Pediatric Foreign Bodies


Eye

Eye Physical Exam Page

CHEMICAL BURNS

  1. Immediately irrigate the eye with lots of water
    • If over the phone, tell the parent to continuously flush the eye
    • If the patient is at the office and you are unable to open the lids, placing a topical anesthetic will allow you to open the eyes and flush
    • Irrigate for about 20 minutes and have patient change gaze to allow total eye to be flushed
    • May need to pick out particulate matter
  2. Check visual acuity
  3. Check for any corneal changes by staining with fleurocein drops
    • If there is an abrasion place antibiotics, cycloplegics, and patch
  4. Refer to ophthalmologist
    • Decreased acuity
    • Burn was with alkali or acid
    • Severe conjunctival swelling
    • Corneal changes

TRAUMA

  • Hyphema - blood in the anterior chamber and will see blood layering
    • May be associated with global injury
      • About 30% will re-bleed leading to acute increase in intraocular pressure
    • Should refer to ophthalmologist immediately for therapy
    • Decrease activity and have frequent examinations
    • Often need to sedate patient
    • Eye shield is used
  • Complicated lid lacerations - Refer to ophthalmologist

INTRAOCULAR FOREIGN BODY

  • There may be minimal symptoms
    • Patient's activity at time of accident most important
    • Often working with drilling or hammering and sudden impact feeling
      • Check visual acuity
      • Check for laceration of the globe, hyphema, pupil changes
      • Refer to ophthalmologist

CORNEAL FOREIGN BODY

  • There is a foreign body sensation
    • Increased tearing, conjunctivitis, and light sensitivity
    • If the onset of symptoms is gradual, suspect keratitis of infectious etiology often associated with wearing contacts or viruses

CONJUNCTIVAL FOREIGN BODY

  • May see under the lid, usually tarsal
    • To see may put topical anesthetic in eye
    • Using cotton applicator, roll the lid over the applicator and then try to scrape with the cotton applicator
    • May use side of 25 gauge needle to remove
    • Should also check for corneal abrasion

CORNEAL ABRASION

  • Tearing, foreign body sensation, light sensitivity
    • Check visual acquity
    • Topical anesthetic to give patient comfort and allow exam
    • Stain with fluorescein
    • If Pt has abrasion, antibiotic, cycloplegic (relax ciliary apparatus), to decrease blinking which is irritating
      • If abrasion above the midline, suspect foreign body under the upper lid
      • Can also give analgesics by mouth
      • Usually better within 24 hours
    • If not improving or very deep, ophthalmology referral
    • Although topical anesthetics like proparacaine and tetracaine will give relief, there use causes corneal thinning and may lead to blindness
      • Never prescribe to patients

PROPTOSIS

  • Forward displacement of the globe due to increased soft tissue or bone
    • Graves disease
    • Tumor
    • Inflammation-orbital cellulitis
    • Urgent referral if
      • Unilateral
      • Acute
      • Painful
      • Motility changes
      • Decreased acquity

 

Ear

Background
  • Definition
    • Foreign object such as insect, organic, or inorganic matter in external auditory canal
Pathophysiology
  • Etiology
    • Younger children more likely to have objects such as beads, toys, pebbles, beans, seeds, or popcorn kernels as foreign body
    • Older children (>10 years) through adults more likely to have insects, most commonly cockroaches, as foreign body
    • Seeds, nuts, plastic toys, and beads are most common objects
       
  • Risk Factors/Predisposition
    • Reasons for foreign body placement likely multifactorial
    • Coexisting ear pathology such as acute otitis media, otitis externa, cerumen impaction, or middle ear effusion
    • Curiosity or fun-making
    • Developmental delay
    • Behavioral Disorder such as ADHD
    • Mental Illness
       
  • Pathology of Disease
    • External auditory canal comprised of cartilaginous portion and bony portion
    • Inner 2/3 is very sensitive bony portion lined with thin vascular skin and periosteum
    • Outer 1/3 is cartilaginous portion
    • Cartilaginous/ bony junction is point of narrowing
    • Abrasion of the ear canal may lead to bleeding & pain
    • Tympanic membrane may rupture
    • Canal erythema, swelling & foul smelling discharge may be late occurrences

History

  • Asymptomatic or incidental examination finding
  • Pain in affected ear
  • Noise or “drumming” in ear associated with insect foreign body
  • Hearing loss
  • Sensation of ear fullness
  • Unilateral otorrhea
  • Bleeding
  • Self-reported by patient or parent

Physical Examination

  • Otorrhea of affected side may be present
  • Direct visualization with otoscope may reveal full view of foreign body
  • Exam should include careful inspection of contralateral ear and nares for other foreign bodies
  • Hearing evaluation pre and post extraction with tuning fork or audiogram may be indicated if reported hearing loss
  • Pneumatic otoscopy could be considered to confirm intact tympanic membrane if low risk of pushing object further into ear canal
  • Examination of canal both pre and post extraction to document any lacerations, hematoma, bleeding, infection, tissue necrosis, or remaining foreign body

Diagnostic testing: Otoscopi visualization

  • Laboratory evaluation
  • Not needed

Differential Diagnosis

  • Tumor or mass
  • Cerumen
  • Otomycosis and exostosis may be some considerations
  • Congenital Cholesteatoma
  • Acute otitis media

Treatment

  1. Acute Treatment
    • With exception of disc batteries, most ear foreign bodies not an emergency and can await specialty consultation if indicated
    • Primary treatment is removal of foreign body using variety of possible techniques
    • Careful consideration should be given to:
      • Clinician dexterity and experience
      • Adequate visualization
      • Adequate support staff
      • Safety and comfort of patient and clinician
      • Availability of appropriate instruments
    • Children should be appropriately restrained, either in supine position or in adult’s lap
  2. Removal Techniques
    • Irrigation
      • Attempt to confirm an intact tympanic membrane with pneumatic otoscopy prior to irrigation
      • Contraindications:
      • Organic matter (such as dried fruit, cotton, beans, peas, and popcorn kernels), due to their hydroscopic properties and propensity to swell when exposed to liquids
      • Disc batteries should never be irrigated due to risk of liquefactive necrosis
      • Perforation of tympanic membrane
      • Commercial irrigators, or a 60 mL syringe with 14- or 16-gauge angiocath, with warm water or saline solution may be used 
      • Direct the stream superiorly (never directly at the tympanic membrane) past the object if possible
         
    • Suction
      • Best for spherical or non-graspable objects not tightly lodged in the canal 
      • Warn patient of noise due to suction device
      • Instruments include Frazer tip suction or Schuknecht foreign body remover
      • Risk of pushing the object further into the canal with the suction device
         
    • Instrumentation
      • Graspable objects with irregular contours that are easily visualized, consider:
        • Alligator or Hartman forceps
        • Cerumen loop
        • Right angle ball hook
      • For smooth or spherical non-graspable objects, a right angle ball hook can be passed behind to foreign body and then used to dislodge or pull the object out of the canal
      • Use caution due to risk of perforation of the tympanic membrane
         
    • Cyanoacrylate Glue
      • Tissue glue or superglue may be applied to end of cotton swab and then glued to foreign body
        • Allow glue to set for 30-60 seconds
        • Requires cooperative patient, thus may be contraindicated in young children
        • Glue on ear canal can be dissolved with acetone if tympanic membrane intact
      • Ear hair or tortuous anatomy may complicate procedure
      • Risk of pushing the object further into ear
         
    • Operative Removal and Specialty Consultation
      • Younger children at higher risk of
        • Requiring anesthesia for extraction, and
        • Failure of removal with direct visualization
      • Success rates of extraction higher with Otolaryngology consultation and otomicroscopy versus direct visualization
        • Some providers may have upright operating microscope availability in their clinic for purposes such as colposcopy
        • Removal with microscopy preferred due to binocular vision and magnification power
      • Indications for referral to Otolaryngologist may include some of the following:
        • Age < 4 years
        • Operator inexperience, uncooperative patient, poor visualization of object, lack of staff or tools, etc.
        • Foreign body in canal >24 hours
        • Existing complication such as perforated tympanic membrane or tissue necrosis
        • Disc batteries (urgent referral highly recommended)
        • Multiple prior attempts
        • Objects near tympanic membrane or deep in bony canal
        • Sharp objects that may cause perforation or laceration during removal
           
    • Special Considerations
      • Live insects can be killed by submerging in mineral oil (microscope oil) or lidocaine prior to extraction attempts
      • Case reports of using acetone and other organic solvents to dissolve Styrofoam, glue, and gum

Follow Up

  • Uncomplicated extractions generally do not require further follow up
  • Early follow up with primary care provider or otolaryngologist may be appropriate if extraction complicated by
    • Canal laceration
    • Tympanic membrane perforation
    • Canal wall hematoma, or
    • Otitis externa
  • Otitis externa and tympanic membrane perforation should be treated appropriately

Prognosis

  • Good, overall
  • Chance of successful extraction diminishes with each attempt, while rate of complications increases with each attempt

Prevention

  • Mostly non preventable
  • Discourage children from putting anything in the ear

Patient Education

  • Describe foreign body in the ear
    • Common foreign bodies
    • Signs/Symptoms
    • Available treatment options & complication
    • Advise on first aid techniques
      • Use gravity to remove foreign body
      • Don't probe the ear
  • Further information is available at

 

Nose

Pathophysiology

  • Children commonly place foreign bodies in orifices
  • Often not reported by child

Diagnosis

  • Nose: Unilateral obstruction w/malodorous discharge
  • Nasal pain
  • Examine other nare & both ears for FB
    • Also look for multiple FB's in same nare

Treatment

  1. In small children
    • Parent occludes unaffected nare & gently puff into the child's mouth to expel FB
    • Less desirable alternative is to use Ambu bag over mouth only as source of positive-pressure ventilation
  2. Removal best done under direct visualization
    • May need local anesthetic & decrease of edema
      • Oxymetazoline spray
      • Phenylephrine spray (0.125% or 0.25%)
    • Spread nares w/nasal speculum if possible
    • Avoid pushing object back (possible aspiration) or wedging it further
  3. Techniques
    • Forceps, curette to grab/pull object
    • Suction tip, Schuchardt Foreign Body remover (suction catheter)
    • May use cyanoacrylate glue on plastic rod
      • Patient must hold still until glue dries
      • Difficult in uncooperative patients
    • Pediatric Fogarty catheter
      • Slip behind object, inflate balloon, remove object with gentle traction
      • May irrigate other nostril with saline solution to force object out
        • May cause choking, sneezing
        • DO NOT irrigate: Vegetable material (beans, etc.)
        • Swells due to water absorption
    • Treat any epistaxis that occurs in the usual manner

Disposition

  1. ENT consult if object difficult to remove
  2. Chronic FB w/drainage: Oral antibiotics after removal
    • Amoxicillin
  3. Discharge w/follow-up to ENT if removal traumatic or concerning
  4. Admit for failure to remove any object w/potential airway compromise

 

Throat & Airway

Background

  • General Information
    • 73% of cases <3 yo
      • Organic causes> nonorganic causes
        • Peanuts account for 1/3
      • Organic sources: carrot, apple, beans, popcorn, sunflower and watermelon seeds
      • Nonorganic sources: small toys (balloons), batteries, other small parts
      • Hot dogs relatively common cause, but seen less often clinically; higher probability of complete aspiration

Pathophysiology

  • Pathology of Disease
    • R>L bronchus>trachea
    • Esophageal FB can compress trachea and cause resp. sxs
  • Incidence, Prevalence
    • 600 pediatric deaths per yr (US) (2/100,000)
  • Risk Factors
    • Age: small airways, lack of fully developed larynx, oral exploration
    • M>F
  • Morbidity / Mortality
    • Unintentional suffocation leading cause of injury-related death in <1 y/o
    • Most serious complication is complete obstruction: most commonly completely obstructed items: hot dogs, grapes, nuts, candies

Diagnostics

  • History
    • Complete obstruction
      • Cough to syncope
    • Incomplete
      • Clinical suspicion most important
        • Initial: paroxysms of cough/choke/gag/wheeze
        • Asymptomatic interval: initial irritative sxs subside
        • Complications: obstruction/erosion/infection
  • Physical Examination
    • Choking
    • Gagging
    • Wheezing or asymptomatic (up to 1/3), cyanosis
      • All have low positive predictive value
  • Presentation
    • (+)H/O of aspiration in 70% cases
    • Clinical presentation dependent on acuteness & location of obstruction
    • Chest auscultation is critical
      • May hear decreased breath sounds/wheezing on side of FB aspiration
      • May have normal finding
  • FB location
    • Laryngeal foreign bodies
    • Can cause acute obstruction
      • FB size and/or edema
    • Sxs: cyanosis, apnea, hoarseness, dysphonia & facial petechia
    • Tracheal foreign bodies
      • Sxs similar to laryngeal foreign bodies
      • Usually no hoarseness/aphonia
      • May also hear wheezing
    • Bronchial foreign bodies
      • Most often have subacute course
      • Typical sxs (65%)
        • Cough
        • Unilateral wheezing
        • Decreased breath sound
  • Diagnostic Testing
    • CXR: + in 70-85%
      • Contralateral mediastinal shift, segmental hyperlucency, atelectasis, pneumonia
      • Opaque foreign body in 10-25%
    • CT scan
    • IF moderate/high index of suspicion, esp. if nuts, proceed to bronchoscopy
  • Laboratory evaluation
    • Not useful
  • Other studies
    • Bronchoscopy is definitive diagnostic and tx modality

Differential Diagnosis

  • Key Differential Diagnoses
    • Asthma
    • Pneumonia
    • Bronchitis
    • Other cardiopulmonary causes dependant on presentation
  • Extensive Differential Diagnosis
    • Croup
    • Epiglottitis
    • Tracheitis
    • Retropharyngeal abscess
    • Esophageal FB

Treatment

  1. Acute Tx
    • ABCs
    • Heimlich if witnessed complete obstruction
    • Laughter or nonintervention if can breathe
  2. Relieve airway obstruction
    • If not rapidly successful laryngoscopy w/Magill forceps or Kelly clamp
  3. Surgical cricothyrotomy
    • If above procedures not available nor immediately successful
  4. If obstruction below cricoid & unable to remove FB
    • Push FB into bronchus & ventilate unobstructed lung
  5. Bronchoscopy is definitive therapy
    • Usually do NOT give antibiotics or steroids first
    • Proper size scope is essential
    • Inhalational anesthesia usually given
    • An OR procedure

Follow Up

  • Prompt referral to specialist for bronchoscopy if indicated

Prognosis

  • Most recover w/ appropriate diagnosis if incomplete aspiration
  • Bronchiectasis may develop for some w/ organic foreign bodies of longer duration

Prevention

  • No nuts or round crunchy objects in <4 y/o
  • Parental supervision during eating
  • Child Safety Protection Act requires choking hazard warning labels on some nonfood items

 

GI

Background

  • Peak incidence between 6 mos-6 yrs
    • Oral exploration developmentally appropriate in 1-2 yr
  • Increased incidence with
    • Psychiatric disorders
    • Cognitive impairment

Pathophysiology

  • Site of foreign body based on zones of narrowing
    • Inferior cricopharynx
    • Where aortic arch crosses esophagus
    • Gastroesophageal junction
  • Incr risk if patient s/p esophageal surgery or caustic ingestion
  • Once through the esophagus most FB will pass uneventfully
    • Exceptions
      • Buttom Batteries
      • Sharp objects
  • Complications include
    • Perforation
    • Impaction
    • Bowel Obstruction

Diagnostics

  • History/Symptoms
    • Dependent on age of patient
    • +/- H/O foreign body ingestion
    • Older, conscious children
      • Can provide some hx
      • Determine onset, time since ingestion
      • Localize pain
    • Infant or non-verbal patient
      • Constipation (persistent)
      • +/ wheezing, choking
      • Respiratory distress
      • Vomiting (from airway compromise)
      • Refusal to eat
      • Bloody saliva
      • Drooling
  • Physical Exam
    • If upper airway perforation
      • Edema, erythema
      • Neck Tenderness
      • Crepitus
    • Abdominal tenderness
      • R/O peritonitis
      • R/O SBO
  • Diagnostic Testing
    • Handheld metal detector useful
  • Diagnostic Imaging
    • Biplane radiographs
      • Will reveal metallic bodies
      • May miss ingested bone, wood, plastic, glass
    • If XR neg consider
      • Barium swallow
        • Access for risk perforation
        • Can compromise subsequesnt endoscopy
      • Endoscopy for definitive Dx
      • URGENT if disk battery or sharp object
  • Special Considerations
    • Food bolus impaction
      • Endoscopy if
        • > 24 hrs
        • Pt unable to swallow secretions
        • Pt in distress
      • High incidence of underlying pathology
      • Glucagon 1.0 mg may promote spontaneous passage
    • Blunt objects
      • Conservative management if object has entered stomach
        • Usually passed spontaneously with 4-6 days
        • X-ray weekly
      • Remove FB endoscopically
        • After 4 weeks in stomach
        • If past stomach, in same location > 1 week
      • Surgical intervention if
        • Fever, vomiting and abdominal pain present
    • Sharp pointed objects
      • EMERGENT if lodged in esophagus
      • 35% risk of complication if FB entered stomach
      • Endoscopy suggested if x-rays (-)
        • Chicken/fish bones
        • Bread-bag clips
        • Toothpicks
        • Needles
      • Follow with daily x-rays if FB not removed
      • Surgical retrieval if not progress x 3days
    • Button (disk) batteries
      • Potentially FATAL in esophagus
        • Tissue on +/- sides activates electric circuit
        • Risk of liquefaction necrosis, perforation of eosphagus
        • Should be recoved IMMEDIATELY via endoscopy
      • Protect airway with overtube or ET tube
      • If safe retrival impossible, should be pushed in to stomach
      • Once in the stomach can pass naturally
        • 85% spontaneous passage within 72 hrs
        • Emetics not helpful-may cause retrograde migration
        • Retrive from stomach if battery has opened or been damamged
    • Narcotic packets
      • Can be seen on x-ray
      • Potentially fatal if contents leak
      • DO not attempt endoscopy due to risk of rupture
      • Immediate surgucal retrieval if
        • Rupture suspected
        • Failure to progress
        • Sign of intestinal obstruction
    • Long objects
      • Longer than 6-10 cm cannot pass duodenal sweep
      • Should be removed endoscopically

Treatment

  1. ABCs: ensure patient airway
  2. Dependent on
    • Age of patient
    • Location in object
    • Relative risk of ingested item
  3. Removal by endoscopy safest
    • May use balloon catheter under fluoroscopy if radiologist experienced
    • Use with caution due to aspiration potential
    • Must be able to stabilize airway
    • Contraindicated if
      • Prev. esophageal surgery,
      • Caustic injestion or
      • FB present > 72 h

Disposition

  1. If foreign body passed to stomach, discharge with outpatient follow-up by MD
  2. If foreign body is esophageal, admit for airway observation & ENT or GI removal
  3. Call button/battery hotline 202-625-3333 prn

 

Rectum

Pathophysiology

  • Intentional insertion of foreign objects
    • May have psychiatric or erotic motivation
    • Secondary gain (eg, prisoners)
  • Can be accidental
    • Especially in children
  • Pt may or may not give history of event

Diagnosis

  • Symptoms
    • Pain or discomfort
    • If perforation
      • Bleeding
  • Physical Exam
    • Majority FBs are"low-lying"
      • Palpable in rectal ampulla on digital exam
    • Exam w/anoscope/proctoscope
    • X-rays
      • Glass/plastic can be hard to visualize clearly
      • May be useful to determine size, shape, location

Treatment

  1. Some foreign bodies may be removed in ED
    • Defer to surgeon to remove in OR
      • Difficult shape/size
      • Sharp edges
      • Glass
  2. ED removal
    • Consider conscious sedation if uncomplicated
      • Consider local anesthesia for pain control and sphincter relaxation
    • Pt in lithotomy position, inject local at 12 o'clock and 6 o'clock on anus, then perform “ring block” around internal sphincter muscles
    • Place index finger of 1 hand in anal canal as guide for placement of needle by other hand
    • Use a 1 1/2 inch needle to reach area
      • Extract object w/ ring forceps
      • Large objects create a vacuum proximal to obstruction
      • Break vacuum by passing catheter open to atmosphere around & behind object
      • If unable to grasp
        • Place several balloon Foleys beyond FB, inflate balloons of Foley cath
        • Apply traction to object by gently pulling Foley cath
      • Consider latex enema for fragile/glass objects (light bulbs)
      • If foreign body is removed in ED and any possibility of perforation repeat proctoscopy
      • Consider observation & repeat x-rays in 12 hrs
  3. Surgery consult is mandatory for any of the following
    • If unable to remove
    • Rectal & anal lacerations
    • Perforation or persistent bleeding
    • Preop: labs, & broad-spectrum abx (2nd gen cephalosporin)

Disposition

  1. If FB removed, send home w/ stool checks; instruct to return for signs of perf, obstruction, bleed
  2. Consider 12 hr observation (NPO) if concerned about occult perf, or to monitor sequelae of anal/rectal lacerations
    • At end of 12 hrs either CT or CXR depending on FB; lacerations use endoscopy
  3. If object sharp, large, bulky, perforation or risk of perforation/obstruction, or if pt intoxicated
    • Admit to hospital

 

Skin & Soft Tissu

Lacerations

Initial Evaluation

  • Determine mechanism of injury
  • Check vital signs for hypotension or tachycardia
  • Hours since injury
  • Foreign bodies
    • X-ray to R/O fracture or metallic foreign body (FB)
    • US or CT if glass or wood FB suspected

Wound Preparation

  1. Prepare site
    • High pressure irrigation with normal saline (or tap water) as needed
      • Pressure should exceed 8 psi
      • Use 35 mL syringe with 19G needle
    • Debride devitalized tissue
  2. Anesthesia as needed
    • 1-2% Lidocaine, +/- epinephrine
      • NO EPINEPHRINE in areas of limited vascularity, (e.g. finger/ toes, ear, penis)
    • Benadryl can be injected locally if allergic to local agents
      • BEWARE - potential for tissue necrosis
    • Topical anesthetics
      • LET (lidocaine, epinephrine, tetracaine)
      • TAC (tetracaine, adrenaline, cocaine)
        • DO NOT use on mucous membranes
      • EMLA: Topical agent

Wound Closure

  1. Examine wound for
    • Depth
    • Structures involved (e.g. tendon, bone, vasculature)
      • Recommended Ortho or Plastics consult
        • Orthopedics if tendon or joint involvement
        • Plastic surgery if facial wound
    • Presence of foreign body
  2. Close superficial wounds with little or no tension via:
    • Steri strips and tincture of benzoin
    • Cyanoacrylates
      • Octyl-2-cyanoacrylate (2-OCA)
      • Surround wound with antibiotic ointment "dam" to prevent adhesive runoff
  3. Close deep wounds with sutures
    • Absorbable stitches for deep tissue as needed
    • Vertical mattress sutures if there is any wound tension
  4. Antibiotics:
    • Not usually indicated
    • Consider if:
      • Grossly contaminated wound
      • Injury present more than 6-8 hours
      • Immunocompromised patient
      • Poor vascularity at wound site
        • Keflex or oral Amoxicillin clavulanate
      • Cat or Human bite wounds:
        • IV Ampicillin sulbactam or oral Amoxicillin clavulanate
  5. Tetanus prophylaxis as needed
  6. Special concerns
    • Longer than 12 hours since injury
      • Consider leaving open
    • Deep puncture wounds
      • Leave open
      • Nu-gauze drain may be helpful
    • Bite Wounds
      • Human
      • Cat
      • Dog

Disposition

  1. Admit PRN severe trauma, open fracture or severe blood loss
  2. Discharge with suture removal as an outpatient
    • 5 days for face or scalp
    • 7 days for arms or anterior trunk
    • 10-14 days for legs or posterior trunk