Ingested and Aspirated Foreign Bodies S. Sarah Green, MD* *Pediatrics, Oregon Health & Science University, Portland, OR. Practice Gaps 1. Choking and the aspiration of food or other foreign objects remain causes of death and morbidity, particularly in the young child. Clinicians must learn to recognize and treat children who have foreign body aspirations. 2. Foreign body ingestion, particularly if undetected, can cause significant morbidity. Clinicians must be aware of the signs and symptoms as well as the management of foreign body ingestion. Objectives After completing this article, readers should be able to: 1. Describe the symptoms and treatment of an esophageal foreign body. 2. Know the signs and symptoms of an aspirated foreign body. 3. Understand how to evaluate a patient with suspected foreign body aspiration. 4. Delineate the possible radiographic manifestations of foreign body aspiration. 5. Explain how to differentiate between asthma and foreign body aspiration. 6. Know how to treat a patient with foreign body aspiration. INTRODUCTION The accidental ingestion of food, toys, and small household objects is a common pediatric complaint, resulting in many clinic and emergency department visits as well as hospitalizations. Infants and toddlers explore their world by putting objects in their mouths, placing themselves at risk for having foreign bodies in the esophagus or respiratory tract. This article reviews the current literature for signs and symptoms of both foreign body ingestion and aspiration as well as recom- mendations for appropriate evaluation and management. FOREIGN BODY INGESTIONS AUTHOR DISCLOSURE Dr Green has fi Background disclosed no nancial relationships relevant to this article. This commentary does not contain Data from the American Association of Poison Control National Poison Data a discussion of an unapproved/investigative System suggest that more than 110,000 ingested foreign bodies were reported in use of a commercial product/device. 430 Pediatrics in Review Downloaded from http://pedsinreview.aappublications.org/ by guest on November 16, 2018 2011, 85% of which occurred in the pediatric population. In the stomach, the child is usually asymptomatic but may that same year, 73% of foreign body ingestions occurred in exhibit clinical manifestations if the esophagus was injured children younger than age 5 years, with a peak incidence during transit of the object. Uncommon complications of between 6 months and 3 years. (1)(2) A combination of objects that travel through the pylorus relate to bowel obstruc- normal developmental curiosity, immature swallowing coor- tion. Symptoms may include abdominal pain, distention, dination, and the absence of molars and premolars puts this vomiting, and feeding intolerance. Bowel perforation is age group at a higher risk for ingestion and aspiration. (3) another rare but significant complication that is characterized Because children who have ingested a foreign body are often by abdominal pain, distention, vomiting, and fever. asymptomatic, the true incidence probably is higher. Subacute or chronic complications of an esophageal Commonly ingested items include coins, magnets, small foreign body may include damaged mucosa or strictures toys, buttons, bones, jewelry, and retained pieces of food. of the esophagus, decreased oral intake, failure to thrive, or Coins are the most common esophageal foreign bodies, recurrent aspiration pneumonia. (11) comprising up to 80% of items retained in the esophagus. (2) Most objects that are ingested pass through the gastro- Evaluation intestinal (GI) tract without incident, but 10% to 20% require Although many children who have ingested foreign bodies endoscopic removal; fewer than 1% require surgical inter- have normal findings on physical examination, a full evalu- vention. (1) Conditions that predispose children to retaining ation should be completed. Initial assessment should include the ingested object include anatomic and functional abnor- examining the airway and assessing breathing efforts. Stridor malities of the esophagus and GI tract, such as strictures, or wheezing could suggest obstruction, compression of the rings, esophageal dysmotility, achalasia, dysphagia, and a his- trachea, or a foreign body aspiration. The neck should be tory of esophageal atresia or tracheoesophageal fistula. (2) In examined for swelling or crepitus, suggestive of possible addition, food impaction can be a presenting symptom of esophageal perforation. Abdominal pain, rigidity, or rebound eosinophilic esophagitis and should be considered, particu- tenderness could be a sign of intestinal or colonic perforation. larly in older children and adolescents. (4)(5)(6)(7) After completing the physical examination, radiographs are often used for further evaluation of a patient with suspected Symptoms and Clinical Presentation foreign body ingestion. A history of ingestion or a choking The symptoms of foreign body ingestion are highly variable episode is sufficient indication to proceed with radiographs and largely dependent on the size and shape of the object, its because many children with confirmed foreign body inges- location, and the duration of time that it has been retained. tions are asymptomatic. Radiographs of the chest, including Up to 50% of children with known foreign body ingestion both posterior-anterior and lateral projections, can be helpful are asymptomatic. (8) The most common area of the esoph- in locating some radiopaque objects but can miss objects that agus in which a foreign body is retained is the upper areabovethethoracicinletorpastthepylorus.(2)Thus, esophagus, at the upper esophageal sphincter. This is the radiographs of the neck and abdomen should also be consid- site in 60% to 75% of cases. Approximately 10% to 20% of ered. Even if objects are radiolucent, there may be indirect esophageal foreign bodies are found in the mid-esophagus, signs of foreign body, such as air fluid levels in the esophagus. which is at the level of the aortic notch. The lower esoph- If patients are symptomatic and radiographs are negative, ageal sphincter is the site for up to 20% of objects retained in endoscopy can be used for diagnosis and treatment. Metal the esophagus. (2)(9)(10) If an object is lodged in the detectors have been found to be useful in some situations, esophagus, particularly in the upper esophagus, symptoms such as finding aluminum soda can flip tops or following can include drooling, blood in saliva, gagging, or dysphagia. coins that are known to have passed to the stomach. This If the object is large enough or oriented so as to compress practice is cost-effective and requires no additional radia- the trachea, patients may present with coughing, respiratory tion, but use of a metal detector cannot rule out all metal distress, or stridor. Some children complain of a pressure items, such as button batteries or needles. (2) sensation or pain in the neck, throat, chest, or abdomen. Special consideration is required if the ingested item is Patients may have vomiting, refuse food, or be irritable. suspected to be a battery or magnet, as discussed later in this Esophageal perforation may be characterized by swelling or article. crepitus of the neck. (2)(9)(11) Objects that travel past the esophagus generally do not Management cause symptoms, unless rare complications such as bowel The treatment of an esophageal foreign body depends on perforation or obstruction occur. (11) If the object passes into what the object is, where it is located, and what symptoms Vol. 36 No. 10 OCTOBER 2015 431 Downloaded from http://pedsinreview.aappublications.org/ by guest on November 16, 2018 the child is having. Although most ingested items pass High-powered magnets have become a more common through the GI tract without incident, there are a few sit- household item with the increasing popularity of magnetic uations in which removing the object is indicated. Most toys. Complications of ingesting more than one magnet or objects found in the esophagus at the time of examination a magnet and another metal object are now recognized. The remain there and may need to be removed by endoscopy. attraction of two objects across the walls of multiple loops of If clinical evaluation suggests esophageal perforation, a sur- bowel has led to ischemia, necrosis, perforation, and fistula. gery consultation should be obtained. Similarly, if there is It is often difficult to determine the presence of one or more concern that a foreign body is causing intestinal obstruction or magnets on a single radiographic view and two views are intestinal or colonic perforation, further evaluation with recommended (Fig 3). In addition, space between magnets abdominal imaging and a surgical consultation is indicated. should be considered concerning for mural entrapment Coins are the most commonly ingested foreign body. On (Fig 4). (16) If there is concern for the ingestion of multiple anteroposterior chest radiograph, a coin in the esophagus magnets or radiographic evidence of gaps between magnets, appears as a circular discs (“en face”), while the lateral view endoscopy should be performed for exploration and demonstrates a thick line (“on edge”). In contrast, a coin in removal. Although one magnet alone is unlikely to cause the trachea appears en face on the lateral view and on edge harm, the history of ingestion is often vague or absent. on the anteroposterior view. (12)(13) It is important to Imaging can help locate a magnet, but endoscopy should be distinguish coins from button batteries because a button considered because of the risk of morbidity and mortality. If battery in the esophagus should be removed urgently. magnets are out of endoscopic reach, surgical consultation A button battery has a “halo sign” or double density at the is indicated. In addition, surgical consultation is urgently periphery of the object en face. In contrast, a coin appears as recommended if there are any clinical or radiographic signs a discoid object of uniform attenuation (Fig 1). of bowel entrapment or perforation and should be consid- Most coins pass into the stomach and through the GI ered if magnets are failing to progress through the GI tract. tract without incident.