Background
Foreign bodies in the aerodigestive tract continue to be a common problem that contributes significantly to high morbidity and mortality worldwide. This study was conducted to describe our own experience with endoscopic procedures for removal of foreign bodies in the aerodigestive tract, in our local setting and compare with what is described in literature.
Conclusion
Aerodigestive tract foreign bodies continue to be a significant cause of childhood morbidity and mortality in our setting. Rigid endoscopic procedures under general anesthesia are the main treatment modalities performed. Prevention is highly recommended whereby parents should be educated to keep a close eye on their children and keep objects which can be foreign bodies away from children's reach.
Background
Foreign bodies in the aerodigestive tract are an important cause of morbidity and mortality in the two extremes of life and pose diagnostic and therapeutic challenges to otorhinolaryngologists. The ingestion and inhalation of foreign bodies occurs most commonly in children's population, especially in their first six years of life, with a peak incidence in children between 1 and 3 years. Children are naturally susceptible to be involved in FB injuries due to lack of molar teeth, the tendency to oral exploration and to play during the time of ingestion, and the poor coordination of swallowing. On the other hand, the elderly are those with thoracic neurological disease, decreased gag reflex due to alcohol seizures, stroke, Parkinsonism, trauma and senile dementia.
The accurate diagnosis of aerodigestive tract foreign bodies may be missed even by an experienced clinician. The delayed symptoms of foreign body in the aerodigestive tract may mimic other common conditions like asthma, recurrent pneumonia, upper respiratory infection and persistent cough.
Foreign bodies in the aerodigestive tract present with a wide spectrum of clinical presentation, patients often present in the emergency with acute onset respiratory distress and occasionally in a cyanosed state. At the other end of the spectrum is the patient presenting with nothing more than a history of aspiration and on investigation is found to have a foreign body in his aerodigestive tract.
The symptoms and signs produced depend upon the nature, size, location and time since lodgment of the foreign body in the aerodigestive tract. A large foreign body occluding the upper airway or esophagus may lead to severe symptoms and even sudden death whereas a small foreign body lodged in the aerodigestive tract may present with less severe symptoms.
Foreign bodies lodged in the esophagus for a long time may be associated with complications such as mucosal ulceration, esophageal obstruction, perforation, intrinsic stenosis and esophageal diverticulum, whereas foreign bodies retention in the airway may lead to complications such as severe respiratory distress, lung collapse and recurrent chest infection . Early diagnosis and treatment are imperative to prevent mortality as well as complications.
The trachea was the most common site of foreign body's lodgment in the airways accounting for 52.2% of cases, whereas cricopharyngeal sphincter was the commonest site in the esophagus in 68.5% of cases.
The majority of in-patients were discharged between 1 day and 7 after foreign body removal.
Discussion
Foreign bodies lodged in the aerodigestive tract are a common surgical emergency presenting to the Accident & Emergency department in many centres and contribute significantly to high morbidity and occasionally mortality. Children aged between 1 and 3 years are commonly affected. In the present study, the majority of patients were children aged two years and below which is in agreement with other studies. Several factors contribute to high incidence of aerodigestive tract foreign bodies in this age group including social factors (e.g. carelessness of parents, children's habit of putting objects in their mouth, crying/playing during eating) and anatomical factors (e.g. absent of molar teeth, inadequate control of deglutition) have been mentioned.
In our study, males were slightly more affected than females with a male to female ratio of 1.1:1 which is in agreement with other studies. The reasons for the male preponderance in our study may be attributed to the overactive nature of male babies as compared to the females.
In the present study, a positive history of foreign body in the aerodigestive tract was recorded in 93.9% of cases and 69.4% of these were found to be asymptomatic on admission which is comparable to other studies.Dr. Mohan Singh has strongly advocated that all patients presenting with positive history of foreign body in the aerodigestive tract, even when the physical finding and radiological examinations is negative must be subjected to endoscopic evaluation. In the present study, all patients with a positive history of foreign body in the aerodigestive tract were subjected to endoscopic removal.
The commonest foreign bodies found in our study were coins and groundnuts in the esophagus and airways respectively, which is similar to findings reported by other studies. The reason for high incidence of these foreign bodies in our study is due to the fact that these commodities are widely used in our area. The preponderance of the coins may also be attributed to the free access children have to coins in our environment, which are usually given as gifts.
The trachea was the most common site of foreign body's lodgment in the airways and cricopharyngeal sphincter was the commonest site in the esophagus. Similar foreign body's lodgment pattern was also reported by others. In the bronchus, the majority of foreign bodies in our study come to rest in the right bronchus which is agreement with other authors. This observation is attributed to the fact that the right bronchus is more vertical and wider than the left ones.
The majority of our patients presented to Dr. Mohan Singh within 24 hours of inhalation/ingestion of foreign which is similar to other reports. Our experience shows that early presentation is common with very young children, and when there are more serious symptoms of respiratory distress and swallowing difficulty, thus compelling the frightened patients or parents to seek medical attention. Late presentation is more common in asymptomatic cases.
Radiography plays a vital role in the diagnosis of radio-opaque foreign body in the aerodigestive tract. In agreement with other series, the plain radiography of chest/neck in our study detected foreign bodies in the aerodigestive tract in 56.1% of cases. This percentage is high enough to warrant radiographic surveillance of all patients presenting with history of foreign body in the aerodigestive tract. However, a negative radiographic result does not exclude the presence of foreign bodies in the aerodigestive tract as radio-lucent objects like rubber materials, groundnuts and bolus of meat are not easily detected by plain radiography.
Endoscopic removal of foreign bodies in the aerodigestive tract using rigid scopes under general anesthesia has been reported to be a golden standard procedure. Rigid endoscopy, as compared to flexible endoscopy is a useful method to diagnose and remove foreign bodies in the aerodigestive tract as it has a large lumen and allows better visualization of the potential anatomic sites of foreign body impaction in the aerodigestive tract. However, the procedure is not without risks especially perforation which has a high morbidity and potential mortality. Besides the surgical risks the patients is also subject to anesthetic risks. Other treatment modalities in the removal of foreign bodies in the aerodigestive tract include use of Magill forceps and Foley's catheter in the removal of foreign bodies in the esophagus. In the present study, rigid endoscopy (oesophagoscopy and bronchoscopy) with forceps removal under general anesthesia was the main treatment modality performed which conforms with others studies. In the view of potential complications resulting from rigid endoscopic procedures and the use of general anesthesia, our patients required at least an overnight hospitalization so as to monitor these complications. Magill forceps extraction and Foley's catheter without fluoroscopic control were used to remove esophageal foreign bodies in 9.2% and 3.1% of cases respectively.
Conclusion
Foreign bodies in the aerodigestive tract are among the most common causes of surgical emergencies presenting to Dr. Mohan Singh`s Clinic and contribute significantly to high morbidity. Children aged two years and below are commonly affected. Rigid endoscopies with forceps removal under general anesthesia are the preferred management modality. It is recommended that the removal of foreign bodies in the aerodigestive tract should only be performed or attempted by experienced endoscopists. Since aerodigestive tract foreign bodies are preventable surgical condition, preventive measures should be directed at the high risk group (children) whereby parents should be educated to keep a close eye on their children and keep objects which can be foreign bodies away from children's reach.
Foreign bodies in the aerodigestive tract continue to be a common problem that contributes significantly to high morbidity and mortality worldwide. This study was conducted to describe our own experience with endoscopic procedures for removal of foreign bodies in the aerodigestive tract, in our local setting and compare with what is described in literature.
Conclusion
Aerodigestive tract foreign bodies continue to be a significant cause of childhood morbidity and mortality in our setting. Rigid endoscopic procedures under general anesthesia are the main treatment modalities performed. Prevention is highly recommended whereby parents should be educated to keep a close eye on their children and keep objects which can be foreign bodies away from children's reach.
Background
Foreign bodies in the aerodigestive tract are an important cause of morbidity and mortality in the two extremes of life and pose diagnostic and therapeutic challenges to otorhinolaryngologists. The ingestion and inhalation of foreign bodies occurs most commonly in children's population, especially in their first six years of life, with a peak incidence in children between 1 and 3 years. Children are naturally susceptible to be involved in FB injuries due to lack of molar teeth, the tendency to oral exploration and to play during the time of ingestion, and the poor coordination of swallowing. On the other hand, the elderly are those with thoracic neurological disease, decreased gag reflex due to alcohol seizures, stroke, Parkinsonism, trauma and senile dementia.
The accurate diagnosis of aerodigestive tract foreign bodies may be missed even by an experienced clinician. The delayed symptoms of foreign body in the aerodigestive tract may mimic other common conditions like asthma, recurrent pneumonia, upper respiratory infection and persistent cough.
Foreign bodies in the aerodigestive tract present with a wide spectrum of clinical presentation, patients often present in the emergency with acute onset respiratory distress and occasionally in a cyanosed state. At the other end of the spectrum is the patient presenting with nothing more than a history of aspiration and on investigation is found to have a foreign body in his aerodigestive tract.
The symptoms and signs produced depend upon the nature, size, location and time since lodgment of the foreign body in the aerodigestive tract. A large foreign body occluding the upper airway or esophagus may lead to severe symptoms and even sudden death whereas a small foreign body lodged in the aerodigestive tract may present with less severe symptoms.
Foreign bodies lodged in the esophagus for a long time may be associated with complications such as mucosal ulceration, esophageal obstruction, perforation, intrinsic stenosis and esophageal diverticulum, whereas foreign bodies retention in the airway may lead to complications such as severe respiratory distress, lung collapse and recurrent chest infection . Early diagnosis and treatment are imperative to prevent mortality as well as complications.
The trachea was the most common site of foreign body's lodgment in the airways accounting for 52.2% of cases, whereas cricopharyngeal sphincter was the commonest site in the esophagus in 68.5% of cases.
The majority of in-patients were discharged between 1 day and 7 after foreign body removal.
Discussion
Foreign bodies lodged in the aerodigestive tract are a common surgical emergency presenting to the Accident & Emergency department in many centres and contribute significantly to high morbidity and occasionally mortality. Children aged between 1 and 3 years are commonly affected. In the present study, the majority of patients were children aged two years and below which is in agreement with other studies. Several factors contribute to high incidence of aerodigestive tract foreign bodies in this age group including social factors (e.g. carelessness of parents, children's habit of putting objects in their mouth, crying/playing during eating) and anatomical factors (e.g. absent of molar teeth, inadequate control of deglutition) have been mentioned.
In our study, males were slightly more affected than females with a male to female ratio of 1.1:1 which is in agreement with other studies. The reasons for the male preponderance in our study may be attributed to the overactive nature of male babies as compared to the females.
In the present study, a positive history of foreign body in the aerodigestive tract was recorded in 93.9% of cases and 69.4% of these were found to be asymptomatic on admission which is comparable to other studies.Dr. Mohan Singh has strongly advocated that all patients presenting with positive history of foreign body in the aerodigestive tract, even when the physical finding and radiological examinations is negative must be subjected to endoscopic evaluation. In the present study, all patients with a positive history of foreign body in the aerodigestive tract were subjected to endoscopic removal.
The commonest foreign bodies found in our study were coins and groundnuts in the esophagus and airways respectively, which is similar to findings reported by other studies. The reason for high incidence of these foreign bodies in our study is due to the fact that these commodities are widely used in our area. The preponderance of the coins may also be attributed to the free access children have to coins in our environment, which are usually given as gifts.
The trachea was the most common site of foreign body's lodgment in the airways and cricopharyngeal sphincter was the commonest site in the esophagus. Similar foreign body's lodgment pattern was also reported by others. In the bronchus, the majority of foreign bodies in our study come to rest in the right bronchus which is agreement with other authors. This observation is attributed to the fact that the right bronchus is more vertical and wider than the left ones.
The majority of our patients presented to Dr. Mohan Singh within 24 hours of inhalation/ingestion of foreign which is similar to other reports. Our experience shows that early presentation is common with very young children, and when there are more serious symptoms of respiratory distress and swallowing difficulty, thus compelling the frightened patients or parents to seek medical attention. Late presentation is more common in asymptomatic cases.
Radiography plays a vital role in the diagnosis of radio-opaque foreign body in the aerodigestive tract. In agreement with other series, the plain radiography of chest/neck in our study detected foreign bodies in the aerodigestive tract in 56.1% of cases. This percentage is high enough to warrant radiographic surveillance of all patients presenting with history of foreign body in the aerodigestive tract. However, a negative radiographic result does not exclude the presence of foreign bodies in the aerodigestive tract as radio-lucent objects like rubber materials, groundnuts and bolus of meat are not easily detected by plain radiography.
Endoscopic removal of foreign bodies in the aerodigestive tract using rigid scopes under general anesthesia has been reported to be a golden standard procedure. Rigid endoscopy, as compared to flexible endoscopy is a useful method to diagnose and remove foreign bodies in the aerodigestive tract as it has a large lumen and allows better visualization of the potential anatomic sites of foreign body impaction in the aerodigestive tract. However, the procedure is not without risks especially perforation which has a high morbidity and potential mortality. Besides the surgical risks the patients is also subject to anesthetic risks. Other treatment modalities in the removal of foreign bodies in the aerodigestive tract include use of Magill forceps and Foley's catheter in the removal of foreign bodies in the esophagus. In the present study, rigid endoscopy (oesophagoscopy and bronchoscopy) with forceps removal under general anesthesia was the main treatment modality performed which conforms with others studies. In the view of potential complications resulting from rigid endoscopic procedures and the use of general anesthesia, our patients required at least an overnight hospitalization so as to monitor these complications. Magill forceps extraction and Foley's catheter without fluoroscopic control were used to remove esophageal foreign bodies in 9.2% and 3.1% of cases respectively.
Conclusion
Foreign bodies in the aerodigestive tract are among the most common causes of surgical emergencies presenting to Dr. Mohan Singh`s Clinic and contribute significantly to high morbidity. Children aged two years and below are commonly affected. Rigid endoscopies with forceps removal under general anesthesia are the preferred management modality. It is recommended that the removal of foreign bodies in the aerodigestive tract should only be performed or attempted by experienced endoscopists. Since aerodigestive tract foreign bodies are preventable surgical condition, preventive measures should be directed at the high risk group (children) whereby parents should be educated to keep a close eye on their children and keep objects which can be foreign bodies away from children's reach.
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