Residency · Residency · Otolaryngology
Pediatric Foreign Body: Airway and Esophageal
Overview
Foreign body ingestion and aspiration are common pediatric emergencies. The otolaryngologist must be proficient in rigid bronchoscopy and esophagoscopy for foreign body retrieval. Button battery ingestion is a true emergency requiring immediate removal due to rapid tissue destruction. Timely diagnosis and management prevent life-threatening complications including airway obstruction, esophageal perforation, and mediastinitis.
Airway Foreign Body
Epidemiology
Peak incidence: ages 1-3 years (oral exploratory phase, incomplete dentition, immature swallowing coordination). Leading cause of accidental death in children <1 year. Most common objects: peanuts, other nuts/seeds, small toy parts, grapes, popcorn. Organic materials cause more inflammation than inorganic.
Clinical Presentation
Choking episode: witnessed event in 80-90% (critical history). Acute phase: coughing, gagging, stridor, wheezing. Asymptomatic interval: foreign body lodges, symptoms may temporarily improve (can mislead clinicians). Complications phase: cough, recurrent pneumonia, atelectasis, wheezing (often misdiagnosed as asthma).
Location
Laryngeal: least common but most dangerous; immediate airway compromise. Right mainstem bronchus: most common site in older children and adults (more vertical angle). Left mainstem bronchus: more common in younger children (more symmetric bronchial angles). Tracheal: ball-valve effect; bilateral air trapping.
Diagnosis
History of choking event is the single most important diagnostic clue. Chest X-ray (AP and lateral): inspiratory and expiratory films. Radiopaque foreign body: directly visible (<20% are radiopaque). Hyperinflation on the affected side (air trapping due to ball-valve effect): best seen on expiratory film. Atelectasis: complete obstruction. Mediastinal shift: toward the contralateral side on expiration. Lateral decubitus films: in young children who cannot cooperate with expiratory films; affected side remains hyperinflated when dependent. CT chest: rarely needed; may help localize radiolucent foreign bodies. Fluoroscopy: dynamic assessment of air trapping and mediastinal shift. Normal X-ray does not exclude foreign body: if clinical suspicion is high, proceed to bronchoscopy.
Management: Rigid Bronchoscopy
Gold standard for both diagnosis and treatment. General anesthesia with spontaneous ventilation (maintain respiratory effort). Ventilating rigid bronchoscope (Storz, Holinger). Systematic examination: larynx, trachea, right and left mainstem bronchi, segmental bronchi. Optical forceps, balloon catheter, or grasping forceps for retrieval. Remove foreign body through the bronchoscope or alongside it. Post-removal: inspect for residual fragments, mucosal injury, granulation tissue. Dexamethasone for airway edema, Chest X-ray post-procedure.
Complications of Delayed Diagnosis
Pneumonia, lung abscess, Bronchiectasis, Granulation tissue formation, Erosion into adjacent structures, Pneumothorax, pneumomediastinum.
Esophageal Foreign Body
Epidemiology
Peak age: 6 months to 3 years. Most common objects: coins (most common in children), food bolus (more common in adults), button batteries, small magnets, sharp objects.
Sites of Impaction
| Site | Level | Frequency | Notes |
|---|---|---|---|
| Cricopharyngeus (UES) | C6 | Most common (70%) | Narrowest point of esophagus in children |
| Aortic arch | T4 | Second most common | Extrinsic compression |
| Lower esophageal sphincter | T11 | Third most common | Physiologic narrowing |
Cricopharyngeus (C6/upper esophageal sphincter): most common site in children (70%). Aortic arch (T4): second most common. Lower esophageal sphincter (T11): third most common. Pre-existing esophageal narrowing: eosinophilic esophagitis, prior repair of esophageal atresia, stricture.
Clinical Presentation
Drooling, dysphagia, odynophagia, food refusal, Chest or neck pain, vomiting. Respiratory symptoms: stridor, wheezing (tracheal compression by esophageal foreign body). May be asymptomatic (especially coins). Infants: irritability, feeding refusal.
Diagnosis
AP and lateral X-rays of the neck and chest: Coins: flat (circular) on AP, edge-on (linear) on lateral (mnemonic: esophageal coin is round on AP). Button battery: double-ring or halo sign on AP (step-off at the junction of anode and cathode). Multiple magnets: may appear as a single foreign body but are dangerous if across tissue layers. Distinguish esophageal from tracheal foreign body: esophageal coin is sagittal (coronal on AP); tracheal coin is coronal (sagittal on AP).
Management
Coins
Observation for 12-24 hours if asymptomatic and in the distal esophagus (may pass spontaneously). Proximal esophageal coins or symptomatic: removal within 24 hours. Methods: rigid esophagoscopy (gold standard), flexible endoscopy, Foley catheter extraction (controversial; must exclude button battery first).
Button Battery (EMERGENCY)
Most dangerous esophageal foreign body. Tissue injury begins within 15-30 minutes of impaction. Mechanism: generates an external circuit; hydroxide ions produced at the negative pole cause liquefactive necrosis (alkaline burn). Burns through esophageal wall in as few as 2 hours. Complications: esophageal perforation, mediastinitis, tracheoesophageal fistula, aortoesophageal fistula (fatal), vocal fold paralysis, esophageal stricture. Management: Immediate removal (within 2 hours of ingestion if esophageal). If ingestion was <12 hours ago and child is asymptomatic with battery in the stomach: may observe with serial X-rays (most pass spontaneously). Honey or sucralfate administration pre-hospital if arrival >1 hour: emerging evidence that these agents neutralize the alkaline burn and reduce injury severity (NBIH National Battery Ingestion Hotline protocol). Post-removal: assess for mucosal injury with endoscopy. If significant burn: esophageal stenting, NPO, serial imaging for delayed perforation/fistula.
Sharp and Pointed Objects
Higher perforation risk, Remove endoscopically regardless of symptoms. Pass the object trailing edge first to minimize mucosal injury.
Multiple Magnets
Two or more magnets (or a magnet + metallic object): can attract across bowel walls causing pressure necrosis, fistula, perforation, obstruction. Endoscopic or surgical removal indicated. Single magnet in the stomach: may observe if no other metallic objects ingested.
Rigid Esophagoscopy Technique
General anesthesia with endotracheal intubation, Jackson or Storz rigid esophagoscope. Position: supine, head extended (sniffing position in infants). Advancement under direct vision; never advance blindly. Identify the foreign body, grasp with optical or alligator forceps. Inspect the mucosa after removal for injury. Post-procedure: chest X-ray, observation for perforation signs.
<image>Radiographic identification of esophageal foreign bodies. Four panels. Panel A: AP chest X-ray showing a coin in the upper esophagus (circular appearance in the coronal plane). Panel B: Lateral X-ray of the same coin seen edge-on (linear appearance). Panel C: AP X-ray showing a button battery in the esophagus with the characteristic double-ring or halo sign indicating the step-off between the anode and cathode. Panel D: AP X-ray of two small magnets in the GI tract that appear to be aligned across bowel walls, suggesting attraction through tissue. Comparison diagram distinguishes coin (uniform disc) from button battery (stepped edge, double density ring) on AP X-ray.</image>
<image>Rigid bronchoscopy for airway foreign body removal. Panel A: Setup showing the ventilating rigid bronchoscope with Hopkins telescope, light source, and anesthesia connection for spontaneous ventilation. Panel B: Endoscopic view of a peanut fragment lodged in the right mainstem bronchus with surrounding mucosal edema and granulation tissue. Panel C: Optical forceps grasping the peanut for removal through the bronchoscope. Panel D: Post-removal endoscopic view showing the right mainstem bronchus with mucosal erythema and granulation tissue but patent lumen. Labels identify the bronchoscope components, foreign body, and relevant airway anatomy.</image>
<image>Button battery esophageal injury mechanism and timeline. Cross-sectional diagram of a button battery lodged in the esophagus showing the electrical circuit generated between the positive (anode) and negative (cathode) poles through the moist esophageal tissue. Hydroxide ions accumulate at the negative pole causing liquefactive necrosis (alkaline burn). Timeline of injury: 15 minutes -- mucosal injury begins; 2 hours -- full-thickness esophageal burn possible; 8-12 hours -- perforation risk; days to weeks -- delayed complications (tracheoesophageal fistula, aortoesophageal fistula, stricture). Post-removal endoscopic images show grades of mucosal injury from superficial burn to deep ulceration.</image>
Clinical Pearls
A witnessed choking event followed by paroxysmal coughing, even with subsequent symptom resolution, should be presumed to be a foreign body aspiration until proven otherwise; normal chest X-ray does not exclude the diagnosis. The "double-ring" or halo sign on AP X-ray distinguishes a button battery from a coin; this distinction is critical because button battery impaction in the esophagus is a surgical emergency requiring removal within 2 hours. Button batteries generate an alkaline burn that begins within 15 minutes; pre-hospital administration of honey (in children > 12 months) may reduce injury severity while awaiting endoscopic removal. Rigid bronchoscopy with spontaneous ventilation is the gold standard for airway foreign body removal; flexible bronchoscopy can be diagnostic but lacks the ventilation capability and instrument channel size for safe removal in children. Expiratory chest films or lateral decubitus films are essential for detecting air trapping from a radiolucent airway foreign body; the affected lung remains hyperinflated while the normal lung deflates. Multiple magnets ingested separately are more dangerous than a single magnet; they can attract across bowel walls causing pressure necrosis, perforation, and fistula formation -- requiring urgent removal.
References
- Fidkowski CW, Zheng H, Firth PG. "The anesthetic considerations of tracheobronchial foreign bodies in children: a literature review of 12,979 cases." Anesth Analg. 2010;111(4):1016-1025.
- Kramer RE, Lerner DG, Lin T, et al. "Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee." J Pediatr Gastroenterol Nutr. 2015;60(4):562-574.
- Jatana KR, Litovitz T, Reilly JS, Koltai PJ, Rider G, Jacobs IN. "Pediatric button battery injuries: 2013 task force update." Int J Pediatr Otorhinolaryngol. 2013;77(9):1392-1399.
- Shlizerman L, Mazzawi S, Rakover Y, Ashkenazi D. "Foreign body aspiration in children: the effects of delayed diagnosis." Am J Otolaryngol. 2010;31(5):320-324.
