Pediatric Examination and Board Review (22 page)

(C) schedule endoscopy in the next 12-24 hours to remove the coin

(D) push the coin into the stomach with an nasogastric tube

(E) admission to the hospital and wait for the coin to pass

9.
If the radiograph reveals an aspirated watch battery, the treatment is

(A) no different from that of an aspirated coin

(B) a more urgent situation requiring more rapid endoscopy because of the risk of tissue injury

(C) a better situation for pushing the object into the stomach because it is smaller than all U.S. coins

(D) admission to the hospital and serial abdominal radiographs documenting the passage of the battery into the stool

(E) send the child home; the battery will pass without intervention

10.
If a foreign body is causing near total tracheal obstruction in a child, you should first

(A) perform a blind oropharyngeal finger sweep

(B) perform a Heimlich maneuver

(C) perform an emergency tracheostomy

(D) perform a needle cricothyroidotomy

(E) A followed by B

11.
The narrowest portion of a toddler’s airway is at the level of the

(A) vocal cords

(B) carina

(C) thyroid cartilage

(D) cricoid cartilage

(E) none of the above

12.
The narrowest portion of a toddler’s upper GI tract is at the level of the

(A) lower esophageal sphincter

(B) pylorus

(C) cricopharyngeus muscle

(D) second portion of the duodenum

(E) carina

13.
The most hazardous items, from the perspective of childhood aspiration, that can be found in a pediatrician’s office are

(A) gauze bandages

(B) ear speculums

(C) cotton balls

(D) examination gloves

(E) toys in the waiting room

14.
Should an airway aspiration event be missed, it is likely to present as

(A) recurrent pneumonia

(B) wheezing

(C) chronic cough

(D) all of the above

(E) none of the above

ANSWERS

1.
(C)
The clinician should be suspicious for the aspiration of some kind of foreign body. Unfortunately, many foreign bodies are radiolucent. Inspiratory and expiratory films should be attempted. Hyperinflation of the lung is seen on the chest radiograph during exhalation when a foreign body is present. The alternative approach is to request both right and left lateral decubitus radiographs. In the decubitus position, there should usually be relative pulmonary volume loss. However, when in the decubitus position on the side where the foreign body has lodged, this expected volume loss will be absent.

2.
(C)
If the child cannot cooperate with the requested CXR or the result is not helpful, airway fluoroscopy is the next test to be performed. With airway fluoroscopy, obstruction of the airway on exhalation is frequently visible; the most common abnormality to be seen is hyperinflation of the lung segment remote from the aspiration.

3.
(B)
Many children who have an airway foreign body have a normal CXR. So a normal radiograph does not exclude this diagnosis.

4.
(A)
A variety of foreign bodies are aspirated by children. One of the most commonly aspirated materials is small food items such as a peanut.

5.
(D)
Lethal foreign bodies are most often balloonlike substances such as latex balloons.

6.
(C)
The most common esophageal foreign body in children is the penny. When left on the floor, a coin is readily available for the exploring hand and mouth of a small child. Apparently the penny is not so valuable as to encourage adults to remove them from the floor when dropped. In fact, there has been discussion among pediatric political action groups to suggest that the penny be designated a public health hazard and eliminated.

7.
(C)
If one suspects a tracheal or bronchial foreign body, the prudent therapeutic intervention is a trip to the operating room. A pediatric anesthesiologist and otolaryngologist should be present. The child should be anesthetized but spontaneously breathing. A flexible or rigid bronchoscope should then be introduced into the airway. The flexible bronchoscope may allow simpler visualization of the airway but is rarely sufficient to retrieve the foreign body. Introduction of a rigid bronchoscope into a small child is almost always required for the removal of the foreign body such as a peanut.

8.
(C)
If an esophageal foreign body is suspected, the urgency to move to the operating room is significantly decreased. An esophageal foreign body often lodges at the cricopharyngeal muscle, the narrowest portion of the esophagus. An object lodged high in the esophagus may be easily aspirated into the airway. Retrieval of esophageal foreign bodies should occur in the operating room, not in the emergency department. There is no role for the use of a balloon catheter to remove an esophageal foreign body in a child. A clinician can worsen the situation if this is attempted. With inadvertent movement of the foreign body into a position obstructing the larynx, a non–life-threatening situation changes into a lifethreatening event. When the trachea or larynx is completely obstructed, the Heimlich maneuver can be lifesaving even in a small child.

9.
(B)
A battery lodged within the esophagus may rapidly produce perforation with life-threatening sequelae. The current generated from the battery and mucosal surface of the esophagus produces sodium hydroxide, which leads to liquefactive necrosis of the tissue, resulting in perforation. Therefore, this situation requires urgent endoscopy for removal.

10.
(B)
Near or total airway obstruction should be treated with a Heimlich maneuver first in older children. In infants a combination of back blows and chest thrusts is recommended. Use of finger-sweep to remove the object from the airway may cause the object to become more deeply lodged and should not be used. If a patent airway cannot be obtained, additional life support may be necessary.

11.
(D)
The anatomy of the upper airway in a small child is significantly different from that of the adult. The cartilage is much less sturdy and therefore much more compressible. The airway in its entirety is smaller, with the narrowest portion at the cricoid ring until the age of 8 years. This is distinguished from the adult airway where the narrowest portion is the vocal cords. In a small child, tracheal foreign bodies are most likely lodged at the cricoid ring. This is a life-threatening emergency. An aspirated tracheal foreign body will be below the level of the vocal cords in the child, well out of sight of an examiner performing direct laryngoscopy. In an adult, a foreign body lodged in the glottis is quite visible on plain direct laryngoscopy. Should the foreign body be small enough to move through the trachea to the mainstem bronchi, either bronchus is vulnerable. Not until the child is approximately 8 years of age, when the anatomy of the airway approximates that of an adult, does the left mainstem bronchus acquire a more acute angle. The development of the aortic knob creates this angle. Therefore, in the older child and adult, an aspirated foreign body usually enters the right mainstem bronchus, whereas in childhood, either bronchus is equally possible.

12.
(C)
Although the narrowest portion of a child’s airway is at the level of cricoid ring, the narrowest portion of the esophagus is the level of the cricopharyngeus muscle. Therefore, it is not unusual to find an esophageal foreign body fairly high in the esophagus. When a large esophageal foreign body is lodged at the level of the cricopharyngeus, significant airway compression can occur and airway symptoms may accompany dysphagia. A high esophageal foreign body is quite vulnerable to aspiration should an inappropriate attempt be made to remove that foreign body with a balloon-tipped catheter.

13.
(D)
A latex glove that has been inflated to assume the character of a balloon may be easily broken and aspirated, an event that can be lethal.

14.
(D)
Aspiration of foreign bodies by children remains a significant problem in the 21st century. Although deaths by aspiration have decreased significantly since legislation has mandated the labeling of toys appropriate for age, mechanical suffocation still accounts for 5% of all unintentional deaths among children in the United States. Almost without exception, the clinical history of a child with foreign body aspiration is marked by an acute choking episode followed by coughing, wheezing, and stridor.

Acquisition of this history mandates the clinician to pursue the possibility of a foreign body aspiration. The child frequently presents with cough and tachypnea with diminished breath sounds, wheezing, stridor, shortness of breath, and retractions. The acute onset of wheezing is the signature of an intrathoracic airway obstruction. The symptoms associated with the foreign body often hint at its location. If the aspirated foreign body is extrathoracic, stridor will predominate; if it is intrathoracic, wheezing will predominate. Once the airway has been significantly compromised, biphasic stridor will be apparent. Of note, an esophageal foreign body can also present with stridor because of compression of the extrathoracic airway. Pneumothorax and esophageal perforation have been reported with esophageal foreign body aspiration. The high likelihood of significant complications combined with the relative low morbidity and mortality associated with an intraoperative examination of the upper airway and upper esophagus mandates that the clinician proceed to the operating room when there is a strong suspicion of an aspirated foreign body. A rate of 10-15% for negative bronchoscopy and esophagoscopy is acceptable when compared with the risk of missing an aspirated foreign body and the consequences of recurrent pneumonia, bronchiectasis, and even death.

S
UGGESTED
R
EADING

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Rimell FL, Thome A, Stool S, et al. Characteristics of objects that cause choking in children.
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