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www.nayyarENT.com 1
Laryngo Tracheo Bronchial Foreign Bodies
Dr. Supreet Singh Nayyar, AFMC
For more topics & ppts, visit www.nayyarENT.com
7/22/2012
Overview IntroductionApplied anatomyAetiologyPresentationPathologyAssessmentDiagnosisComplicationsManagementPost Op CareSummaryReferences
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IntroductionOrifices
Curiosity of children
Minor irritation / Life threatening Problem
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Applied anatomy
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• The diameter of the right main bronchus is larger than the left,
• The angle of divergence from the tracheal axis is smaller on the right,
• Airflow through the right lung is greater than through the left,
• The carina is more likely to be located to the left of midline rather than to the right.
Site of Lodging of Foreign Body Right Main Bronchus
Infant larynxMore anterior &
higher in neckEpiglottis larger,
longer & angled more over glottis
Larynx cone-shaped: narrowest at cricoid ring
Trachea 57mm long, diam 4 mm
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Paediatric airway
All cartilaginous supporting framework are soft, pliable & prone to collapse.
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Rapid Subglottic EdemaSupraglottis :
surrounded by loose connective tissue, prone to edema which grows rapidly
Inflammation from epiglottis can spread quickly to pre-epiglottic & para-glottic spaces.
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Rapid Subglottic Edema
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Aetiology Age/Sex
Predisposing factors-◦ Interference with deglutition reflex ◦ Unconscious patient◦ Pharyngeal / laryngeal paralysis◦ Improper mastication with hurried swallowing
Types ◦ Inert / Non inert
Region
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PresentationTypical History immediately after
aspirationPresenting after respiratory
complications
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Pathogenesis of bronchial obstruction
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Stop valve Bypass valve Oneway valve
Hence clinical features will vary
Immediate assessmentQuick history and physical
examination
Vital parameters
SpO2 monitoring
ABG
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SpecificIndirect Laryngoscopy
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SpecificFibreoptic Laryngoscopy
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SpecificDirect LaryngoscopyFibreoptic & Rigid Bronchoscopy
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Diagnosis
The plain chest radiography Sensitivity 66%Specificity 51%Both AP & Lat view required for exact
localizationMay be still useful in radiolucent foreign
bodies due to features of obstructive emphysema (or the ball valve mechanism)
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Radiology in Foreign Body
Radiology in Foreign Body
Radiopaque FB (23.3%)*Hyperinflation or obstructive emphysema
(21.8%)*Hyperinflation or obstructive emphysema
with atelectasis in the same hemithorax (18%)*
Lobar atelectasis (12.8%)*Whole-lung atelectasis (6.8%)*Shift of mediastinal shadow (11%)*Aeration within an area of atelectasis (6%)*
* Girardi G, Contador AM, Castro-Rodriguez JA.Pediatr Pulmonol. 2004 Sep;38(3):261-4
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CT Scan
Normal CTHRCTReconstructionVirtual Scopy
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Reconstruction
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Virtual Imaging:◦ Volume rendered
images◦ Navigation beyond
obstruction
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Magnetic Resonance Imaging
◦Better sequences◦Better characterization
of lesion
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Complications
Respiratory distress
AsphyxiaCardiac arrestFeverLaryngeal edemaPneumothorax
HemoptysisPneumoniaBronchiectasisBronchial
strictureSurgical
emphysema
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Emergency Management
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< one year: Back blows/abdominal thrusts
Emergency Management
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Small Child: Back blows
Emergency Management
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Older Children /Adults: Heimlich manouvere
Emergency managementFinger Sweeping – Not
recommended*Tracheostomy might be required
* Scot Brown Otorhinolaryngology 7th Ed pg 1188
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Endoscopic removal
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Rigid bronchoscopy Fibre-optic
Endoscopic removal
Sniff position for aligning axes
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Endoscopic removal
Distorted anatomy at depthsStudy x-rays, lie/ diameterApproach carefully, bleeding+Create forceps spaceInorg. Fbs –USUALLY TRAILINGCareful at glottis, tongue– can
strip foreign body Good bronchial toilet required
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Endoscopic removal
Use of Fogarty catheter
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Endoscopic removal Flexible bronchoscopic view of a
large foreign body (mini light bulb lodged in the right main bronchus of a 7-year-old boy (left, A).
The ureteral stone basket inserted through the 1.2-mm working channel of the bronchoscope has grasped the foreign body (right, B),
Proximal portion of the foreign body is pulled in to distal end of the endotracheal tube by the flexible bronchoscope (right, C).
Once the foreign body is thus secured,the entire apparatus (endotracheal tube, flexible bronchoscope, and basket with the foreign body in it) is removed en masse from the airways.
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Endoscopic RemovalUse of laryngeal
mask airway with fibreoptic bronchoscope
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Endoscopic removalUnder fluoroscopic
control
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A foreign body (straight pin, arrows), aspirated into the right middle lobe of a 6-year-old girl, is seen on posteroanterior (A) and right lateral (B) radiographs
The foreign body could not be visualized by paediatric flexible bronchoscopy. It was, however, extracted by using a paediatric flexible bronchoscope and a ureteral stone forceps under fluoroscopic guidance.
Endoscopic Removal
New instruments – Optical Grabbing Forceps
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Post op careOxygenWatch SpO2SteroidsNebulized asthalin / steroidsChest physiotherapy
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SummaryMost common among childrenPotentially life threateningImmediate ManouveresEarly removal to prevent oedemaDiagnosis & imagingEndoscopes & TrainingPost op care
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References
Scott Brown ORL HNS,7th Edition Cummings ORL HNS, 4th Edition Gray’s Anatomy, 38th Edition Various sources from internet
(http://chestjournal.chestpubs.org) Previous presentations on similar topics in department Use of a Fogarty catheter for bronchoscopic removal of a
foreign body. J M Wiesel, R Chisin, R Feinmesser and I Gay Chest 1982;81;524a-524
Flexible Bronchoscopic Management of Airway Foreign Bodies in Children James P. Utz, John C. McDougall and W. Mark Brutinel Chest 2002;121;1695-1700
Retrieval of Aspirated Foreign Bodies in Children Using a Flexible Bronchoscope and a Laryngeal Mask Airway Avraham Avital, M.D., David Gozal, M.D., Kamal Uwyyed, M.D.,and Chaim Springer, M.D.
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Thank you
for more topics & ppts, visit
www.nayyarENT.com
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