Children with foreign bodies are certainly not foreign to the emergency department. Through natural curiosity, a child may place a foreign object into various body orifices. It may be aspirated into the respiratory tract, swallowed into the alimentary canal, lodged in an external auditory canal, a nostril, or an eye. Others may become firmly attached to various parts of the body, with examples being zippers, fish hooks, rings, and constricting hairs or threads. Button batteries and magnets are unique hazards and will be discussed separately.

Suspected foreign body aspiration is a common emergency department problem. This occurs most commonly in children less than 3 years old,¹ with a peak incidence in the 10- to 24-month age group.² The vast majority, 80% to 90%, are endobronchial, with the remainder being laryngeal and tracheal.¹ Deaths are more likely for laryngeal and tracheal foreign bodies, with toy balloons³ and hot dogs⁴ comprising a large proportion of this group. The most common endobronchial foreign bodies are nuts and seeds.⁵

Patients with a laryngeal or tracheal foreign body typically present with dramatic symptoms and signs: obstructive (cough, stridor, dyspnea, retractions, cyanosis) and voice alteration (hoarseness, dysphonia, or aphonia).

Typical laryngeal and tracheal foreign bodies are fish bones, eggshells, and grapes.¹ These require immediate removal. Laryngeal foreign bodies may be amenable to removal in the emergency department using McGill forceps with direct visualization. Children with tracheal foreign bodies require emergent referral for endoscopic removal.

Endobronchial foreign bodies are marked by three clinical stages.¹ The initial stage, impaction of the foreign body, is marked by choking, gagging, coughing, and respiratory difficulty. This is followed by a relatively asymptomatic phase (tolerance of the foreign body), which may last for hours or days. The third stage, the complication stage, is a consequence of obstruction and infection. The child may have atelectasis, pneumonia, or abscess.

Diagnosis of foreign-body aspiration is often challenging. Not uncommonly, the caregiver is unaware of the event. Both the caregiver and the clinician may not relate the child’s symptoms to a foreign body. Physical examination findings can vary from none to unilateral decreased air entry or wheezing. The sensitivity and specificity of the history for foreign-body aspiration are 75% to 91% and 10% to 92%, respectively.² For physical examination, they are 57% to 86% and 26% to 72%, respectively.² Because the history and physical examination have unsatisfactory sensitivity and specificity, investigations play an essential role in the diagnosis of endobronchial foreign body.

The gold standard for the diagnosis of an endobronchial foreign body is endoscopy.⁶ Thus, negative endoscopies are unavoidable. The chest radiograph may not be helpful unless a radiopaque foreign body was aspirated. However, 80% to 96% of airway foreign bodies are radiolucent.² Obstructive emphysema with air trapping is the most common chest radiograph abnormality, seen in 17% to 69%.² Atelectasis is seen in 12% to 41%, and the chest radiograph is normal in 14% to 37%.²

Chest radiographs taken during inspiration and expiration (Fig. 12-1) have 65% sensitivity in patients who do not have a clinically obvious foreign-body aspiration. For a patient with a right-sided endobronchial foreign body, the expiratory view would show a shift of the mediastinum to the left and hyperaeration of the right lung. Fluoroscopy showing the same mediastinal shift and decreased diaphragmatic excursion of the affected side supports the diagnosis.

Recently, multi-detector computed tomography of the chest has shown high sensitivity (94%) and specificity (95%) for foreign-body aspiration in children.^6,7 Exposure times are brief (2–7 seconds) and radiation exposure is modest. However, a retained endobronchial foreign body risks chronic morbidity. Thus a negative CT does not rule out the need for endoscopy.

Management of a child with a suspected foreign-body aspiration consists of addressing respiratory distress or failure if present. For children with an obvious aspiration—for example, those with a clear history of placing a foreign body in the mouth, followed by an abrupt onset of coughing, gagging, or choking and with unilateral wheezing—obtain a chest radiograph and immediately refer for endoscopy. In less obvious cases, consider inspiratory and expiratory radiographs, fluoroscopy, and multi-detector computed tomography of the chest if available. In most cases, referral to an endoscopist is indicated for those children with a history of a foreign body in the mouth with a choking and coughing paroxysm.

Ingestion of a foreign body is a common emergency department problem. Esophageal foreign bodies are twice as common as endobronchial foreign bodies.¹ However, spontaneous passage occurs in 80% to 90% of patients, whereas 10% to 20% require endoscopic removal and less than 1% require surgical intervention.⁸ Most esophageal foreign bodies are coins—88% in one series.⁹ They typically lodge in one of three locations (Fig. 12-2): 60% to 70% at the thoracic inlet, 10% to 20% in the mid-esophagus at the level of the aortic notch, and 20% at the lower esophageal sphincter.⁸

Esophageal foreign bodies, like their endobronchial counterparts, may manifest three clinical stages.¹ The initial symptoms are typically abrupt and dramatic. They include choking, gagging, drooling, vomiting, odynophagia, dysphagia, and chest pain. If the foreign body is large enough, pressure upon the airway may produce paroxysms of coughing.¹ Symptoms diminish over time, much like endobronchial foreign bodies.¹ Prolonged presence within the esophagus can lead to perforation and infection, tracheoesophageal fistula, and aortic-esophageal fistula.¹⁰

Most children presenting with a history of foreign-body ingestion are asymptomatic because of passage into the stomach. It is important to determine whether there were any symptoms at the time of the event, such as gagging, choking, or apparent discomfort. Obtain radiographs of the cervical, thoracic, and abdominal regions if the object is radiopaque and large enough to lodge within the esophagus (coin-sized) (Fig. 12-2). In a prospective study, 9 of 30 children with esophageal coins were asymptomatic at the time of assessment in the emergency department. It is unclear whether these children had symptoms at the time of ingestion. The presence of symptoms in the emergency department had a sensitivity of 70%, a specificity of 77%, a positive predictive value of 81%, and a negative predictive value of 65% for the presence of a coin in the esophagus.¹⁰

Refer all children with significant symptoms, such as respiratory difficulty, pain, or inability to swallow their oral secretions, for immediate endoscopic removal. For children with esophageal coins and mild or no symptoms, consider a watch-and-wait approach for 8 to 16 hours.¹¹ During this observation period, approximately 25% to 30% of esophageal coins pass spontaneously into the stomach.¹¹ While under observation, ensure no oral intake to prepare for endoscopy under general anesthesia.

Another method for esophageal foreign-body removal is balloon (Foley) catheter extraction with fluoroscopy.^9,12

In two large series of 468⁹ and 415¹² children, there were high success rates of 88% and 91%, respectively. Epistaxis occurred in several patients. There were no significant complications in one series⁹ and a 1% rate in the other.¹² Despite these high success and low complication rates, this technique is often criticized. Criticisms include inadequate visualization, the possibility of missing underlying pathology, injury, or additional foreign bodies, absence of airway protection with the possible risk of aspiration of the foreign body, and discomfort to the patient.¹² In most institutions, endoscopic removal under anesthesia is the procedure of choice.

Another treatment strategy for esophageal coins is bougienage using a Hurst esophageal dilator.¹³ Measure the distance between the tip of the nose and the epigastrium, which is used as the insertion depth of the dilator. Place the child on the caretaker’s lap and achieve restraint using a “bear hug.” There is no anesthetic administration. The dilator is passed through the mouth to the measured depth and immediately removed. Order a radiograph after the procedure to confirm coin location. The success rate was 95% in 372 children and there were no significant complications.¹³

Intravenous glucagon has been recommended as a treatment for esophageal foreign bodies. However, this was shown to be ineffective in a placebo-controlled trial of children with esophageal coins.¹⁴

Radiolucent esophageal foreign bodies are much more challenging. Symptoms include pain, drooling, refusing oral intake, dysphagia, and vomiting. Conventional radiographs are occasionally helpful if an air–fluid level is seen in the esophagus. For the child with a possible radiolucent esophageal foreign body, consider a radiological contrast study and referral to an endoscopist.

Nasal foreign bodies in children are a frequent problem.^15–17 The array of objects is broad, with beads, pebbles, plastic toys, nuts, and seeds being the most common.^15–17 The emergency physician can remove most of these.¹⁷ The typical patient is a 3- to 4-year-old child who is brought to the emergency department with a chief complaint of nasal foreign body and is asymptomatic. Possible symptoms are discomfort and difficult breathing. A less frequent presentation is a child with a unilateral foul nasal discharge without a history of nasal foreign body.

There are several techniques for removal of foreign bodies from the nose. The choice is dependent upon the type of foreign body and its location in the nostril (Table 12-1).