AUTHORS
Crick Watkins, DO, Assistant Professor, Department of Emergency Medicine, Wake Forest University, Winston-Salem, NC
Chad D. McCalla, MD, Assistant Professor, Department of Emergency Medicine, Section of Pediatric Emergency Medicine, Wake Forest University Baptist Medical Center, Winston-Salem, NC
PEER REVIEWER
Robert A. Felter, MD, FAAP, FACPE, Clinical Professor of Pediatrics, Georgetown University School of Medicine, Washington, DC
To reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing Medical Education guidelines, we disclose that Dr. Dietrich (editor), Dr. Skrainka (CME question reviewer), Ms. Wurster (nurse planner), Dr. Watkins (author), Dr. McCalla (author), Dr. Felter (peer reviewer), Ms. Coplin (executive editor) and Ms. Mark (executive editor) report no relationships with companies related to the field of study covered by this CME activity.
EXECUTIVE SUMMARY
- In the external auditory canal, button batteries, which are capable of inducing liquefactive necrosis upon discharge of the alkali contents, necessitate urgent removal and often require consultation with an ear, nose, and throat surgeon for removal.
- Common chief complaints for nasal foreign bodies include epistaxis, nasal pain, or nasal congestion/ rhinorrhea. Any child who presents with unilateral mucopurulent nasal drainage should be assumed to have a retained foreign body and a prompt close investigation should be initiated.
- Small magnets in the nose have a unique set of risks that requires prompt removal; multiple magnets may compress tissue between the attracted magnets, leading to necrosis.
- Coins comprise about 70-80% of all esophageal foreign bodies, followed by batteries, magnets, toys, food (either by impaction or fish bones). Jewelry and beads are most likely to get stuck at one of three places of narrowing within the esophagus: thoracic inlet (approximately 75% of the time), retrocardiac, or the lower gastroesophageal sphincter.
- When differentiating coins from button batteries, in the coronal orientation, button batteries are bilaminar and have a halo, or double ring, whereas coins do not. When seen in profile (often via a lateral X-ray), a battery will have a discernible step-off where the anode and cathode separate.
- Button batteries lodged in the esophagus are considered a surgical emergency, and if not removed promptly can rapidly lead to mucosal necrosis and perforation. Endoscopy is the preferred method of removal, over bougie or Foley catheter, as this method allows for direct visualization of the mucosa to document any injury.
- Single magnet ingestion typically is not problematic, and should be treated similarly to other blunt object ingestions, with most passing spontaneously, unless they are large enough to get caught in the esophagus or at the pylorus.
- Multiple magnet ingestion or co-ingestion of another metallic object in the digestive tract can cause the objects to attract to one another, sometimes across bowel walls and lead to impingement of the bowel, which can then cause bowel wall ischemia, pressure necrosis, ulceration, fistualization, perforation, obstruction, and volvulus.
A common presentation to the emergency department, foreign bodies of the head and neck have a broad range in severity, from minor retrieval to life-threatening airway compromise. This article will review the most recent literature on the diagnosis and management of ear, nose, and throat foreign bodies with discussion separated by location.
— Ann M. Dietrich, MD, FAAP, FACEP, Editor
Aural Foreign Bodies
Foreign bodies in the ear, specifically the external auditory canal (EAC), contribute to an estimated 50,000 annual emergency department (ED) visits, according to a recent national consumer safety database analysis.1 Of these visits, the most frequent age of the patients is between 2 and 8 years, with a near equal distribution of males (49.3%) and females (50.7%).1-3 One recent study suggested a possible association between attention-deficit/hyperactivity disorder and elementary school-age children found to have aural foreign bodies.6 By far, the most common objects placed in the EAC are items of jewelry, with beads comprising the overwhelming majority in this category.1,3-4 Other common objects found include cotton swabs, paper products, erasers, Styrofoam, toys, BBs, and popcorn kernels. Insects, which also comprise an important subset of foreign bodies, are more commonly associated with poor living conditions, present as abrupt onset otalgia, and can pose a particular challenge in removal.
Very rarely are EAC foreign bodies considered a true emergency; however, there are a few circumstances in which timely removal is of greater urgency. This is particularly important with button batteries, which are capable of inducing liquefactive necrosis upon discharge of the alkali contents. The presence of a button battery within the EAC often necessitates consultation with an ear, nose, and throat (ENT) surgeon for removal. Other emergent conditions involve the insertion of larger foreign bodies that result in perforation of the tympanic membrane (TM), necessitating consultation with an otolaryngologist (ENT). Prompt removal, however, remains important for all types of foreign bodies, as their presence induces ongoing canal irritation, which increases inflammation around the object and may lead to greater difficulty of retrieval.4
The anatomy of the ear is such that the narrowest portion of the EAC is at the transition from the cartilaginous outer ear to the distal bony portion, beyond which the sensitivity of the skin markedly increases due to the minimal cushioning of the underlying bone.2,5 Foreign bodies within the petrous portion of the canal are often the most difficult to remove, due to becoming wedged in the narrow lumen, and are most fraught with complications since they are close to the TM.2 The insertion of a foreign body is often an unwitnessed event. Children who come to the ED for evaluation may present after having told a parent they put an object in the ear, but also may have chief complaints of ear pain, fullness, or difficulty hearing.2 Sudden onset otalgia, especially at night, or uncontrollable irritability in preverbal children is often the presenting symptom for insects in the canal. Foreign bodies also may be an incidental finding on exam, especially in preverbal children. The most common secondary complications associated with aural foreign bodies include otitis externa from local skin irritation, otorrhea, TM perforation, and canal lacerations.2
No diagnostic imaging or laboratory studies are indicated for foreign bodies of the EAC since the diagnosis is made upon visualization of a foreign body within the canal. The differential also remains very limited. However, it is important to distinguish from a cholesteatoma, which is an accumulation of squamous epithelium within the skull base.8 They can be congenital or acquired, but most often appear as a white/yellow mass on or adjacent to the TM. If seen, the patient should be referred for close ENT follow-up, as cholesteatomas can lead to bone destruction and permanent hearing loss if not managed promptly.
Most aural foreign bodies can be successfully removed in the ED. Some foreign bodies are more commonly associated with failed attempts, such as round objects wedged deep in the canal or adherent/adjacent to the TM, and consideration should be made for early ENT referral depending on the practitioner’s comfort level with the procedure.6 As with any procedure, proper setup can improve success and limit complications. Depending on the patient’s age and level of cooperation, it may be necessary to restrain the patient using a papoose board.9 In addition, distraction and redirection through a child life specialist, where available, can markedly reduce distress on the child. If those resources are not available or effective, it still may be necessary to administer an anxiolytic or, less commonly, procedural sedation for successful retrieval.6,10 Removal of EAC foreign bodies can be a very sensitive procedure; however, pain control is difficult to achieve with topical agents, and performing an ear block will only add to the distress.6 Good visualization is also crucial for successful retrieval of foreign bodies, and helping the emergency provider select the best tool for the procedure and guide movements during the removal of the object. An otoscope with a round eyepiece can provide improved visual field over a rectangular piece, and a bedside microscope can provide the best magnification.9
The risk of complications increases with multiple attempts at retrieval of an EAC foreign body.4 Proper tool selection is important, as there are various techniques for retrieving aural foreign bodies depending on the object. Most fall into a category of graspable (paper, organic material, toys) vs. the more difficult non-graspable (beads, BBs, popcorn kernels).2,6,9 Forceps, and in particular alligator forceps, work best for graspable objects.9 For non-graspable objects, an assortment of tools is available, including cerumen curettes, wire loops, or blunted 90-degree angle hooks.6,9 Each of these allows the provider to reach past the visualized edge of the object to pull the foreign body toward the outer ear. Suction catheters are another option for non-graspable objects, particularly Schuknecht catheters with curved umbrellas at the distal end to increase contact surface area.6 Insert the catheter tip carefully into the canal under direct visualization until gentle contact is made with the foreign body.6,9 Use a finger to occlude the side port, generating suction at the tip and allowing the object to be removed.9 Take care not to apply too much pressure in making contact with the object, as this can push it farther into the narrow portion of the canal and wedge it more tightly.6 Irrigation also may be used to flush out non-graspable objects.6,9 Use commercially manufactured irrigation products or simply affix an 18 gauge or 20 gauge angiocath to a syringe and flush the canal with water at body temperature.11 Take care not to flush too hard, as this may push the foreign body farther back in the EAC or cause damage to the TM. Note that irrigation should be avoided with most organic material or anything that has absorption capabilities, because it will increase swelling and may lodge the object within the canal and/or markedly increase its friability, hindering removal.2,6,10,11 Irrigation is contraindicated in the setting of button batteries because it increases the risk of leakage of the internal alkali contents, which may result in serious chemical burns of the EAC.2,6
When removing insects, first euthanize them with mineral oil, lidocaine, or alcohol by placing several drops within the canal, unless TM perforation is seen or suspected.2,3 This prevents the insect from moving against the sensitive canal during retrieval attempts. The dead insect may be removed under direct visualization using forceps.
Occasionally, a patient may present with having put cyanoacrylate (Super Glue) in the ear, forming a cast within the EAC. Make attempts to dissolute using acetone or 3% hydrogen peroxide.6 Apply drops filling the canal with approximately 10 minutes in between followed by attempts to remove the cast.6 Avoid attempting to remove any cast adherent to the TM, as this could lead to TM lacerations. Consult with an ENT surgeon anytime TM perforation is suspected or seen, as well as for any significant canal trauma that may need repair. Also refer to an ENT when there are any sharp object foreign bodies, foreign bodies adjacent to the TM or tightly wedged in the EAC, or failed attempts by the ED provider.2
Following successful removal of the foreign body, reassess the canal for any additional retained objects and evaluate for any injuries such as canal lacerations or TM perforation that may have occurred during the insertion of the foreign body or from retrieval. Simple abrasions and lacerations of the canal, as well as any otitis externa that may have been caused by the presence of the foreign body, can be treated with topical antibiotic drops.2 However, more serious complications, such as TM perforations or, more rarely, ossicle damage, will necessitate ENT consultation in the ED for further management. It is important to examine the other ear thoroughly to ensure no additional foreign bodies are seen and to adequately document findings. In most cases, children may be discharged home once a foreign body is removed. Prevention is the only way to reduce the recurrence, which is why it is important to take time to discuss with parents/guardians the types of objects typically inserted in the EAC and encourage appropriate supervision when children are around those items.
Nasal Foreign Bodies
Nasal foreign bodies resulted in approximately 40,000 annual ED visits, according to a recent analysis of the Nationwide Electronic Injury Surveillance System database.12 Of these ED visits, the vast majority were children younger than 5 years with a slight majority of females (57.3%) to males (42.7%).12 The makeup of nasal foreign bodies is similar to ear foreign bodies, with jewelry, predominantly beads, accounting for nearly half.12 Other common objects found include paper, food, toys, buttons, coins, pens/pencils/crayons, and button batteries.2,3,12 Much like aural foreign bodies, most patients present to the ED after having told a parent they put something in their nose. Other common chief complaints for nasal foreign bodies include epistaxis, nasal pain, or nasal congestion/rhinorrhea. Any child who presents with unilateral mucopurulent nasal drainage should be assumed to have a retained foreign body, and a prompt close investigation should be initiated.2,3,6
Most foreign bodies in the nose end up along the nasal floor below the first turbinate or anterior to the middle turbinate, but they can be found anywhere in the nasal cavity. When found or suspected, remove nasal foreign bodies promptly, as they may be inhaled farther into the upper respiratory tract and pose a risk of possible aspiration.5
Button batteries are a common nasal foreign body and carry a unique set of risks that require urgent removal. If left in place, severe chemical burns can occur from the alkali contents should they leak, leading to mucosal damage, necrosis, and septal perforation.3 Fortunately, a recent study revealed the most common complications associated with button batteries are not serious chemical burns, but rather other complications resulting from the presence of a foreign body.12,13
In addition to batteries, small magnets have a unique set of risks and require prompt removal. Especially in the case of multiple magnets, tissue may be compressed between the attracted magnets, leading to necrosis. A recent multiyear analysis of a national safety database demonstrated the majority of cases (63%) of intranasal magnets involved multiple magnets; however, there has been a decreasing incidence of cases in recent years and a trend toward more adolescent patients using faux piercings.14 Some foreign bodies may go unnoticed for years, forming into a rhinolith from mineral deposits on the surface of the object. If seen, refer patients to an ENT, as they often require surgery for removal.5,16
No imaging studies or routine laboratory assessments are indicated for the evaluation of nasal foreign bodies. However, in a child with unilateral discharge, or situations in which attempts to visualize are challenging, plain radiographs may assist with identification and localization of the foreign body. The differential diagnosis for nasal foreign bodies remains limited, as the diagnosis is made upon visualization. As previously mentioned, any unilateral nasal discharge should raise suspicion for a retained foreign body and should be investigated thoroughly. Sinusitis can present with isolated drainage from one nostril, but is a diagnosis of exclusion. Some pediatric cancers, such as rhabdomyosarcoma, may present as a unilateral intranasal mass, but the course of development will often aid in distinguishing it from a retained foreign body.2 If a mass is suspected, refer promptly to ENT for further evaluation.
Proper preparation before the removal of the foreign body increases the success of the process. This includes the use of papoose or wrapped sheet restraints as needed and patient distraction techniques as described in aural foreign body removal preparation. Approximately five minutes before attempting to remove the foreign body, treat the patient topically with a combination of a nasal decongestant consisting of either phenylephrine or oxymetazoline plus an anesthetic such as lidocaine.2,9 This will aid success by reducing swelling around the object to allow it to move more easily, improving visualization, decreasing pain associated with the extraction process, and minimizing any induced epistaxis that may occur as a part of the procedure through vasoconstriction of the superficial blood vessels.9 It may be necessary to re-apply this topical medication just before the procedure to allow for additional swelling reduction to areas now accessible following the first treatment.9 Use caution once swelling around the object is reduced, as there is the possibility the foreign body may move farther back in the nasopharynx and run the risk of aspiration.3 Similarly, because of the communication with the lower airway, any removal technique may move the object posteriorly and run the risk of aspiration. Avoid use of procedural sedation or any anxiolytic medication that reduces the patient’s innate ability to protect the airway.6
For older children who are more cooperative, first try to have the patients expel the object by occluding the opposite nostril and forcefully blowing air through the nose. Instruct the child to inhale through the mouth and not the nose so as not to draw the foreign body farther in the nasal cavity and/or possibly aspirate it. If the object needs to be actively retrieved, a good light source, such as an otoscope with a speculum or headlamp/portable light in conjunction with a nasal speculum, can help improve visualization. Nasal foreign bodies, similar to aural foreign bodies, are delineated into categories of graspable vs. non-graspable objects.3,9 The former can be removed with tools such as alligator, Tobey, or bayonet forceps; suction tip catheters, cerumen curettes, wire loops, and right angle hooks are helpful for the latter, while under direct visualization.9 Another removal technique uses positive pressure from the mouth to propel the object forward. An older child can be instructed to occlude the unaffected nostril and forcibly blow his nose, taking care to breathe in through the mouth first so as not to draw the foreign body farther into the nose. In younger patients unable to follow instructions, the same mechanism can be achieved through a technique known as a “parent’s kiss,” in which the parent occludes the unaffected nostril, places his/her mouth over the child’s mouth and blows.3 Additionally, a bag-valve-mask or anesthesia bag with high-flow oxygen applied only over the patient’s mouth can be used to generate similar positive pressure if the child is accompanied by someone unwilling to try the above technique.6
There is a potential for inducing barotrauma from these techniques, including orbital emphysema, pneumothorax, and pneumomediastinum, but these are relatively rare occurrences.15,17 Similarly, a nasal wash uses the buildup of pressure behind the object to push it out. This should be limited to older children who can cooperate and have the ability to protect their airway.15 To achieve this, fill a bulb syringe with approximately 7 mL of saline and insert it into the unaffected nostril while the patient is sitting upright.15 Compress the syringe, flushing out the opposite nostril and expelling the foreign body.6,15 As with irrigation for ear foreign bodies, this method is contraindicated with button batteries and should be avoided for foreign bodies of vegetable matter.15 A Foley catheter also may be used to pull the object from the nose. For this technique, lubricate a small 5 or 8 French catheter and advance it past the foreign body with balloon deflated. Once past, expand the balloon with up to 2 mL of water and slowly withdraw the catheter from the nose, pushing the foreign body out with it.15 A Katz extractor is a specialized, single-use tool that uses a similar technique as a Foley catheter with a smaller lumen tube that allows for greater ease of maneuvering past the foreign body and a small, inflatable bulb at the distal end to allow for drawing the foreign body anteriorly.
For all techniques, the most common complications include local mucosal irritation or trauma resulting in epistaxis, which is usually transient.15 The most serious complication is causing the foreign body inadvertently to move farther into the nasal cavity during attempts at retrieval, further wedging it or risking aspiration. Because the mucosa heals rapidly, there is little risk of secondary infections if the object is removed in a timely fashion. Consult with an ENT surgeon for the following: button batteries not easily retrieved, unsuccessful attempts at removal by the ED provider, children with known bleeding disorders, complications from a chronic foreign body (such as septal destruction, granulation tissue, or otolith formation), or suspected mass.2
Upon successful removal of the foreign body, patients may be safely discharged home. Carefully inspect the opposite naris to ensure no additional foreign bodies are seen. It is important to reiterate to parents/guardians the importance of appropriate supervision and what type of objects are most likely to be placed in the nose or ear and therefore to keep from reach.
Foreign Body Ingestion and Aspiration
Foreign body ingestion and aspiration in children is a very frequent and sometimes serious problem, with most cases involving children between the ages of 6 months and 6 years.18-19 The most recent data from 2014, reported to the National Poison Data System, show there were more than 100,000 exposures, 72,000 of which were in children younger than 5 years of age.20 This number probably underestimates the true incidence, as many cases are managed and resolved at home, go unnoticed, or are not reported once medical attention is received. The majority of ingested foreign bodies pass through without complication, as only 10-20% will require endoscopic removal and less than 1% will require surgical intervention.21 Although usually benign, foreign body impaction can have serious complications, such as esophageal or tracheal erosion, perforation, tracheal compression, or recurrent pneumonia, making expeditious recognition and management a necessity.22
The age group at the highest risk for foreign body ingestion/aspiration are those children between 2 and 4 years of age, accounting for approximately 75% of all foreign bodies.19-20 At this age, children are mobile, extremely curious, and tend to explore their world by placing things in their mouths, noses, or ears.23 Common risk factors are being left unsupervised with inappropriate sized toys or jewelry, being given inappropriate sized or textured foods to eat, or being fed items by older siblings. Additionally, children with underlying medical problems, such as developmental delay, swallowing dysfunctions, and autism, are at higher risk.24 Adolescents also occasionally will present with foreign bodies, commonly due to inappropriate eating habits (i.e., eating too fast, not chewing appropriately), risk-taking behaviors (carrying objects in their mouths, substance abuse), or the presence of intraoral piercings.
Ingested Foreign Bodies
The esophagus is one of the more common places for foreign bodies to be found. Coins comprise about 70-80% of all esophageal foreign bodies, followed by batteries, magnets, toys, food (either by impaction or fish bones), and jewelry.23,25-26 Most swallowed objects are able to pass through into the stomach; however, the size of the object and the age of the child are important factors. For example, most 2-year-old children will be unable to spontaneously pass a large coin, whereas many adolescents will not have any problems. Objects are most likely to get stuck in three places of narrowing within the esophagus:
- the thoracic inlet (approximately 75% of the time);
- retrocardiac, where the heart pushes on the esophagus causing an anatomical narrowing; or
- the lower gastroesophageal sphincter.27
Esophageal stricture, history of repaired esophageal atresia or tracheoesophageal fistula, Nissen fundoplication, and eosinophilic esophagitis all put children at higher risk for impaction and should be inquired about while taking the child’s medical history.27
Ideally these cases would be straightforward; however, this often is not the case, as upwards of 40-50% of these ingestions are unwitnessed.18 These children often will present with symptoms of esophageal obstruction or the object will be found incidentally while being evaluated for other concerns, such as having a chest X-ray as part of a fever evaluation. Depending on the report, about 50% of children with esophageal foreign bodies are asymptomatic at the time of evaluation, so a good history and physical exam are a necessity.28 Presenting symptoms depend on the type and size of the foreign body ingested, the duration of time that has passed since the ingestion, and the location where the object is impacted. Common symptoms include:
- drooling and inability to tolerate secretions, especially if located higher up in the esophagus;
- frequent and repetitive vomiting;
- throat and/or chest pain, which can be the sole complaint for distal esophageal foreign bodies;
- difficulty breathing if the object is large enough to cause tracheal compression;
- difficulty talking and swallowing;
- fussiness and food refusal, which may be the only symptom in the younger child; and
- fever if the foreign body has been present for an extended period of time.27,29-30
By some reports, up to 70% of the time, the physical exam is unremarkable.28 The exam should immediately focus on the ABCs (airway, breathing, circulation), making sure that the airway or breathing is not compromised. Once addressed, other physical exam findings can be searched for, and include:
- throat or neck pain, crepitus, and decreased range of motion concerning for esophageal perforation;
- abdominal pain, rebound, and guarding concerning for abdominal perforation; and
- stridor and/or wheezing if there is significant tracheal or mainstem bronchus compression.31
All patients with suspected foreign body ingestion should have imaging done to determine the location of the foreign body if present. Fortunately, about 75% of ingested foreign bodies are radiopaque, and can be easily seen on radiographs.32 However, food impactions, toys, or other organic materials are radiolucent and will likely not be seen on X-ray, making the diagnosis difficult in the child with an unclear history and few symptoms. Occasionally, more subtle findings of air fluid levels in the esophagus or bone particles from food can be seen, but the yield is relatively low. If a radiolucent foreign body is suggested, more advanced imaging or definitive treatment should not be delayed while waiting for X-rays.
For esophageal foreign bodies, all patients should receive both anterior-posterior (AP) and lateral films to better characterize the nature and confirm the location of the foreign body. For example, coins and button batteries can look very similar on AP imaging, but differences are easily detected when a lateral image is obtained. Occasionally, CT scan and upper gastrointestinal imaging can be helpful in locating radiolucent foreign bodies when plain X-rays are nondiagnostic; however, both carry the risks of radiation exposure and contrast administration. These concerns have led some pediatric centers to perform endoscopies on these children to avoid risks associated with these more advanced imaging studies.
Once a foreign body is located, the determination must be made as to the identify the foreign material and how expediently it needs to be removed. The benefits of removal must be weighed against both the likelihood that the object will pass on its own and the risks of doing the procedure. In general, once an object reaches the stomach, it has about a 90% chance of passing asymptomatically through the remainder of the gastrointestinal tract.19,21 Exceptions to this are large objects (greater than 2.5 cm generally will not pass through the pylorus), younger age of the child, and long objects (greater than 6 cm have a higher likelihood of becoming entrapped by the pylorus or in the duodenum).33
Indications for urgent removal are listed below:18
- Unstable patients: those with any signs of airway compromise, abdominal perforation, or intestinal obstruction (vomiting, severe abdominal pain, abdominal distension);
- Disk battery in the esophagus;
- Esophageal obstruction manifested by the inability of the child to handle secretions;
- A foreign object that has been impacted in the esophagus for > 24 hours or the actual ingestion time is unknown;
- High-powered magnets (especially if multiple) in the esophagus or stomach;
- Sharp or long (> 5 cm) objects located in the esophagus or stomach.
Patients who do not meet the above-mentioned criteria often can be managed conservatively, either under observation in the ED or an inpatient unit vs. home with close supervision and primary care follow-up. Coins or other blunt objects lodged in the esophagus can be observed for spontaneous passage for 12-24 hours if the child remains asymptomatic.34,35 Many objects that have passed into the stomach, with the exception of long, sharp objects and magnets, will spontaneously pass and these children can be safely observed on an outpatient basis with follow-up radiographs or screening of stool output.
Foreign bodies can be removed by several techniques. Flexible endoscopy is most common, as it not only can visualize and retrieve the object, but also can visualize the surrounding tissue looking for damage the object may have caused.21,36 If the object is in the posterior pharynx or proximal esophagus, McGill forceps and a laryngoscope may be all that is required for removal.37-38 Some institutions have been studying the feasibility of bougienage, with good results, for blunt objects, especially coins.39-40 In this method, a bougie is inserted into the esophagus and the object is pushed into the stomach. This procedure generally has been well tolerated by patients and has had few documented complications; however, consideration must be taken to determine the likelihood of the object passing through the stomach once there. Foley catheters also have been shown to have some usefulness with blunt object removal.41 Using this method, a Foley catheter is inserted into the esophagus and fed distally past the obstruction under fluoroscopic guidance. Once past, the balloon is inflated with contrast, and the Foley is then withdrawn, pulling the object into the patient’s mouth where it can then be easily removed. This method should be used with caution and in the appropriate situation because of the risk of perforation and aspiration of the foreign body since the esophageal mucosa cannot be directly visualized.
Specific Esophageal Foreign Bodies
Coins
As mentioned earlier, coins are the most common objects ingested by children and account for approximately 70-80% of cases.23,25-26 Fortunately, these objects rarely cause long-term problems, but they can lead to significant symptoms, anxiety, and distress for the child. Depending on where the coin is impacted can determine what symptoms the child may display. For coins in the proximal esophagus, drooling, vomiting, inability to handle secretions, cough, and respiratory distress are more likely to be seen, as opposed to the coins in the distal esophagus that may only cause pain with swallowing.18
Plain radiographs must be obtained to document where the coin is located in the esophagus and whether it can be expected to pass. The orientation of the coin on AP imaging can help determine whether the coin is in the esophagus or trachea. Coins having a coronal alignment (“en face”) are more likely to be in the esophagus. Those with a sagittal alignment on AP films are more likely to be in the trachea due to incomplete fusing of the posterior tracheal rings.19 (See Figure 1.) Although this is usually the case, it is not universal, as there have been cases with sagittally aligned coins still being esophageal in location.42-43
Figure 1. X-rays Demonstrate Coin in Upper Esophagus |
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Notice that on AP films the coin face will be apparent, and the profile will be seen on lateral films
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Lateral radiographs are also necessary in coin ingestions to ensure that indeed a coin was ingested and not a button battery. Many of these ingestions are unwitnessed, and small children are not always able to differentiate between a coin and a battery. Also, sizes of coins and batteries can be very similar — a 20 mm battery is essentially the same size as a penny (19 mm) and a nickel (21 mm).44 Fortunately, batteries are designed to have some distinct characteristics that when seen on a plain film can help to differentiate them from coins. (See Figure 2.) When seen in the coronal orientation, button batteries are bilaminar and have a halo, or double ring, whereas coins do not. Additionally, when seen in profile (often via a lateral X-ray), a battery will have a discernible step-off where the anode and cathode separate.45 Coins do not have this feature, except in the rare occurrence in which multiple coins of various sizes have been ingested and are stacked next to each other. If either of these two characteristic features are seen, or if the emergency physician cannot reliably conclude that the object is a coin and not a button battery, then urgent removal is required.
Figure 2. Button Battery Seen on X-ray |
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Notice the “double halo” when seen on the anterior view, and a step off when seen laterally.
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Once it is determined that a child has a coin ingestion, management then depends on the age of the child, the likelihood of the coin passing into the stomach, and whether the child is symptomatic at the time of presentation. Older children with distal coins often can undergo watchful waiting, as many of these will pass spontaneously into the stomach.34-35,46 Younger children with more proximal coins typically will require some form of removal, as their esophagus generally is not large enough to accommodate easy passage. Many experts recommend that it is safe to watch the asymptomatic child for 8-16 hours prior to removal of the coin, usually in the ED or other inpatient setting. One study found that 14% of coins in the proximal esophagus, 43% in the middle third, and 67% of coins in the distal third of the esophagus spontaneously passed. Of those that did, 75% did so within 6-10 hours.47 Glucagon once was thought to be helpful in assisting passage through its ability to relax the esophageal smooth muscle; however, glucagon is no longer recommended as it has been shown to lead to vomiting, which then can cause aspiration or esophageal perforation.48
Removal techniques were mentioned previously and include endoscopic removal, forceps removal if in the very proximal esophagus, bougienage, and Foley catheter removal.
Button Batteries
Button batteries also are commonly ingested foreign object that can have serious health implications. Found in many common household items such as toys, watches, and hearing aids, they are easily accessible to children. In 2014, more than 3,200 button battery ingestions were reported to the National Poison Data System, of which more than 2,100 were reported in children younger than 6 years of age.20 Unlike coins, these ingestions carry a high incidence of morbidity and mortality if not recognized and managed emergently.
Button batteries lodged in the esophagus are considered a surgical emergency, and if not removed promptly can rapidly lead to mucosal necrosis and perforation; necrosis has been reported to occur in as little as 2-6 hours post-ingestion. Mucosal damage occurs by the following:49-50
- direct pressure necrosis if left in over a prolonged period of time;
- liquefaction necrosis due to electrical discharge that flows from the negative pole of the battery and into the surrounding tissue, causing necrosis;
- leaking of the battery contents. This is not commonly seen; however, it may be present if the child has been chewing on the battery prior to ingestion. Heavy metal poisoning from these batteries is also a rare phenomenon and is not likely to contribute to morbidity.49-51
Guidelines developed by the National Battery Ingestion Hotline are available and can help with the management of these ingestions. In addition, the hotline is available 24/7 by calling (202) 625-3333. (See Figure 3.) If a child is suspected of ingesting a button battery, emergent radiographs are indicated to determine the location of the battery. As mentioned previously, characteristics that distinguish button batteries from coins include a double halo on the face view and a step off when seen laterally. If the battery is found to be in the esophagus, then emergent endoscopy is indicated; watchful waiting for spontaneous passage is not appropriate. Endoscopy is the preferred method of removal, over bougie or Foley catheter, as this method allows for direct visualization of the mucosa to document any injury. For batteries in the stomach, management depends on the presence of symptoms, the age of the child, and the size of the battery. In asymptomatic children, observation is recommended, as these objects should pass without difficulty. However, urgent removal is indicated if the child develops symptoms or if the battery is still present on repeat abdominal X-rays after 10-14 days. A notable exception to this guideline is recommended for children younger than 6 years of age who have ingested a battery > 15 mm. These children require a repeat film in four days; if the battery is still present in the stomach at this time, endoscopic removal is indicated.51
Figure 3. Button Battery Ingestion Algorithm |
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SOURCE: Reprinted with permission from National Capital Poison Center’s National Battery Ingestion Hotline Battery Ingestion Triage and Treatment Guideline. Available at: http://www.poison.org/battery/guideline. Adapted from Litovitz T, Whitaker N, Clark L, et al. Emerging battery ingestion hazard: Clinical implications. Pediatrics 2010; 125:1168-1177. |
Magnets
Found in many children’s toys, jewelry, and electronics, magnets are a common presence in a child’s environment. Fortunately, some manufacturers have discontinued such toys (i.e., Buckyballs).52 However, despite warnings from the Consumer Product Safety Commission about the dangers of magnets in objects, they are still available and easily accessible by small children. Single magnet ingestion typically is not problematic, and should be treated similarly to other blunt object ingestions.53 Most will pass spontaneously, unless they are large enough to get caught in the esophagus or at the pylorus. On the other hand, multiple magnet ingestion or co-ingestion of another metallic object does hold unique problems. Multiple magnets in the digestive tract can attract one another, sometimes across bowel walls.54-55 This leads to impingement of the bowel, which can then cause bowel wall ischemia, pressure necrosis, ulceration, fistualization, perforation, obstruction, and volvulus. Fortunately, magnets can be readily seen on X-rays; however, it can be difficult to determine if there is a solitary magnet or multiple magnets present.56 Multiple views are needed to determine number and orientation. Visualization of stacks of magnets with a small space in between or magnets in close proximity to one another is concerning for impingement and needs to be managed as such.
Hussain and colleagues have developed management algorithms for single and multiple magnet ingestions.53 Management of a single magnet ingestion is usually conservative, but only if it can be reliably determined that there is no other magnet or other metallic co-ingestion. If a solitary ingestion can be determined reliably, then close observation with serial radiographs is indicated. No effort at removal should be made unless the child is symptomatic. For multiple magnets in the esophagus or stomach, urgent removal is recommended. If the magnets are beyond the stomach and the child is symptomatic (i.e., is having vomiting, abdominal pain, or other signs of obstruction or perforation), then emergent surgical removal should be strongly considered. For asymptomatic children, management is conservative with serial X-rays to document passage. Removal is then indicated if the child develops symptoms or the magnets fail to progress, as both suggest entrapment of bowel wall.
Sharp and Long Objects
Sharp, pointy objects, such as safety pins, needles, fish bones, and toothpicks, can present a surgical emergency, as 15-35% of these found in the esophagus lead to perforation.21,57-58 (See Figure 4.) These can sometimes be difficult to see on an X-ray, especially if radiolucent, so a concerning history or exam should warrant emergent endoscopy.34 Urgent removal is indicated if these objects are found in the esophagus or stomach.34 Watchful waiting is recommended if the object has advanced past the pylorus, with surgical retrieval indicated if the child becomes symptomatic.34
Figure 4. X-rays from a Child Who Swallowed an Earring |
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Notice that more than one view may be necessary.
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Long objects, such as toothbrushes and spoons, are unusual to see in younger children, but can be seen as intentional ingestions in adolescents and adults. The biggest risks posed from these are impaction/obstruction in the esophagus, at the pylorus, and the first segment of duodenum.25 These children can present with signs of obstruction, including abdominal pain, vomiting, and distension. Objects greater than 6 cm are most likely to get impacted in adults and, therefore, should be removed if easily accessible (i.e., in the esophagus or stomach).33 It is unclear in smaller children what length requires intervention, but anything more than 3-4 cm should be consideredfor removal.21
Food Bolus
Meat is one of most common foods that can result in an esophageal food impaction. Usually seen in adults, this also can occur in adolescents through rapid eating with incomplete chewing. Often, this can be seen as a symptom of an underlying esophageal pathology, such as eosinophilic esophagitis or reflux esophagitis.59-61 Children with a history of esophageal stricture due to repaired tracheoesophageal fistula or esophageal atresia are at higher risk.62 Urgency of removal depends on the child’s ability to handle his or her secretions.24,34 Given that many food boluses will pass spontaneously, observation for up to 12 hours can be considered in the asymptomatic child who is handling secretions. Conversely, if the child cannot handle secretions, is vomiting, or presents with respiratory distress, then more urgent removal is indicated. Endoscopy is the recommended removal method, as most children also will need esophageal biopsies to determine any underlying pathology that predisposed them to an impaction.34,63 The bolus should be removed in a piecemeal fashion until it is small enough to be gently pushed down into the stomach. Other interventions, such as papain (can lead to aspiration, pneumonitis, esophageal perforation),34,64 and glucagon (can cause vomiting and aspiration),48,65 are no longer recommended. Esophagrams with oral contrast also are not routinely recommended unless the diagnosis is unclear, as the contrast can induce vomiting and lead to aspiration, or make direct endoscopic visualization and removal more difficult.25
Foreign Body Aspiration
Foreign body aspiration predominantly occurs in children younger than 4 years of age, with a peak incidence at 1-2 years of age. It is attributed to about 150 deaths per year, and approximately 17,000 ED visits.66 Aspiration of food can occur, with round fruits, nuts, hard candy, and seeds being most common. Other objects, such as smaller toys and jewelry, can be aspirated as well. Toy balloons, rubber gloves, or similar objects cause the highest number of fatal aspirations. Round objects (i.e., marbles), compressible objects, or those possessing a smooth surface are also very dangerous due to their ability to completely occlude the airway.67 Young children have underdeveloped molars and subsequently lack the ability to effectively chew and swallow, and when combined with inappropriate food size, choking events can occur. Other risk factors include playing with small toys, having older siblings who are feeding the child inappropriate items, being allowed to ambulate while eating, and developmental delay. The delayed child can pose a diagnostic dilemma, as many will not be able to give a history of aspiration, and often present as not acting like him/herself. Most foreign bodies wind up in a mainstem bronchus (80-90%), usually in the right mainstem because of the wider diameter and less acute angle it takes off of the trachea. Other locations include the trachea (3-12%) and the larynx (3-12%).68
About 50% of the time, children will present with symptoms following a witnessed choking event. Unfortunately that means that 50% of the time, this history will not be present, making the diagnosis difficult. Sometimes these children just present with a chief complaint of chronic cough or recurrent pneumonia.67 Symptoms depend on the location of the foreign body.69
- Larynx — aphonia, dysphonia, or hoarseness. These children can also present in full respiratory arrest if the foreign body is completely occlusive, making this one of the most dangerous aspiration types.
- Trachea — stridor (usually biphasic), cough, and respiratory distress. May also have tenderness over the trachea.
- Bronchus — cough, focal wheezing, decreased breath sounds over affected lung. It can be hard to differentiate from an asthma attack. However, wheezing with foreign bodies should be limited to a single lung or even lobe, whereas wheezing with asthma should be more global. In addition, recurrent pneumonias in the same area of the lung should raise concern for foreign body aspiration.
Imaging
All children who present with concern for foreign body aspiration should have an AP and lateral chest X-ray, possibly even a neck X-ray depending on symptoms. Radiopaque objects will be identified easily; however, if the object is r adiolucent, a negative chest X-ray does not exclude an aspiration.70 There may be more subtle findings such as obstructive atelectasis, midline shift, or overinflation. Lateral decubitus films and chest CTs are rarely helpful and should not be obtained routinely.71,72 Occasionally in a cooperative child, inspiratory/expiratory films can provide helpful information, but the yield on these is usually low. Even with negative imaging, bronchoscopy still may be necessary if the history and physical exam are concerning and suggestive of an aspiration event.70
Management
Foreign body aspiration is a medical emergency that needs to be addressed promptly. If the foreign body is thought to be lodged above the vocal cords and the child is either in full arrest or on the verge of decompensation, back blows and/or the Heimlich maneuver should be attempted. Blind finger sweeps are contraindicated. However, if the child shows signs of a partial obstruction, i.e., can still speak and cough, then intervention should be limited due to concerns of converting a partial obstruction into a complete one. If initial efforts of removal are unsuccessful, then direct laryngoscopy with removal of the object should be attempted immediately, preferably in the controlled setting of an operating room if feasible. If the object cannot be retrieved and is above the carina, then an attempt to push it more distally with an endotracheal tube should be made. Using the endotracheal tube, try to push the foreign body into either mainstem bronchus, then retract the tube to the level of the carina, thereby allowing ventilation of the unaffected lung. Children who are asymptomatic or mildly symptomatic should be kept calm with supplemental oxygen if needed, while appropriate imaging and consultations are made. Even if the child has negative imaging, but has a concerning history, symptoms, or physical exam findings, further consultation with a subspecialist still needs to be made. In many cases, these children will undergo bronchoscopy to clearly rule out foreign body.
The treatment of choice in these cases is bronchoscopy, in most cases using a rigid scope;67,69 however, some centers are performing flexible bronchoscopy. Determination of method usually depends on the type and size of the object, the location of the object in the respiratory tree, and the severity of symptoms the child is experiencing.
CONCLUSION
A common presentation to the ED, foreign bodies of the head and neck have a broad range in severity, from minor retrieval to life-threatening airway compromise. Certain objects, such as button batteries and magnets, require special considerations to avoid devastating consequences to the child. All providers need to understand potential issues, complications, and indications for referral to optimize each child’s outcome.
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MONOGRAPH: Diagnosing and managing ear, nose, and throat foreign bodies with discussion separated by location.
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