4 What are the common esophageal sites for lodgment of foreign bodies?

Most esophageal foreign bodies (60–70%) lodge at the level of the thoracic inlet at the cricopharyngeus muscle (Fig. 14-1). The other sites of lodgment include the lower esophageal sphincter and the level of the aortic arch. Patients with histories of congenital esophageal abnormalities or acquired strictures have objects (usually meaty foodstuffs) that impact at the area of anatomic narrowing.

Figure 14-1 Coin in the esophagus (plain radiography).

McGahren ED: Esophageal foreign bodies. Pediatr Rev 20:129–133, 1999.

Schunk JE, Corneli H, Bolte R: Pediatric coin ingestions: A prospective study of coin location and symptoms. Am J Dis Child 143:546–548, 1989.

5 What is the most common esophageal foreign body in children?

Coins are the most common esophageal foreign body, and pennies the most common coin in the United States. In cultures where fish is a main food staple, fish bones are common.

6 For a patient with a quarter in the stomach, how much time should be allowed for passage out of the stomach?

Some authors recommend a long period of observation (up to 6 weeks) for passage. Complications are uncommon; however, family members may not be willing to wait that long.

7 For an ingested coin that is in the stomach or beyond, should the family check the stool to ensure safe passage?

There is no good reason to recommend this unless the family interest level is particularly high. If the foreign body is not found, the family may request more unnecessary x-ray studies. Blunt small objects (coins) pass the remainder of the gastrointestinal tract without complications, typically in 3–8 days. The clever physician might suggest that the family “watch for any change.”

8 How should an esophageal foreign body be removed?

There is no single answer; not all esophageal foreign bodies are the same, and not all operators are created equal. Local referral patterns and provincial practice guide this decision. Esophagoscopy, used at many centers, is effective for essentially all types of foreign material, and complications are rare. Typically this is performed after the child receives general anesthesia. Alternatively, flexible endoscopy can remove some foreign bodies and may not require general anesthesia.

For blunt objects, the fluoroscopic Foley catheter technique can be used when skilled operators are available. The catheter is passed (through the nose) under fluoroscopic guidance beyond the coin; the balloon is inflated; and the object is pulled into the mouth, where it is expectorated. Alternatively, it can be pushed into the stomach. Bougienage also is used to advance blunt objects into the stomach. The “penny pincher” technique involves an endoscopic grasping forceps within a soft rubber catheter. The catheter is advanced under fluoroscopic guidance and the grasping forceps used to retrieve the coin. These three methods should not be used for sharp objects (e.g., screws, staples, or the little “scotty dog” from the Monopoly game), or when there is associated respiratory distress or stridor. These methods without direct visualization should not be used for objects impacted more than a few days.

Gauderer MW, DeCou JM, Abrams RS, Thomason MA: The “penny pincher”: A new technique for fast and safe removal of esophageal coins. J Pediatr Surg 35:276–278, 2000.

Schunk JE: Foreign body-ingestion/aspiration. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 307–314.

Schunk JE, Harrison AM, Corneli HM, Nixon GW: Fluoroscopic Foley catheter removal of esophageal foreign bodies in children: Experience with 415 episodes. Pediatrics 94:709–714, 1994.

Soprano JV, Mandl KD: Four strategies for the management of esophageal coins in children. Pediatr 2000;105:e5.

9 Is there a role for observation of impacted esophageal coins?

Many studies have shown that some (at least 30%) impacted esophageal coins pass spontaneously. If a blunt foreign body (e.g., coin) has been impacted for only a short duration, it is reasonable to allow for a short period (<1 day) for spontaneous passage as long as the child is comfortable. Repeated x-ray is needed to demonstrate that the coin has moved into the stomach.

Conners GP, Cobaugh DJ, Feinberg R, et al: Home observation for asymptomatic coin ingestion: Acceptance and outcomes. The New York State Poison Control Center Coin Ingestion Study Group. Acad Emerg Med 6:213–217, 1999.

Sharieff GQ, Brouseau TJ, Bradshaw JA, Shad JA: Acute esophageal coin ingestions: Is immediate removal necessary? Pediatr Radiol 33:859–863, 2003.

Soprano JV, Fleisher GR, Mandl KD: The spontaneous passage of esophageal coins in children. Arch Pediatr Adolesc Med 153:1073–1076, 1999.

10 What site of esophageal impaction is most likely to pass spontaneously?

Traditional teaching suggested that spontaneous passage of impacted esophageal foreign bodies, and particularly coins, was more likely from the lower esophageal sphincter. However, it is clear that spontaneous passage can occur from all typical (and nonpathologic) impaction sites.

Conners GP, Cobaugh DJ, Feinberg R, et al: Home observation for asymptomatic coin ingestion: Acceptance and outcomes. The New York State Poison Control Center Coin Ingestion Study Group. Acad Emerg Med 6:213–217, 1999.

Soprano JV, Fleisher GR, Mandl KD: The spontaneous passage of esophageal coins in children. Arch Pediatr Adolesc Med 153:1073–1076, 1999.

11 Can you promote passage of an impacted blunt esophageal foreign body with medication or otherwise?

Though some have reported successful use of medication, this information is clouded by the occurrence of spontaneous passage. A recent study found no benefit of using glucagon to induce passage of esophageal coins in children. Common sense agrees with those who advocate trial of carbonated beverage, bread, or crackers to promote passage from the esophagus, but there is no published data comparing such methods.

Mehta D, Attia M, Quintana E, Cronan K: Glucagon use for esophageal coin dislodgment in children: A prospective, double blind, placebo-controlled trial. Acad Emerg Med 8:200–203, 2001.

12 How quickly can a disc battery injure the esophagus?

Some reports suggest that impaction duration of less than 4–8 hours can cause mucosal injury. Removal should be emergent.

Samad L, Ali M, Ramzi H: Button battery ingestion: Hazards of esophageal impaction. J Pediatr Surg 34:1527–1531, 1999.

Sigalet D, Lees G: Tracheoesophageal injury secondary to disc battery ingestion. J Pediatr Surg 23:996–998, 1988.

13 Can other impacted blunt foreign bodies injure the esophagus?

Blunt foreign bodies are unlikely to injury the esophagus acutely. With increased duration of impaction, the mucosa grows over the object and serious complications may result. Undiagnosed, impacted blunt objects (even coins) have caused esophageal perforation, esophageal obstruction, abscess, mediastinitis, tracheoesophageal fistula, and even the potentially fatal aorto-esophageal fistula.

Katz KR, Emmens RW, Wood BP: Esophageal obstruction and abscess formation secondary to impacted eroding tiddlywink. Am J Dis Child 143:961–962, 1989.

Stuth EA, Stucke AG, Cohen RD, et al: Successful resuscitation of a child after exsanguination due to aortoesophageal fistula from undiagnosed foreign body. Anesthesiology 95:1025–1026, 2001.

14 Should sharp foreign bodies be removed from the stomach?

Most small, sharp foreign bodies (e.g., nails, pins, tacks, staples) are well tolerated. However, there is concern about the tendency for sewing needles to cause intestinal perforation. Objects that are larger than 4–5 cm may not negotiate the tighter bends in the gastrointestinal tract; consultation is recommended.

Panieri E, Bass DH: The management of ingested foreign bodies in children—a review of 663 cases. Eur J Emerg Med 2:83–87, 1995.

Schunk JE: Foreign body-ingestion/aspiration. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 307–314.

15 Classically, children with foreign bodies lodged in a bronchus or smaller airway have cough, decreased breath sounds, and new-onset wheezes. How often is this clinical constellation present?

Only about one-third of children with an aspirated foreign body have this classic triad. The longer the foreign body has been in place, the more likely this triad will be present, and the more prominent the symptoms. One study noted that 57% of children with foreign-body aspirations presented to the emergency department (ED) without symptoms, and 19% had normal physical examinations.

Losek JD: Diagnostic difficulties of foreign body aspiration in children. Am J Emerg Med 8:348–350, 1990.

Metrangolo S, Monetti C, Meneghini L, et al: Eight years’ experience with foreign-body aspiration in children: What is really important for timely diagnosis? J Pediatr Surg 34:1229–1231, 1999.

16 What do children aspirate?

Aspirated foreign bodies vary widely, but foodstuffs predominate. Nuts (especially peanuts) are the most common, followed by raw apples and carrots, seeds, and popcorn. Radio-opaque objects account for less than 15% of the cases.

Black RE, Choi KJ, Syme WC, et al: Bronchoscopic removal of aspirated foreign bodies in children. Am J Surg 148:778–781, 1994.

17 What signs/symptoms may be present in a child who aspirates a foreign body?

18 Should all children with a proven aspirated foreign body be admitted?

Yes. Since there are case reports of objects moving and causing acute respiratory distress or even obstruction, all children with an aspirated foreign body should be admitted until definitive removal of the foreign body.

19 How are the signs and symptoms of an aspirated foreign body different from those of other respiratory conditions?

Signs and symptoms of aspirated foreign bodies do not differ from those of very common conditions such as croup, asthma, bronchiolitis, and pneumonia. The history is key. In almost all instances of bronchoscopy-proven foreign-body aspiration, there is a history of choking—if only the appropriate questions are asked. For any pediatric patient with acute onset of respiratory symptoms or new onset of wheezing or coughing, a probing question regarding recent episodes of choking (especially with nuts, carrots, apples, or popcorn) detects most cases.

20 What is the best way to diagnose an aspirated foreign body?

Bronchoscopy is the only definitive way to diagnose airway foreign bodies. In the uncommon instances of radio-opaque objects (<15%), a plain x-ray is diagnostic. In many other instances, an inspiratory/expiratory chest x-ray will show indirect evidence of a retained foreign body: air trapping on the side of the foreign body during expiration. In equivocal cases, fluoroscopy may detect the object. However, fluoroscopy is only 70% sensitive. When there is a clear history of a choking episode involving the usual substances, with or without new symptoms or signs, the patient should undergo bronchoscopy, regardless of radiographic findings.

Black RE, Choi KJ, Syme WC, et al: Bronchoscopic removal of aspirated foreign bodies in children. Am J Surg 148:778–781, 1994.

Metrangolo S, Monetti C, Meneghini L, et al: Eight years’ experience with foreign-body aspiration in children: What is really important for timely diagnosis? J Pediatr Surg 34:1229–1231, 1999.

Schunk JE: Foreign body-ingestion/aspiration. In Fleisher GR, Ludwig S (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 307–314.

21 Are some foreign bodies more concerning when aspirated?

Of the commonly aspirated foodstuffs, nuts and other oil- or fat-containing substances present the greatest concern because they can contribute to a chemical pneumonitis. Sharp objects are uncommon, and most aspirations of radio-opaque objects tend to be inert. Some objects can be expected to dissolve without significant complications. Using candy as an example, small pieces of aspirated M&M candies are well tolerated, whereas pieces of peanut M&M candies must be removed.

22 A teenage boy presents to the ED after a choking episode while drinking beer. He reports that he removed the pull-tab of a beer can and placed it inside the can. Then he believes he may have swallowed or aspirated the pull-tab while gulping beer. What study is best to determine the location of the pull-tab?

Computed tomography of the chest may be needed. Plain radiographs generally do not show an aluminum pull-tab of a beer or soda can.

Bradburn DM, Carr HF, Renwick I: Radiographs and aluminum: A pitfall for the unwary. BMJ 308:1226, 1994.

23 What are the symptoms of a nasal foreign body?

Children usually report a nasal foreign body to family members after experiencing minimal discomfort or airway obstruction. In many instances, the family has already tried to remove it and failed. A unilateral purulent nasal discharge (due to prolonged impaction) occurs in less than one-third of cases.

Baker MD: Foreign bodies of the ears and nose in childhood. Pediatr Emerg Care 3:67–70, 1987.

24 What methods are available to remove nasal foreign bodies?

Removal with a forceps or alligator forceps under direct visualization is common. Though facilitated by a nasal speculum, this method cannot remove all nasal foreign bodies. Some objects are hard to grasp because of their shape (e.g., a small toy car wheel). Also, the mucous-laden nasal environment can hinder the process. A more reliable technique uses a small (6 Fr) Foley catheter:

Additional methods to remove a nasal foreign body rely on applying positive pressure to the mouth with a bag-mask apparatus. When the patient closes the glottis, passage can be affected by occluding the uninvolved nostril. Squeeze the bag forcefully over the mouth to expel the foreign body from the nose. Alternatively, ask a parent to blow into the patient’s mouth with the uninvolved nostril occluded. This is a low-cost, nonthreatening alternative.

Backlin SA: Positive-pressure technique for nasal foreign body removal in children. Ann Emerg Med 25:554–555, 1995.

Kadish H, Corneli HM: Removal of nasal foreign bodies in the pediatric population. Am J Emerg Med 15:54–56, 1997.

25 What methods are available to remove ear foreign bodies?

For most objects, direct visualization and use of an alligator forceps is effective. Irrigation may recover many other foreign bodies. Do not use irrigation for vegetable matter; the foreign body will swell and hinder removal. Some physicians use a drop of quick-acting glue on the noncotton end of a cotton swab and place this against the foreign body to allow it to be pulled out. Care must be taken not to glue the stick or the foreign body to the patient’s ear canal.

Baker MD: Foreign bodies of the ears and nose in childhood. Pediatr Emerg Care 3:67–70, 1987.

26 What about roaches and other insects in the external canal?

A moving insect in the ear canal is very painful and distressing. Lidocaine sprayed into the ear may encourage a hasty exit from the canal. Mineral oil placed in the canal may “drown” the insect and quickly relieve pain. The immobile insect can then be removed under direct visualization.

27 Should children be sedated for ear or nose foreign-body removal?

This depends on your level of comfort, but in general, nose foreign bodies can be removed without sedation. However, the inner one-third of the external auditory canal is exquisitely sensitive, and sedation may be needed for difficult foreign bodies in the ear. Refer ear foreign bodies where previous attempts have created ear canal trauma, or cases where the foreign body is against the tympanic membrane and not amenable to irrigations.

Bressler K, Shelton C: Ear foreign-body removal: A review of 98 consecutive cases. Laryngoscopy 103:367–370, 1993.