Swallowed Impacted Foreign Body-gp1

SWALLOWED IMPACTED FOREIGN BODY

SWALLOWED IMPACTED FOREIGN BODY

AETIOLOGYSENTATION NAME AGE

children often affected.

LOSS OF PROTECTIVE MECHANISMUse of upper denture – prevent tactile

sensation and FB is swallowed undetected.

Loss of consciousnessEpileptic seizuresDeep sleepAlcoholic intoxication

CARELESSNESSPoorly prepared foodImproper mastication, hasty drinking

and eating.

NARROWED ESOPHAGEAL LUMEN.Esophageal stricture or carcinoma.

PSYCHOTICSFB swallowed in suicidal attempt.

SITES OF IMPACTION

Tonsil Base of

tongue/vallecula Pyriform fossa

Esophagus

TONSILSharp fish bone or needle in one of

tonsillar crypts. Easily observed by oropharyngeal

examination and removed.BASE OF TONGUE/VALLECULA

Fish bone/needleCan be observed by mirror examinationCan be removed by curved forceps.

PYRIFORM FOSSAFish bone, chicken bone, needle, denture.

Small FB – removed under LA with curved forceps.

Large FB/children – under GA by endoscopy.

ESOPHAGUSCoin, piece of meat, chicken bone, denture, safety pin, marble

FB can be held up at 4 constrictions

4 CONSTRICTION OF ESOPHAGUSpharyngo –

esophageal junction (C6)-upper esophageal

sphincter(15 cm)

Bronco-aortic constriction (T4)

L main bronchus (T5)

diaphragmatic constriction (T10)-lower esophageal sphincter (40 cm)

At or just below cricopharyngeal sphincter-commonest site.

Flat objects (coins) – held up at sphincter. FB which pass the sphincter can be held

up at the next narrowing at broncho – aortic constriction / at the cardiac end

Sharp or pointed objects lodge anywhere in esophagus

CLINICAL FEATURES

History of initial choking or gagging. Discomfort or pain

Location- depend on site of impacted FB.

Increase on attempts to swallow. Dysphagia

Partial or total obstruction. Partial to total due to edema

Drooling of saliva In total obstruction. Aspirated saliva – pneumonitis.

Respiratory distressimpacted foreign body in upper

esophagus compress post wall trachea.

Substernal or epigastric painEsophageal spasmIncipient perforation.

SIGNS

Tenderness in lower part of neck on R / L of trachea

Pooling of secretion in the pyriform fossa on indirect laryngoscopy

Foreign body may be seen protruding from the oesophageal opening in the postcricoid region

INVESTIGATIONS

1. Plain x-ray -to show presence and location of radio-

opaque foreign bodySoft tissue lateral view of neck PA and lateral view of chest Children- x-ray from nasopharynx to

rectum (multiple foreign body may have been ingested)

A coin in this child esophagus.

This x-ray reveals a butterfly-shaped earring at the cricopharyngeus, the entrance to the oesophagus.

2.Fluoroscopy- cotton soaked in barium/barium filled capsule to swallow Passage observed through esophagusTo see radiolucent FB

MANAGEMENT

1. Esophagoscopic removal Most foreign body can be removed by

esophagoscopy under GA.2. Cervical esophagotomy

For impacted foreign body or sharp hooks (partial dentures located above thoracic inlet)

Removal through an incision in the neck and opening of cervical esophagus

3. Transthoracic esophagotomy For impacted foreign body of thoracic

esophagus Chest is opened at appropriate level.

Foreign body which has reached stomach may pass through GIT without difficulty→carefully examined the stools every day

Take normal diet and no purgatives should be administrated to hasten the passage

Operative interference may required when:

Pt complaint pain and tenderness in abdomen

F. bodies are not showing any progress (Serial x-ray taken at few days interval)

F. body is 5cm/longer in a child below 2 y.o

Presence of pyloric stenosis

COMPLICATIONS

Respiratory obstruction tracheal compression by FB, laryngeal edema

(in infants, children) Periesophageal cellulitis and abscess in

neck Perforation

by sharp objects may perforate esophageal wall (mediastenitis,

pericarditis or empyema), aorta (fatal). Tracheo-esophageal fistula - rare Ulceration and stricture

Overlooked FB

References: Dhingra, Diseases of ENT 5th edition