngeal denture


Shuaib 4 yr old boy: ingestion of a metallic spring



A 24 days old neonate!

Normal CT

HRCT

Reconstruction

Virtual ScopyIf x ray is unsuccessful in localizing the FB, and FB is strongly suspected, next option is computed tomography. Today Ct offers not only the option of normal and high resolution CT, but also of 2D reconstruction and virtual scopy.


These are photographs of 2D CT

reconstruction. Altough these

particular photographs are not of FB

obstruction, but they do clearly show, how clearly this technique

can localize any obstruction in normal

airway.


These are the photographs of Virtual imaging or virtual endoscopy. In this images

of all 3 dimensions are combines with a computer

software and is used to create 3 D images similar

to actual endoscopy. Advantage is that not only

it is non invasive but ou can actually naviagate or

do scopy beyoynd the actual obstruction as well.

In this lower image you can easily see the c shaped tracheal rings and distal

carina


Next among the investigations is MRI.

Can give better sequences especially

in relation to radiolucent and vegetative Fbs.

Also useful for better characterization of lesions resulting as

long term sequelae of fb obstruction.


Aspirated and ingested foreign bodies representan emergency. The diagnosis depends mainly onclinical grounds, supplemented sometimes by ra-

Iological examinations (plain chest radiograph orBarium swallow occasionally.(

Varieties of vegetable and non-vegetable foreign bodies are encountered. Edentulous people withpartial dentures frequently present with ingestionof either their dentures or food- related articles like bones or meat.

Long- standing cases of aspirated foreign bodiesare frequently encountered. Family negligence orfear from bronchoscopy as well as physician un-awareness are responsible for late presentation.


The problem of foreign bodies in the oesophagus differs from that of foreign bodies further down in the GIT. The oesophagus is a rather passive and inadaptable organ and its peristalsis is not strong enough to prevent its retaining swallowed objects of many kinds. For the same reason, perforation from a foreign body is more likely to occur in the oesophagus than in the rest of the GIT.

A foreign body which has become arrested in the oesophagus should be removed as soon as the diagnosis is made for the following reasons:Once an object is impacted in the oesophagus the chance of spontaneous passage is small.

Oedema from local trauma tends to grip the object more firmly making later manipulation increasingly difficult.

Perforation of the oesophagus is much more serious and dangerous than perforation of any other part of the GIT.


This is an opportunity to inform the medicalsociety in this city that ingested and aspiratedforeign bodies can be safely managed in ourbronchoscopy unit.

Clinical awareness is the key to make a diagno-sis. Non-resolved cough in a child should raisesuspicion of foreign body inhalation.

Normal chest radiograph does not exclude thediagnosis .


Careful history may help to distinguish foreignbody aspiration from inflammatory conditionsLike croup or congenital disorders like laryngo-malacia or tracheo-malacia. However, the differ-entiation may be sometimes impossible. Then,bronchoscopy is the only way of diagnosis.

In cases of definite foreign body aspiration,bronchoscopy is curative; the child can go home the same day. If the foreign body is long-standing, a period of antibiotic therapy is needed.

Tracheostomy may be needed after removal offoreign body. Increasing strider due to laryngeal

oedema is the usual indication .


Safe bronchoscopy is an art which needsplenty of time and practice to be mastered.

It requires a team of bronchoscopist andefficient anaesthesiologist aided by well-trained paramedical personnel in a unit

equipped with all necessary endoscopic andmonitoring instruments.

Although paediatric rigid bronchoscopyis explained to the family as risky procedurefor medico-legal aspects; it is a safe one

provided it is done by expert hands .


foreign bodies in aero-digestive tracts

Health & Medicine

abdulsalam y taha

theforeign body

basket withthe foreign

inflated andthe foreign

positive bronchoscopy

negative bronchoscopy

patients children

year old