Foreign Body of Airway

Foreign Body of Airway

Foreign body aspiration represents a critical paediatric emergency that demands immediate recognition and intervention. It predominantly affects children under 1-4 years of age, with a higher incidence in boys. Young children frequently place small objects in their mouths, and their underdeveloped chewing ability (due to lack of molars) increases the risk of aspiration. Eating while playing, running, or crying also significantly increases risk. However, it can also occur in adults, particularly during alcoholic intoxication, under general anaesthesia, or following sedation. The overall mortality rate is approximately 1%, tragically making it a leading cause of accidental death in children under three years of age.

Classification of Foreign Bodies (FBs)

1. Vegetative (Organic)
2. Non-vegetative foreign bodies (Inorganic)

Feature	Vegetative FBs (Organic)	Non-Vegetative FBs (Inorganic)
Examples	Peanuts (most common), seeds, nuts, popcorn, legumes.	Plastic toy parts, coins, metallic objects, batteries.
Age Group	More common in younger children (< 3-4 years).	More frequent in older children (> 5 years) and adults.
Inflammatory Reaction	High. Release of fatty acids (especially from peanuts) causes marked, rapid, severe mucosal inflammation, oedema, and granulation tissue formation (Bronchitis/Pneumonitis).	Low. Less immediate inflammatory response.
Radiopacity	Radiolucent (Invisible on plain X-ray).	Often Radio-opaque (Visible on plain X-ray).
Urgency	More urgent removal due to rapid inflammation.	Less urgent unless it is a Button Battery (chemical burn risk).

Anatomical Sites of Lodgement

The most common sites of lodgement are the Right bronchus > left bronchus > trachea > larynx > lung. It is more commonly lodged in the right main bronchus because it more wider and less angulated (more in line with the trachea) than the left main bronchus.

Clinical Presentation: The Triphasic Course

A foreign body that partly blocks the larynx can cause throat discomfort, hoarseness, loss of voice, breathing difficulty, cough, and sometimes blood in the cough. A large foreign body can block the airway completely and cause acute breathing distress. The clinical presentation of FBA is highly variable, often following a triphasic course, which every student must recognise.

1. Initial Phase (Immediate). This phase is characterised by the sudden onset of symptoms as the foreign body impacts the airway, lasting only minutes. The Classical Signs are choking, gagging, violent coughing paroxysms, hoarseness, and reflex laryngospasm. If the obstruction is severe, it can rapidly progress to cyanosis, aphonia, asphyxia, and death.
2. Asymptomatic Interval (Symptom-Free). This is the most dangerous phase because a false sense of security develops. The initial cough and gag reflex subside as the tracheobronchial tree becomes tolerant to the foreign body. The child may appear deceptively normal, yet the FB remains lodged, awaiting secondary complications.
3. Complication Phase (Late). Symptoms reappear days or weeks later due to secondary pathology. Tracheobronchial foreign bodies are associated with higher complication rates compared to other sites.

• • Local: Mucosal oedema, ulceration, granulation tissue formation, and mucosal injury.
  • Pulmonary: Recurrent or persistent cough, persistent or recurrent wheezing (often unilateral), fever, signs of pneumonia, lung collapse (atelectasis), or hyperinflation.

Clinical features according to the site of lodgement

The site of the foreign body often determines the clinical presentation and management; therefore, predicting the site is key.

1. Larynx: Partial obstruction leads to hoarseness, stridor, dyspnoea, prolonged atypical croup or odynophagia, and complete obstruction leads to hypoxia, laryngospasm or death by asphyxiation.
2. Trachea: A tracheal foreign body not large enough to move into the bronchi will move up and down the trachea with respiration, leading to a palpatory thud and an audible slap.
3. Main Bronchus: There is a classical triad of wheezing, cough and ipsilateral diminished air entry.
4. Small Bronchi/Bronchiole: A foreign body small enough to reach the tertiary bronchi will lead to localised expiratory wheeze. The wheeze occurs due to partial blockade of the bronchi.

Viva tip: Sudden onset of a wheeze, usually unilateral, in a child not previously known to have asthma, should raise a suspicion of FB inhalation.

Diagnosis

1. History and Physical Examination

• History: A sudden episode of choking, coughing, or gagging is the most important clue.
• Examination: Look for the Classical Triad, check for signs of respiratory distress, and perform a full chest auscultation. Unilateral wheezing is a powerful sign.

2. Imaging: Chest X-rays are normal in 11–26% of cases unless there are radio-opaque foreign bodies (metallic foreign bodies like coins or button batteries) present. Identification of the location of a swallowed or inhaled coin on X-ray depends on how it appears in AP and lateral views. In the trachea, the appearance is the opposite: it looks like a line on AP view and round on lateral view. In the oesophagus, the coin usually looks round on AP view and is seen end-on or as a line on lateral view. This difference is because the oesophagus is wider from side to side than front to back, whereas the trachea is wider from front to back than side to side.

Vegetative foreign bodies can result in atelectasis, hyperinflation, mediastinal shift, pneumonia and pneumothorax. Classically, there is hyperinflation of the lung on the side of the foreign body due to the ‘ball-valve’ effect.

3. CT Scan: When radiographic findings are inconclusive but clinical suspicion remains high, a CT scan can detect radiolucent foreign bodies (peanuts, whistles, and plastic toys), but it cannot replace rigid bronchoscopy.

4. Rigid bronchoscopy: Rigid bronchoscopy under general anaesthesia stands as the diagnostic and therapeutic gold standard. It allows for direct visualisation of the foreign body and its removal. However, a negative bronchoscopy doesn’t mean failure – surgeons must still suspect foreign body aspiration since the tests miss it 60% of the time.

Treatment

1. Heimlich manoeuvre: It is an emergency life-saving procedure performed to dislodge foreign body objects from the upper airway (above the level of cricoid cartilage) and has significantly reduced fatalities. The steps of manoeuvre are different in conscious and unconscious patients.

Conscious patients:

1. Indication: Complete obstruction (patient is choking and is not able to speak, cough or breathe).
2. Contraindication: Infants, children less than one year age, partial obstruction (patient is able to speak, cough or breathe) and unconscious patients. Manoeuvre may dislodge the foreign body and lead to complete airway obstruction.
3. Technique: Stand behind the person. Make a fist and place it just above the belly button (navel), below the rib cage and grab your fist with your other hand. Give quick, strong upward and inward thrusts (towards yourself). Repeat 6–10 times until the object comes out. Be gentle with children and avoid injury to organs like the liver, spleen, and ribs. In obese or pregnant patients, use chest thrusts instead of abdominal ones. If nobody is present to assist in the Heimlich manoeuvre, the choking individual may self-administer thrusts with his or her fist or by forcibly leaning against a firm object such as the back of a chair.
4. Complications: Oesophageal rupture, diaphragmatic hernia and mediastinal emphysema.

 Unconscious patients:

1. Indication, contraindication & complications are the same as above.
2. Technique: First, position the patient supine and seek immediate help. Then the finger sweep manoeuvre is done, i.e., removal of the foreign body with the finger only if the foreign body is visible. Check the mouth for any visible foreign object and remove it if possible. Assess breathing, and if absent, initiate Heimlich’s manoeuvre by delivering 5–6 upward and backwards abdominal thrusts just above the navel. Continue the cycle of finger sweep, rescue breaths, and abdominal thrusts until breathing is restored. If the obstruction is at the glottis or supraglottis and persists, an emergency cricothyrotomy or tracheostomy may be necessary to secure an airway and stabilise the patient for hospital transfer.

 Child patients: In cases where a child is choking and unable to breathe, start with a sequence of back blows followed by chest thrusts. After the chest thrusts, perform a tongue-jaw lift by placing your thumb in the child’s mouth, grasping the lower incisor teeth, and gently lifting the jaw to open the airway. Check for any visible foreign body and remove it if present. Begin rescue breathing and continue repeating the sequence of back blows, chest thrusts, and tongue-jaw lift until the foreign body is expelled or the child resumes normal breathing.

2. Rigid Bronchoscopy: Flexible bronchoscopy is a useful diagnostic tool for detecting airway foreign bodies, but the gold standard remains rigid bronchoscopy under general anaesthesia. A direct laryngotracheobronchoscopy or microlaryngotracheobronchoscopy (MLTB) should be promptly performed to identify and remove the foreign body. Common airway foreign bodies include plastic toys with whistles, which may be accidentally inhaled by children while playing, and broken seeds that can release oil, leading to granulation, inflammation, and swelling. In such cases, topical adrenaline reduces inflammation & bleeding from inflamed tissue. After removing the foreign body, a second look is essential to ensure no fragments remain. Complications (4% risk) include pneumothorax, haemorrhage, and hypoxia, with higher risks in infants and prolonged procedures.

If endoscopic removal fails, surgical alternatives such as tracheal fissure (similar to a tracheostomy incision) for tracheal foreign bodies, or thoracotomy for bronchial foreign bodies, may be necessary. A negative bronchoscopy doesn’t mean failure – surgeons must still suspect foreign body aspiration since the tests miss it 60% of the time. Delayed diagnosis can cause permanent lung damage (like bronchiectasis), so stay alert.

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High-Yield Points for Quick Revision

1. Most Common Site. Right Main Bronchus (Wider, Shorter, Less Angulated).
2. Gold Standard. Rigid Bronchoscopy (Diagnostic and Therapeutic).
3. Most Common FB. Peanuts (Vegetative, Radioluscent, Highly Inflammatory).
4. Classic Triad. W.C.D. (Wheeze, Cough, Diminished Air Entry).
5. Radiological Sign. Ball-Valve Effect (Hyperinflation on affected side on Expiratory X-ray).
6. Heimlich Manoeuvre. Indicated for Complete Obstruction in patients > 1 year.
7. Button Battery. Urgent removal due to risk of chemical burn/perforation.
8. Long-Term Complication. Bronchiectasis (due to chronic obstruction/infection if diagnosis is delayed > 3 months).

Clinical Scenarios for Practical & Viva Prep

Scenario 1: The Choking Toddler

Case: A 2-year-old boy is brought to the Emergency Department with a sudden onset of severe coughing and respiratory distress immediately after eating peanuts. The child is now quiet, with no stridor, but his mother reports a brief choking episode an hour ago. On examination, he has a localised expiratory wheeze and decreased air entry on the right side.

• Question 1: What is the most likely diagnosis? Answer: Foreign Body Aspiration (most likely a peanut in the right bronchus).
• Question 2: What is the most crucial next step in management? Answer: Prepare for and perform Rigid Bronchoscopy under general anaesthesia. The “asymptomatic interval” is misleading; the clinical history and findings (unilateral signs) mandate definitive intervention.
• Question 3: Which radiological finding is most pathognomonic, and how is it confirmed? Answer: The “Ball-Valve” Effect (air trapping causing hyperinflation), confirmed by an Expiratory Chest X-ray or Fluoroscopy.

Scenario 2: The Atypical Asthmatic

Case: A 7-year-old girl has been treated for recurrent, non-responsive asthma over the last 4 months. She has a persistent cough and unilateral wheezing on the left side that does not improve with bronchodilators. Her parents recall a distant, minor choking episode while she was playing with a small toy whistle.

• Question 1: What should be the primary suspicion now? Answer: Retained Foreign Body Aspiration. The diagnosis of “asthma” is a common misdiagnosis for a chronic FBA.
• Question 2: What is the best diagnostic step, given the long duration? Answer: CT Scan (High-Resolution) to confirm the presence of a radiolucent FB and assess for secondary changes like localised pneumonia or bronchiectasis, followed by Rigid Bronchoscopy for removal.
• Question 3: If the FB is a small plastic whistle, what is the immediate risk during the initial choking episode? Answer: Laryngeal obstruction leading to severe dyspnea, laryngospasm, and sudden asphyxiation.

Foreign Body Airway MCQs 

1. The definitive gold standard procedure for both diagnosis and therapeutic removal of a tracheobronchial foreign body in a child is: A. Flexible Bronchoscopy B. High-Resolution CT Scan C. Rigid Bronchoscopy D. Tracheal Fissure
2. A 3-year-old child presents with sudden coughing and a unilateral expiratory wheeze. A Chest X-ray is normal. The most likely foreign body aspirated is: A. A coin B. A metallic pin C. A button battery D. A peanut
3. The most common site of lodgement for an aspirated foreign body in the airway is the: A. Larynx B. Trachea C. Right Main Bronchus D. Left Main Bronchus
4. A “Ball-Valve” mechanism in a bronchial foreign body leads to which of the following radiological signs? A. Atelectasis on the affected side. B. Mediastinal shift towards the affected side. C. Pneumothorax. D. Hyperinflation of the affected lung on expiration.
5. The Heimlich maneuver is contraindicated in a patient who is: A. Obese B. Pregnant C. A conscious infant (< 1 year) D. Unconscious adult
6. The classical triad of a bronchial foreign body consists of cough, wheezing, and: A. Stridor B. Fever C. Hoarseness D. Diminished ipsilateral air entry
7. A major risk factor associated with a retained vegetative foreign body (like a peanut) is: A. Its large size causing complete obstruction. B. Its sharp edges causing mucosal tear. C. The release of fatty acids causing severe inflammation and granulation. D. Its metallic nature causing chemical burns.
8. Which of the following surgical procedures is considered when a bronchial foreign body removal fails endoscopically? A. Laryngectomy B. Cricothyrotomy C. Thoracotomy D. Tracheostomy
9. The asymptomatic interval following a foreign body aspiration is dangerous primarily because: A. The foreign body may move to the opposite bronchus. B. It gives a false sense of security, delaying definitive intervention. C. Granulation tissue begins to form during this period. D. The patient develops secondary bacterial infection.
10. In a conscious adult with complete airway obstruction, the appropriate modification for performing the Heimlich maneuver on a pregnant woman is to use: A. Back blows B. Chest thrusts C. Increased force on abdominal thrusts D. Abdominal thrusts above the sternum

MCQ Answers and Explanations

1. C. Rigid Bronchoscopy: It is the only modality that is both diagnostic and therapeutic, allowing controlled removal and airway maintenance.
2. D. A peanut: Vegetative FBs are radiolucent (normal X-ray) and common in this age group, causing secondary signs like wheeze/air trapping.
3. C. Right Main Bronchus: Due to its wider diameter, shorter length, and more vertical angle.
4. D. Hyperinflation of the affected lung on expiration: The ball-valve effect allows air in but restricts air out, leading to air-trapping/hyperinflation.
5. C. A conscious infant (< 1 year): In infants, back blows followed by chest thrusts are performed to avoid liver/spleen injury.
6. D. Diminished ipsilateral air entry: The classic triad is cough, wheeze, and diminished air entry.
7. C. The release of fatty acids causes severe inflammation and granulation: This is the hallmark of a vegetative FB, often necessitating topical adrenaline during removal.
8. C. Thoracotomy: This is the surgical approach to access and remove a long-standing, distal bronchial foreign body.
9. B. It gives a false sense of security, delaying definitive intervention: The apparent normalcy prevents parents/doctors from seeking/performing definitive treatment.
10. B. Chest thrusts: To avoid pressure on the gravid uterus.

Frequently Asked Questions in Viva

• What is the classic clinical presentation triad of a bronchial foreign body? The classic triad is cough, unilateral wheezing, and ipsilateral diminished air entry.
• Why is the right main bronchus the most common site for foreign body lodgement? The right main bronchus is wider, shorter, and less acutely angled than the left, making it a more direct pathway from the trachea.
• Why is a chest X-ray often normal in a case of confirmed foreign body aspiration? A chest X-ray is often normal because the most common aspirated objects, such as peanuts and seeds, are radiolucent (not visible on plain X-ray).
• What is the “Ball-Valve” effect in foreign body aspiration? The Ball-Valve effect is the mechanism where the foreign body allows air to pass into the lung on inspiration but restricts its exit on expiration, leading to air trapping and hyperinflation.
• When is it permissible to delay rigid bronchoscopy for a foreign body? A delay of up to 24 hours is permissible only in an asymptomatic, hemodynamically stable patient with a non-high-risk foreign body (not batteries or reactive organic material), to ensure optimal surgical and anesthetic team readiness.
• What is the alternative emergency procedure for an infant (< 1 year) who is choking? The alternative is a sequence of five back blows followed by five chest thrusts, repeated until the object is expelled.
• What is the most serious long-term complication of a delayed foreign body diagnosis? The most serious long-term complication is the development of chronic lung damage, most commonly bronchiectasis.
• Download the full PDF Link:

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Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Cummings, Otolaryngology-Head and Neck Surgery.
• Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
• Ballenger’s, Otorhinolaryngology Head And Neck Surgery
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
• Ganong’s Review of Medical Physiology.
• Guyton & Hall Textbook of Medical Physiology.

Author:

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

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