Occult suprachoroidal foreign bodies: a 3-case report.

Extraction of Airway Foreign Body in Adults

Extraction of Airway Foreign Body in Adults

Swallowed Foreign Bodies in Children: Aspects of Management

The current paper presents the case of a patient with a retained foreign esophageal body, removed through open surgery (lateral cervical esophagotomy). The foreign body was a partial dental prosthesis with a metal hook that anchored it to the patient’s remaining natural teeth. The foreign body was lodged in the esophageal wall and the previous endoscopical extraction attempt had failed. The patient was transferred to our department from a regional hospital where an endoscopic attempt at removing the foreign body had failed. The patient complained of descending odynophagia and dysphagia for solids. After the previous esophageal endoscopy, the patient complained of retrosternal pain and pressure. A CT-scan with contrast of the neck and chest regions was performed. A secondary endoscopical exploration of the esophagus was performed, thus the foreign body’s location was precisely identified. We discovered that its metal grappling device was anchored in the lateral esophageal wall thus preventing endoscopic removal without tearing the esophageal wall open. As the patient’s current state was degrading (descending pains and risk of mediastinitis), we considered another transfer to be an unfortunate choice, so we chose an open surgery approach. We opted for a lateral cervical esophagotomy. The surgery was performed under general anesthesia, and the retained foreign body was removed. The lateral wall of the esophagus was perforated and torn open vertically at the spot where the metal hook of the prosthesis lodged itself into the muscle wall. A 4‑centimeter incision circumscribed both parietal lesions and allowed the removal of the foreign body without any further damage. Postoperatively, a nasogastric feeding tube was maintained for 14 days. Ten days after the surgery a follow‑up CT-scan was performed. The imaging exam did not show any mediastinal or retromediastinal fluids. After the nasogastric feeding tube was removed the patient was gradually allowed back on solids without any complaints.

To compare clinical signs, clinicopathological abnormalities, imaging findings and outcome of dogs with linear and non-linear foreign bodies in the gastrointestinal tract. Retrospective review of case records of dogs with a confirmed diagnosis of gastrointestinal foreign body. Signalment, history, clinical signs, clinicopathological data, diagnostic imaging studies, surgical and endoscopic procedures, hospital stay, costs and outcome were compared between groups. A total of 176 dogs had linear and 323 had non-linear foreign bodies. Dogs with a linear foreign body were more likely to have a history of vomiting, anorexia, lethargy and pain on abdominal palpation. They were also more likely to have the foreign body anchored in the stomach and continuing into the small intestine, experience intestinal necrosis, perforation and peritonitis, and require intestinal resection and anastamosis. The duration of hospitalisation was longer for dogs with linear foreign body (3 versus 2 days), and the cost of treatment was 10% higher. However, in both groups, 96% of dogs survived to hospital discharge. Dogs with a linear foreign body had more severe clinical signs and gastrointestinal pathology, and an increased duration of hospitalisation and cost of care. However, overall survival rates were not different in dogs with linear and non-linear foreign bodies.

An Unusual Presentation of a Retained Esophageal Foreign Body

Complete upper airway obstruction by a foreign body is adramatic and acute emergency situation, and can result in rapid development of hypoxia, circulatory arrest and death. Special Magill pliers with an adjustable video optical system have been developed for airway inspection to facilitate efforts to remove foreign bodies causing obstruction of the upper airway. To remove asimulated airway foreign body from acardiopulmonary resuscitation (CPR) manikin, either with normal Magill pliers or with the newly designed video Magill pliers. After abrief introduction, 81kindergarten teachers, 51pupils (age 10-14years) and 52prospective emergency physicians were asked to remove a2 × 2 "Lego" brick from the hypopharynx of aCPR manikin using either standard Magill pliers or the newly designed video Magill pliers. The formal hypothesis was that there would be no differences between the methods. Successful removal was defined as when the first removal attempt resulted in the Lego brick passing beyond the teeth of the manikin within 60s. The use of the video Magill pliers resulted in significantly higher success rates in removal of the simulated foreign airway body within 60 s compared to standard Magill pliers in kindergarten teachers (84% vs. 30%, p < 0.0001), pupils (84% vs. 18%, p < 0.0001) and prospective emergency physicians (92% vs. 40%, p < 0.0001). The time needed for removing the foreign airway body was significantly shorter in groups using the video Magill pliers (kindergarten teachers 29 ± 18s vs. 45 ± 19 s, pupils 29 ± 18s vs. 54 ± 14 s, and prospective emergency physicians 33 ± 18s vs. 45 ± 20 s; p < 0.0001). In an analogue points system (from 1 very simple to 10 extremely complicated), the user friendliness of the video Magill pliers was judged to be significantly higher than the standard Magill pliers (2.8 ± 1.6 vs. 7.8 ± 2.7 kindergarten teachers, 2.0 ± 1.3 vs. 7.2 ± 2.5 pupils and 3.2 ± 2.2 vs. 4.9 ± 3.1 prospective emergency physicians, p < 0.0001). Visibility of the airway foreign body was estimated to be significantly better employing the video Magill pliers compared to the standard Magill pliers (1.9 ± 1.4 vs. 9.8 ± 0.6 kindergarten teachers, pupils 1.3 ± 0.6 vs. 9.2 ± 1.6, prospective emergency physicians 2.3 ± 1.8 vs. 9.1 ± 2.3, p < 0.0001). In this study kindergarten teachers, pupils (aged 10-14 years) and prospective emergency physicians had higher success rates in less time and reported better user friendliness and visibility using video Magill pliers compared to standard Magill pliers for removing asimulated foreign body from aCPR manikin airway.

1. The experience based on 150 cases of oesophageal and 7 cases of foreign bodies in air passages recorded. 2. Foreign bodies in the air passages constitute a real emergency requiring prompt, planned, informed removal by a competent bronchoscopist and anaesthetist. Most foreign bodies are removed successfully by this method but in certain long standing and firmly impacted ones a thoracotomy offers the only safe approach. 3. Oesophageal foreign bodies either pass naturally or the impacted ones are removed endoscopically. In few cases where the foreign body is firmly wedged in cervical or thoracic osophagus a cervical or transthoracic oesophagotomy is done.

Sumary. The aim is to investigate the features of pathogenesis in capsule formation around metallic foreign bodies of soft tissues.&#x0D; Materials and methods. The results of a study of 6 patients with metallic foreign bodies of soft tissues with a carrier period of 16 to 50 years were analyzed. 3 injured had foreign bodies of gunshot origin and 3 patients had foreign bodies as a result of personal injury. Used clinical, laboratory, instrumental, histological, immunohistochemical, X-ray spectrometric studies.&#x0D; Results. All foreign soft tissue bodies were removed with the capsule. By gender: 5 men and 1 woman. By localization - the lower extremity. Pain was present in all the victims. Radiography and ultrasound were informative, magnetodetection is informative only at the superficial location of a foreign body. The foreign bodies were made of gray cast iron and steel needle wire. Histologically, immunohistochemically and radiospectrometrically, it has been found that the capsule formation around the foreign body is affected by the mechanism and extent of damage to the soft tissues, the composition of the metal and its coating, and the carrier term of the foreign body.&#x0D; Conclusions. Depending on the composition of the metal and its coating, there is a different rate of oxidation of the foreign body in the soft tissues: oxidation of metal foreign bodies of fire origin is faster. The formation of the capsule around the foreign body is affected by the mechanism of tissue damage: when the needle penetrates, the soft tissues are destroyed minimally, in the case of gunshot wounds, they are destroyed more. Spectral analysis data in conjunction with morphological studies are the basis for the removal of a foreign body of inflammatory origin along with the capsule.

Advisability of magnets in neurotrauma is due to pattern of patients admitted to neurosurgical departments of military hospitals with wounds accompanied by intracranial fixation of foreign metallic ferromagnetic bodies. To study dimensions, mass and magnetic properties of fragments extracted from gunshot wounds inflicted by modern weapons; to assess the feasibility of devices and instruments for removing foreign bodies. We analyzed foreign bodies extracted after gunshot wounds. Shape, dimension, weight and magnetic properties were studied. We estimated 532 foreign bodies (497 surgeries) extracted at the Kirov Military Medical Academy and 83 foreign bodies (79 surgeries) extracted at the Burdenko Military Clinical Hospital. Distribution by anatomical regions was established for both groups. We intraoperatively used cylindrical neodymium magnets 3×20 and 5×20 mm to extract magnetic foreign bodies. These magnets were brought to the target using standard surgical tweezers or original devices. The median mass of removed fragments was 0.385 (Q1-Q3=0.12-1.435; min-max≤0.01-30.5) g at the Kirov Military Medical Academy and 0.4 (Q1-Q3≤0.001-1.6; min-max≤0.01-11.4) g at the Burdenko Military Clinical Hospital. Magnetic foreign bodies were found in 501 (94.2%) and 74 (94.8%) cases, respectively. In 8.8% of cases, foreign bodies were not removed due to difficult-to-reach location accompanied by higher risk of adverse outcomes after extraction. Extracted foreign bodies after combat injuries have magnetic properties in 94% of cases. Intraoperative magnet allows for safe extraction of fragments in 91% of cases. Devices with adjustable magnetic field strength seem perspective. Further analysis of indications for removal of wounding projectiles in primary and, especially, repeated surgical treatment of craniocerebral wounds is needed.

Background: Foreign body (FB) ingestion is a frequent home accident in the pediatric population and is one of the leading causes of morbidity and mortality in children. We aimed to describe the problem of pediatric esophageal FB ingestion at King Abdulaziz University Hospital over 10 years regarding patient, visit, and management characteristics and identify the pediatric specialty team that was called first to the emergency department in such cases. Materials and Methods: This retrospective study included 117 pediatric patients admitted for esophageal FB ingestion in a tertiary care center in Saudi Arabia from 2011 to 2020. We used Chi-squared and one-way analysis of variance tests to determine the associations. Data on demographic and clinical variables were compared between patients with and without neurodevelopmental disabilities, and their associations were assessed. Results: The mean age of patients was 4.7 ± 3.7 years, with slightly higher rates in males (57.3%). Six patients (5.1%) had a history of preexisting esophageal conditions, and five (4.3%) had previous FB ingestion. The most commonly ingested item was a coin (n = 53) and was mostly located in the upper esophagus (n = 56). Gastrointestinal and respiratory symptoms occurred in 78 and 29 patients, respectively. The Otolaryngology Department contributed the highest number of admissions (63.8%). Conclusion: FB ingestion is common in Saudi Arabian preschoolers. These data indicate the need for caregivers to be educated about FB ingestion. Additional investigations should emphasize addressing the consequences of FB ingestion.

Foreign body (FB) ingestion is common among children. Complications following FB ingestion are reported to be around 1%. The prevalence of acute appendicitis caused by FB ingestion is rare. We present a case of a young girl who presented to the emergency department with acute appendicitis secondary to FB ingestion. A previously healthy 5-year-old girl presented to the emergency department with nonspecific gastrointestinal symptoms as well as a history of recent FB ingestion. Her physical examination was in keeping with acute appendicitis, and a computed tomography abdomen and pelvis confirmed the presence of FB distal to the neck of the appendix and measures around 6 mm causing obstruction and dilatation. At the time of laparoscopic appendectomy, acute appendicitis with perforation was confirmed and the patient had an uneventful postoperative course and was discharged home on the 5th day with satisfactory outcome. Presentation of FB ingestion can vary. Most physicians are aware of the respiratory and gastrointestinal symptoms that can occur; however, the possibility of FB causing acute appendicitis should also be considered.

Pediatric Rigid Bronchoscopy for Foreign Body Removal

Rigid bronchoscopy is a procedure that is performed in order to directly visualize the upper and lower airway, and is carried out for either a diagnostic or therapeutic purpose. Suspected foreign body (FB) aspiration is the most common indication for performing this procedure in the pediatric age group at the Philippine Children’s Medical Center where a recent census (May 2008 to April 2009) showed that of 21 cases where rigid bronchoscopy was performed, 10 were for suspected FB aspiration. A review of 101 cases in the same institution showed that the average age of patients with FB aspiration was 2 years and the most common item aspirated was a peanut followed by the atis (sweetsop) seed and chicken bone chips. The most common inorganic foreign body was an earring and “whistle” (which broke off from a toy).1 It is more common in males probably because of their usually more active nature and is frequently found in the right mainstem bronchus, where the FB more easily lodges - being straighter, shorter and wider in diameter. FBs are life-threatening events in children that require early diagnosis and prompt successful management.2&#x0D; A good history, physical examination and analysis of diagnostic tests are vital in every situation. In most cases, the child’s aspiration of the foreign object is a witnessed event 3 and this history of aspiration is the most sensitive diagnostic tool. The main symptoms include choking, prolonged cough, and dyspnea. Abnormal physical examination findings are found in 67% to 80% of cases and include unilaterally decreased breath sounds, wheezing and stridor.2, 4 Radiographic procedures may show abnormal findings in only about 68-86% of cases.4 5 The most useful radiographs requested are the chest posteroanterior (anteroposterior in infants and small children) and lateral views which may help localize the impaction site when the object aspirated is radiopaque.3 However, most inhaled FBs are radiolucent, and their presence can be suspected by obtaining inspiration and expiration views to demonstrate unilateral hyperinflation. Other suggestive features include atelectasis, pneumothorax and pneumonia. These indirect radiologic features of FB inhalation are present in 76% of cases.2, Where inspiration and expiration views cannot be obtained, as in very young children, left and right decubitus views may be helpful. 6 Fluoroscopic studies may also be obtained along with the plain radiographs, however, specificity and sensitivity are not very high.4 Virtual bronchoscopy may also be used in patients with suspected FB aspiration. Virtual bronchoscopy which uses multislice computerized tomography (MDCT) with realistic 3-dimensional reconstruction may be helpful in detecting and localizing the FB prior to any surgical procedure and thus decreasing the number of patients needing diagnostic bronchoscopies.7 Flexible fiberoptic bronchoscopy under local anesthesia and premedication may also be performed in cases of suspected FB aspiration wherein clinical and radiologic findings are not consistent with FB aspiration. When no FB is visualized, the patient is saved a rigid bronchoscopic procedure under general anesthesia.8 Flexible fiberoptic bronchoscopy is also used therapeutically to remove FBs in the bronchus, however, successful removal is more common with rigid bronchoscopy.&#x0D; All the necessary instruments needed for the procedure must be prepared. As much as possible 2 of each instrument are prepared: 2 bronchoscopes (one estimated from the age and size of the child and one smaller than that – just in case!), 2 suction devices (if one gets clogged up, the other one is ready) and 2 forceps. The peanut forceps is ideal, not only for peanuts but usually for other nuts as well; the alligator forceps is useful for relatively flat foreign bodies; while the “jaw type” forceps appears to be useful for everything else.9 The instruments are then tried, to check if they are in working order before commencement of anesthesia. This involves checking the transparency of the glass window plug, ensuring that the light source and the proximal prismatic light deflector are both illuminating, and trying out all the forceps and suction tips. It is best to try the instruments on an object similar to what the child aspirated.3 The surgical assistant, nurse and instruments are usually on the right (if the surgeon is right-handed) and anesthesiologist on the left. The suction and bronchoscope are then made ready. Knowledge of the anatomy of the tracheobronchial tree is imperative to be able to navigate through this area while looking for the FB.&#x0D; The use of optical forceps with mounted rod-lens telescopes has made the removal of airway FBs simpler, quicker and safer. These new devices have led to decreased complication rates and fewer missed or incomplete FB removals. While access to FBs located in the distal small segmental bronchi especially in very young children may be limited with the use of optical forceps,10 this can be overcome by removal of the connecting bridge to allow the optical forceps to be passed distal to the tip of the bronchoscope. &#x0D; An anesthesiologist familiar with the procedure must be called in. It is very important to have discussed the case and the procedure with the anesthesiologist prior to the operation to minimize confusion and promote harmony. Most anesthesiologists have become at ease with giving intravenous general anesthesia which circumvents the use of potentially noxious gases. Assisted spontaneous ventilation can avoid the need for muscle relaxation and paralysis so that the wake-up time is shortened. Intravenous general anesthesia with propofol and assisted spontaneous ventilation is currently the frequently used anesthetic technique for rigid bronchoscopy although volatile agents and gases are still used.11,12 &#x0D; The patient is placed supine on the operating table. A shoulder roll is not required. After induction of anesthesia, the patient is hyperventilated to 100% oxygen saturation to take full advantage of operating time.3 A topical anesthetic (lidocaine or tetracaine) is sprayed into the laryngeal area and distally into the trachea to lessen stimulus and pain, thus lowering the level of the anesthetic agent used and minimizing the possible occurrence of laryngospasm after the procedure.12 The state of dentition is inspected and a tooth guard placed over the upper teeth. Although it is possible to do bronchoscopy directly without using a laryngoscope, it is more expedient to use the laryngoscope (with the left hand) to visualize the larynx.&#x0D; The assistant (most likely the ORL resident but occasionally, a nurse) hands over the bronchoscope (to the right hand) without the glass window plug initially (because it may fog up or fall off) and the bronchoscope is inserted by looking through the bronchoscope as it passes through the larynx. Rotating the bronchoscope by 900 (with the axis of the lip in the anteroposterior axis of the glottis chink) is often useful for easier bronchoscopic insertion.2 Never force the bronchoscope into the larynx – if there is difficulty, reposition the laryngoscope to better visualize the larynx. Where exposure of the larynx is adequate, inability to pass the bronchoscope may be due to the bronchoscope lip hitting a vocal fold instead of entering the glottic chink. Another possibility is that the bronchoscope is too large to fit through a narrowed subglottis. The laryngoscope is removed once the bronchoscope has been inserted and the anesthesiologist connects the anesthetic tube to the standard 15-mm adapter of the bronchoscope and the glass window plug is inserted (this is again removed when the forceps is introduced or suctioning needed). A 0o telescope of the appropriate size may be inserted at this time or even during the initial insertion of the bronchoscope. &#x0D; The left hand is placed over the tooth guard and the thumb and index finger are used to support the bronchoscope being held in the right hand, much like a billiard cue. The left thumb lifts the bronchoscope off the tooth guard to enable the bronchoscope to be advanced without resistance. The bronchoscope is advanced slowly, always ensuring that the lumen is clearly in view, and suctioning whenever needed. Once the carina is seen, the main bronchus, where the FB is likely to be located, is then entered. Turn the head to the left to enable passage into the right main bronchus, and then to the right to enter the left main bronchus. Some degree of neck flexion can also be helpful in aligning the main bronchus. The bronchoscope is advanced until it is as near as possible to the FB to allow accurate suction of secretions so that the surgeon can determine how best to orient the forceps during application. The bronchoscope is then slightly withdrawn to allow the forceps to be freely inserted beyond the bronchoscope. The forceps are opened as widely as possible as this stretches the airway walls and allows the foreign body to fall into the jaws of the forceps which is then firmly grasped. Care must be taken not to push the FB further down the airway. If the FB fits through the bronchoscope, then it is pulled right through without removing the bronchoscope. However, if the FB does not fit through the bronchoscope, then the bronchoscope has to be withdrawn with the FB trailing behind held by the forceps. It is important to keep your eyes (and hands) on the bronchoscope and forceps at all times.&#x0D; The FB may become caught in the larynx or dropped into the trachea, causing complete airway obstruction. This possibility should always be anticipated and equipment be able to deal with this needs to be readily at hand. To prevent the FB being lost at the laryngeal inlet, the bevel of the bronchoscope is moved around over the FB by rotating the bronchoscope 900 and the bronchoscope is slightly tilted down at this area. A firm grip on the forceps with the FB must be maintained and hopefully, it is still there when the forceps is removed from the oral cavity. If the FB has been removed from the tracheo-broncial tree, but is not found in the forceps, the naso-oro-hypo pharynx should be checked in addition to a repeat bronchoscopy.&#x0D; All throughout the procedure, it is imperative to listen to the sound of the oxygen saturation monitor for signs of desaturation and to inquire from the anesthesiologist regarding the condition of the patient. If desaturation occurs, the bronchoscope is moved back out of the bronchus and into the trachea to allow the anestheshiologist to ventilate the patient through the bronchoscope adaptor. If this is due to a large FB that slipped while in the trachea, then, the FB must be removed right away or pushed back into the bronchus to regain the airway. &#x0D; Once the FB is removed , a second bronchoscopic examination is done to check for any pooling of secretions or blood that may need to be suctioned or for any remnant of the FB- which may have accidentally separated from the bigger piece- that has to be retrieved. Small pieces can often be removed by suctioning. &#x0D; Rarely, a tracheostomy may have to be performed for a FB that, during extraction, will not fit through the laryngeal inlet. Tracheotomy is performed while the bronchoscope is in place and with the forceps grasping the FB. The FB is extracted through the tracheostoma. Afterwards, tracheostoma is closed with sutures and regular wound care is initiated.&#x0D; If the procedure took less that an hour with minimal trauma, then the child is assisted with ventilation until he/she recovers full spontaneous respiration. A dose ofteroids may also be given (I.V. Dexamethasone, 1.0 to 1.5 mg/kg; maximum, 20 mg). The patient is brought to the post-anesthesia room and observed. &#x0D; Delayed diagnosis and intervention (24 hours or more) were found to be related to higher complication rates such as recurrent or chronic pulmonary infections and prolonged hospital stay. 13 Thus the need for early diagnosis and treatment of cases with suspected FB aspiration.

Objective: To analyze the current situation and the trend of the death due to foreign body in airway in children less than 5 years old in China from 1990 to 2017. Methods: Using the mortality data of foreign body in airway in China from 1990 to 2017 from the Global Disease Burden 2017 (data covered 31 provinces, autonomous regions, municipalities, as well as Hong Kong and Macau Special Administrative Regions, excluding Taiwan Province) to describe the death status of children under 5 years old due to foreign body in airway in China, and to calculate the relative change and 95% uncertainty interval (UI) of mortality rate and proportion of children under 5 years old due to foreign body in airway between 1990 and 2017. The robust linear regression was performed with the first-order lag of mortality, and the supremum Wald test was used to explore whether the mortality trend had obvious structural changes around a certain time point. Results: In 2017, the mortality rate of children under 5 years old due to foreign body in airway in China was 8.57/100 000 (95%UI: 7.41/100 000-9.57/100 000), and there was no significant difference between boys (9.05/100 000, 95%UI: 6.82/100 000-10.23/100 000) and girls (8.02/100 000, 95%UI: 7.02/100 000-9.12/100 000). The supremum Wald test showed that there was a structural change around the year of 2005 (P<0.001) in terms of the mortality rate of foreign body in the airway among children under 5 years old, which depicted a relatively stable trend before 2005 and a significant downward trend after 2005. Compared with 1990, the mortality rate of foreign body in airway among children, boys and girls under 5 years old in 2017 decreased by 49.32% (95%UI: 37.78%-65.41%), 41.22% (95%UI: 25.68%-68.26%) and 56.91% (95%UI: 44.78%-66.70%), respectively; the mortality proportion of foreign body in airway among increased by 153.33% (95%UI: 75.99%-204.56%), 171.05% (95%UI: 48.75%-239.63%) and 137.90% (95%UI: 86.62%-198.09%), respectively; the rank of foreign body in airway in all disease increased by 6 and became the first leading cause of injury from the second. Conclusion: From 1990 to 2017, the mortality rate of foreign body in airway among children, boys and girls under 5 years old in China generally showed a downward trend. Compared with 1990, the mortality proportion of foreign body in airway among these population increased by a relatively large extent in 2017.