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A retrospective review of complicated foreign bodies of upper aerodigestive tract

Despite significant advances in prevention, first aid and endoscopic technology, foreign bodies of the upper aerodigestive tract in paediatric population remains a diagnostic and therapeutic challenge. Inhalation/ aspiration of foreign bodies (FB) into upper aerodigestive tract are very commonly encountered by otorhinolaryngologists but sometimes it can lead to fatal consequences. It is estimated that 1500 deaths occur annually related to the ingestion of foreign materials and 3000 deaths occur annually due to complications of foreign material aspiration. Special attention is to be given in cases of foreign bodies in esophagus and bronchus as they are the most difficult ones to identify and retrieve. The specific manifestations of an FB in the esophagus depend on the type of FB, the site where it is lodged, the degree of obstruction, and the length of time between ingestion and evaluation. In many children’s recurrent pneumonia and upper respiratory tract infections, or conditions that do not respond to appropriate medical management in children should always raise the suspicion of an aspirated foreign body.


INTRODUCTION
Despite significant advances in prevention, first aid and endoscopic technology, foreign bodies of the upper aerodigestive tract in paediatric population remains a diagnostic and therapeutic challenge. Inhalation/ aspiration of foreign bodies (FB) into upper aerodigestive tract are very commonly encountered by otorhinolaryngologists but sometimes it can lead to fatal consequences. It is estimated that 1500 deaths occur annually related to the ingestion of foreign materials and 3000 deaths occur annually due to complications of foreign material aspiration. 1 Special attention is to be given in cases of foreign bodies in esophagus and bronchus as they are the most difficult ones to identify and retrieve. The specific manifestations of an FB in the esophagus depend on the type of FB, the site where it is lodged, the degree of obstruction, and the length of time between ingestion and evaluation. 2 In many children's recurrent pneumonia and upper respiratory tract infections, or conditions that do not respond to appropriate medical management in children should always raise the suspicion of an aspirated foreign body. 3

METHODS
A retrospective study from May 2011 to May 2013 was conducted in department of ENT-Head and Neck Surgery, Rajarajeswari Medical College and Hospital, Bangalore. The data was retrieved from the medical records department with the permission of institutional ethical committee and collected data was analyzed using Microsoft excel.
A total of 50 eligible patients were reviewed who got operated for foreign body in upper aerodigestive tract.

Inclusion criteria
Patients of any age group presented with or without history of swallowing, inserting or inhaling foreign bodies with symptoms like dysphagia, drooling of saliva, stridor, wheeze and acute respiratory distress were included in the study.

Exclusion criteria
Those patients in whom foreign body was removed in the minor operation theatre without any sedation were excluded from the study. Foreign bodies passing beyond oesophagus and foreign body in the lung tissue were not included in the study.

Procedure
All the procedures were performed under general anesthesia. For nasal foreign bodies in most of the cases 0 degree nasal endoscope was used to visualize the foreign body and removed with the help of Tilley's forceps and curved probe, similarly for the digestive tract foreign bodies' rigid oesophagoscope was used and for the bronchial foreign bodies both rigid and flexible bronchoscopes were used for the removal of foreign bodies.

RESULTS
Cases were categorized as nasal foreign bodies, digestive tract foreign bodies and airway foreign bodies. Analysis of positive cases revealed the following observations.

Gender
A total of 50 patients were included in the study out of which 35 patients were male and 15 patients were female.

Age of the patient
Most of the patients were in age group of 1-5 years i.e. 20 patients, 15 patients were in age group of 5-10 years, 6 patients were in age group of 10-15 years and rest of the patients i.e. 9 patients were in age group of 15-30 years.

Percentage
In our study nasal foreign bodies were seen in 48% of the patients, airway foreign bodies were found to be in 28% of the patients and 24% of the patients presented with digestive tract foreign bodies.

Site of foreign body
The most common site of foreign body impaction was nasal cavity (33%), cricopharynx was the second most common site (22%), and the third most common site was right main bronchus (17%). Other sites of foreign body impaction are depicted in Figure 3.

Nature of foreign body
Vegetative foreign bodies were seen in 54% of the patients and non vegetative foreign bodies were seen in the 46% of the patients.

Complications
Nasal bleeding was the most common complication that was encountered in 3 patients, other complications encountered were; septal perforation, mucosal injury in nasal cavity, pneumonia and broncospasm.

DISCUSSION
Foreign body in the airway constitute a medical emergency and requires immediate attention, the basic principles of their extraction were meticulously developed by Jackson, whose concepts of the mechanical problems encountered and demonstration of their solutions are responsible for keeping morbidity and mortality at minimum. 1 Koempel et al in their clinical study stated that commonest symptoms are drooling of saliva, dysphagia, poor feeding and vomiting. 2

Age of presentation
In our study of foreign bodies in aerodigestive tract about 20% of the patients were 1-5 years. This is similar to Lemberg et al review of patients treated over a 5-year period in which 17% of the patients were 5 years of age or older. 4 These data suggest that older children and adolescents represent a distinct group of patients at risk for foreign body accidents.

Types of foreign body
Nasal foreign bodies: In our study we encountered a wide range of foreign bodies, of which tamarind seed 25% and ground nut 13% were the most common found foreign bodies in the nasal cavity. In total, 54% of the cases were vegetative foreign bodies and 46% were non-vegetative.
Digestive tract foreign bodies: Currency coins 67% were the most common followed by meat piece 17% in our study. Fish bone and other substances were also encountered. Hawkins in his paper on 246 oesophagoscopies performed over a 19-yearperiod to remove blunt oesophageal foreign bodies reported that 81% of the foreign bodies were coins which correlate with our study. 5 Airway foreign bodies: In our study, tamarind seed 36% was the most common, followed by ground nut 21% along with betel nut 21%. In Banerjee, et al's an analysis of the management of 223 children with laryngotracheobronchial foreign bodies 168 cases (66.4%) of the recovered foreign bodies were organic in origin, the majority of them being peanuts which is similar to our study. 6

Site of foreign body
Nasal cavity foreign bodies: 96% of the cases were unilateral cases in our study; foreign body in right nasal cavity was 50% and 46% in the left nasal cavity.
Digestive tract foreign bodies: In our study 67% of the cases, foreign bodies were in Cricopharynx, 25% were in pyriform sinus. In a study by Shivakumar et al, of the total number of 152 patients, most of blunt foreign bodies in children 83.5% were impacted in post cricoid region whereas in adults, the foreign bodies 37.5% were seen in upper esophagus which correlates with our study. 7 Airway foreign bodies: In our study, right main bronchus constituted 50% followed by left main bronchus. In a retrospective review of 400 Chinese children who had inhaled foreign bodies was undertaken, the majority of the foreign bodies were found most often in right bronchial tree (46%) which is similar to our study. 8

CONCLUSION
Foreign bodies in the upper aerodigestive tract are a common clinical problem in otolaryngological practice as evident in this study. Symptoms of foreign bodies in the aerodigestive tract are mainly non-specific and needs high degree of suspicion, experience and clinical acumen. Signs are also variable from case to case and inconstant in a particular case. However the only single reliable factor is a positive history which often is not contributory in spite of careful and tactful attempt to elicit it and particularly in children where it goes unnoticed. An orderly and systematic approach along with proper history and clinical examination is keystone in diagnosis and early management.