Upper Aerodigestive Tract Foreign Body Impaction

Overview

The upper aerodigestive tract includes the mouth, nose, pharynx (throat), larynx (voice box), trachea (windpipe), and esophagus. Foreign body impaction occurs when an object becomes stuck in any part of this tract.

Foreign body impaction in the upper aerodigestive tract is a serious medical condition that requires prompt attention. The incidence and management of this condition vary across countries, including Ghana, USA, UK, and South Africa etc.

Epidemiology of Foreign Body Impaction

Oropharynx, Hypopharynx, and Esophagus

In the USA, UK, and South Africa, food bolus impaction is a common cause of obstruction, especially in adults.
In Ghana, coin, fish bone, dentures, peg-hook ingestion, are common causes of foreign body impaction, particularly in regions with fish-rich diets. Coin ingestion/ impaction are commoner in children 5 years and below. Denture impaction is commoner among the elderly, with female preponderance.

Larynx, Trachea, and Bronchi

Foreign body aspiration is more common in children, with accidental ingestion or aspiration of objects while playing being a significant risk factor.
In adults, hasty eating, ill-fitting dentures, and improper food preparation are common risk factors.

Pathophysiology

Foreign body impaction occurs when an object becomes lodged in the aerodigestive tract, potentially causing obstruction, inflammation, or damage to surrounding tissues.

Symptoms and signs

Difficulty swallowing (dysphagia)
Sore throat
Ear pain (otalgia)
Neck mass or swelling
Respiratory distress (in cases of laryngeal or tracheal obstruction)

Management

Options of Management

1. Endoscopy:

A common method for diagnosing and treating foreign body impaction, particularly in the esophagus.
2. Surgery:

May be required for complicated cases or when endoscopy is unsuccessful. Surgical approach may be lateral pharyngotomy, for foreign bodies impacted in the cervical oesophagus or thoracotomy in cases of impaction in the lower oesophagus.
3. Radiography:

Plays a central role in diagnosing esophageal foreign bodies. Soft tissue X-ray of the neck is a valuable imaging modality for localizing foreign bodies impacted in the upper aerodigestive tract.. CTscan is indicated for long-standing foreign body impaction and/or complications.

Complications

Delayed diagnosis can lead to increased complication rates, including:

Obstruction
Inflammation
Damage to surrounding tissues
Potential for fatal outcomes in severe cases

Comparison of Management Across Countries

While specific data on management practices in each country is limited, the general approach to treating foreign body impaction involves a combination of endoscopy, surgery, and *radiography. The American Society for Gastrointestinal Endoscopy (ASGE) and European Society for Gastrointestinal Endoscopy (ESGE) provide guidelines for managing ingested foreign bodies and food impactions.

Given the variability in foreign body types and patient populations across countries, management strategies may be tailored to specific contexts.
For instance, in Ghana, where coin, dentures and fish bone ingestion are common, healthcare providers may be more vigilant in suspecting foreign body impaction in patients with compatible symptoms.

Management of Ingested Foreign Bodies and Food Impactions - Guidelines

Ingested foreign bodies and food impactions are common medical emergencies that require prompt attention. The management of these conditions involves a multidisciplinary approach, including gastroenterology, surgery, ENT surgeons, cardio thoracic surgeons and radiologist.

Management of Airway

The first priority in managing ingested foreign bodies is to ensure a secure airway. If the patient is experiencing respiratory distress or the foreign body is causing airway obstruction, immediate intervention is necessary.

Timing

The timing of intervention depends on the type of foreign body, its location, and the patient's symptoms.

Emergency endoscopy is recommended for:

- Foreign bodies causing airway obstruction or severe respiratory distress.
- Sharp or pointed objects in the esophagus or stomach.
- Disk batteries in the esophagus.
- Narcotic packets in the gastrointestinal tract.

Timing of endoscopy for ingested foreign bodies

1. We suggest avoiding contrast radiographic examinations before removal of foreign objects.
2. We suggest an otorhinolaryngology consultation for foreign bodies at or above the level of the cricopharyngeus.
3. We recommend emergent removal of esophageal food bolus impactations and foreign bodies in patients with evidence of complete esophageal obstruction.
4. We suggest that acceptable methods for the management of esophageal food impactions include en bloc removal, piecemeal removal, and the gentle push techniques.
5. We suggest endoscopic removal of all objects with a diameter larger than 2.5cm from the stomach.
6. We suggest endoscopic removal of sharp – pointed objects or objects longer than 6 cm in the proximal duodenum or above.
7. We recommend emergent removal of disk batteries in the esophagus.
8. We recommend urgent removal of all magnets within endoscopic reach. For those beyond endoscopic reach, close observation and surgical consultation for nonprogression through the GI tract is advised
9. We suggest that coins within the esophagus may be observed in asymptomatic patients but should be removed within 24 hours of ingestion if spontaneous does not occur.
10. We recommend against endoscopic removal of drug-containing packets.

Equipment

1. Endoscopes:

Flexible or rigid endoscopes are used to visualize the foreign body and facilitate removal.
2. Retrieval devices

Various devices, such as forceps, snares, and baskets, are used to retrieve foreign bodies.
3. Over tubes

These tubes can be used to protect the airway and facilitate the removal of foreign bodies.

Specific Foreign Bodies

Short-blunt objects (e.g., coins):

If the object is wider than 2.5 cm, it may not pass through the pylorus, and endoscopic removal may be necessary.
Observation may be considered for objects that are smaller and have passed into the stomach.
Long objects:

These objects may require endoscopic removal, especially if they are causing symptoms or are at risk of causing intestinal obstruction.
Sharp-pointed objects (e.g., office pins, fish bone or meat bones):

These objects require urgent endoscopic removal, especially if they are in the esophagus or stomach. Sharp-pointed objects that are obliquely or transversely oriented have the tendency to migrate into surrounding tissues, and consequently can migrate into a major vessel like the carotid or internal jugular vein, resulting in fatal exsanguination.
Disk batteries:

If a disk battery is lodged in the esophagus, emergency endoscopy is necessary to remove the battery and prevent tissue damage. If the battery has passed into the stomach, observation may be considered, but close monitoring is necessary to ensure the battery passes through the gastrointestinal tract without causing harm.
Magnets:

If multiple magnets are ingested, they can attract each other through the intestinal wall, causing serious complications. Endoscopic removal may be necessary.
Narcotic packets:

Endoscopic removal of narcotic packets is generally not recommended due to the risk of packet rupture and narcotic overdose. Surgery may be necessary if the packets become obstructed or cause intestinal damage.

Stomach and Small-Bowel Foreign Objects

Observation:

Many foreign objects that have passed into the stomach or small bowel can be managed with observation, as they will often pass through the gastrointestinal tract without causing harm.
Endoscopic removal:

May be considered for objects that are causing symptoms, are at risk of causing intestinal obstruction, or are not progressing through the gastrointestinal tract.

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