A. Epidemiology

1. Typically children under 4 years of age
2. Reflects natural curiosity of children of this age
3. Affects thousands of children every year
4. Boys slightly higher incidence than girls

B. Common Objects

1. Coins
2. Food
3. Small metal and plastic toys
4. Buttons
5. Bones
6. Batteries
7. Sharps: Pins, safety pins, or thumbtacks
8. Wood
9. Glass

C. Signs and Symptoms

1. Dysphagia
2. Drooling
3. Vomiting
4. Anorexia
5. Cough
6. Choking, cyanosis
7. Wheezing
8. Hemoptysis
9. Upper respiratory infection or pneumonia
10. Cervical or chest pain
11. Fever

D. Anatomical Location of Foreign Body

1. Proximal esophagus
   1. Level of cricopharyngeal muscle and thoracic inlet
   2. Most common location
   3. Coins oriented in transverse position (widest opening in esophagus)
2. Middle esophagus: level of carina and aortic arch
3. Distal esophagus: proximal to the gastro-esophageal junction
4. Level of pre-existing esophageal stricture from pre-existing condition

E. Diagnostic evaluation

1. Obtain chest radiograph
2. Repeat film if time has passed since initial evaluation
3. Consider esophagraphy to rule-out radiolucent foreign body

F. Removing Foreign Body (objects which don't spontaneously pass)

1. Rigid or flexible esophagoscopy
2. Balloon catheter extraction under radiologic guidance
3. Bougienage
4. Awaiting spontaneous passage
   1. Object must be in distal esophagus with ingestion less than 24 hours ago
   2. Parents must watch for passage of object in stool
   3. Invasive removal required if not successful
5. Sharp Objects
   1. Must be removed from esophagus but can be allowed to pass spontaneously once in stomach
   2. Best technique is direct visualization with rigid or flexible esophagoscope
   3. Rigid scope allows for removal of the object in protective sheath
6. Batteries
   1. Must be removed from stomach due to corrosive effects of acid environment
   2. May be followed into intestine with radiographs every 2-3 days to monitor progress
   3. Abdominal pain may be a reason for surgical exploration

G. Esophagoscopy

1. Rigid or flexible
2. Most common invasive technique used
3. Allows direct visualization
4. Variety of types and sizes of extraction tools can be used
5. Nearly 100% success but expensive procedure
6. Technique
   1. Child put under general anesthesia
   2. Neck placed in the sniffing position
   3. Esophascope introduced through endotracheal tube
   4. Foreign body visualized with telescope
   5. Grasper introduced through sheath
   6. After grabbing object, sheath telescope, and grabber are removed together
   7. Reintroduction of telescope will assess residual damage to the esophagus
7. Flexible esophagoscopy can be done with sedation for objects in:
   1. Lower esophagus
   2. Stomach
   3. Duodenum

H. Balloon Catheter Extraction

1. Performed under radiologic guidance
2. Lower cost removal method without need for general anesthesia
3. No direct esophagus visualization
4. Technique
   1. Child calmed without sedation (allows for airway protection)
   2. Child put in oblique prone position
   3. Under flouroscopic guidance, catheter is passed through the nose or mouth
   4. Inserted to beyond the foreign body
   5. Balloon inflated with contrast material to the width of the esophagus
   6. Catheter gently withdrawn bringing foreign body along
   7. The foreign body is removed through the mouth (McGill forceps may be required)
   8. Esophagraphy recommended after difficult or bloody extractions
   9. Alternately can push object into stomach with balloon catheter

I. Bougienage

1. Pushing of foreign body into stomach using a bougienage
   1. Not commonly used
   2. Effective only for witnessed ingestions of smooth objects
   3. Only used within 24 hours of ingestion
2. Procedure performed while child is in the emergency department
3. Technique
   1. Unsedated child sits upright
   2. Well-lubricated bougie dilator is passed through the mouth
   3. Foreign body is pushed into the stomach
   4. Position is reconfirmed using Chest X-ray
   5. Parents watch for spontaneous passage in the stool

K. Complications

1. Problems arise from foreign body or method used to remove them
2. Overall rate is less than 2%
3. Persistently lodged foreign bodies, sharp objects or batteries cause the most problems
4. Types of injury
   1. erosion or perforation of the esophagus
   2. Tracheal compression
   3. Mediastinitis
   4. Esophageal-tracheal or esophageal-vascular fistulas
   5. Extraluminal migration of foreign body
   6. False esophageal diverticulum

References

1. Bergreen BJ, et. al. 1993. Gastrointestinal Endoscopy. 39:626
2. McGahren ED. 1999. Pediatrics in Review. 20:(4):129