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Foreign Body of Airway

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Foreign Body of Airway

Foreign body aspiration represents a critical paediatric emergency that demands immediate recognition and intervention. It predominantly affects children under 3-4 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.

Vegetative v/s Non-vegetative foreign bodies

Vegetative materials (e.g., seeds and nuts) are common in younger children (<3-4 years) due to inadequate chewing, while Non-vegetative objects (plastic toy parts or small metallic objects) are more frequent in those over 5 years. The mortality rate is approximately 1%, making it a leading cause of accidental death in children under 3 years of age. Tracheobronchial foreign bodies are associated with higher complication rates compared to other sites.

Clinical presentation

It varies based on the obstruction site, with symptoms including choking signalled by coughing, hoarseness, shortness of breath leading to cyanosis, asphyxiation and death. The most common sites of lodgement are Right bronchus > left bronchus > trachea > larynx > lung. It is more commonly lodged in the right main bronchus because it more wider and less angulated than the left main bronchus. Urgency depends on the clinical condition of the patient, with delay till next morning is permissible in asymptomatic cases unless the patient is unstable or high-risk objects (e.g., batteries, peanuts, broken seeds) are involved.

Symptoms according to the site of lodgement

  • Bronchus: There is a classical triad of wheezing, cough and ipsilateral diminished air entry is seen.
  • Trachea: Audible “slap” or palpable “thud” sound during breathing.
  • Larynx: Partial obstruction leads to hoarseness, stridor, dyspnoea, prolonged atypical croup or odynophagia and complete obstruction leads to hypoxia, laryngospasm or death by asphyxiation.

Diagnosis

  • 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. 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.
  • CT Scan: When radiographic findings prove inconclusive but clinical suspicion remains high, a CT scan can detect radiolucent foreign bodies (peanuts, whistle and plastic toy) but cannot replace rigid bronchoscopy.
  • Rigid bronchoscopy: Rigid bronchoscopy under general anaesthesia stands as the diagnostic and therapeutic gold standard. 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 increases the risk of chronic complications, such as chronic cough, wheezing and bronchiectasis, particularly if the foreign body remains beyond three months, so stay alert.

Treatment

  1. Heimlich manoeuvre
  2. Rigid Bronchoscopy

1. Heimlich manoeuvre: It is an emergency life-saving procedure performed to dislodge foreign body objects from the airway 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: Partial obstruction (patient is able to speak, cough or breathe). 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.
  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. 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 stabilize 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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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 ENT Textbook

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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