Current Approach to Diagnosis and Treatment of Foreign Body in Otorhinolaryngology

Abstract

Foreign body (FB) in ENT is a condition frequently seen in, but not exclusive to, the pediatric population. In adults, poor eating habits, loss of dentition, alcohol consumption, and old age are the factors predisposing patients to FB pathology. Foreign bodies can be classified by type and by localization. By type, FB can be broadly classified as organic or inorganic. Special attention must be devoted to batteries. By location, FBs are commonly classified as aural, nasal, pharyngeal, ingested, and aspirated. High level of suspicion is essential for FB diagnosis. Normal physical exam does not exclude FB diagnosis. Frontal and lateral plain radiographs are helpful, but not sensitive in every case. The majority of ingested FB are low risk objects and pass through gastrointestinal tract without causing any problems. Bronchoscopy should be performed whenever there is a reasonable suspicion of aspirated FB. Recurrent or long-standing pulmonary problems warrant FB consideration.

1. Introduction

A foreign body (FB) is “an object in an organ or body cavity that is not normally present” (according to the Agency for Healthcare Research and Quality (AHRQ)—US Department of Health & Human Services). It remains a diagnostic and surgical challenge, even for experienced otolaryngologists. Foreign body in ENT is a condition most commonly seen in, but not exclusive to, the pediatric population. Infants (1–12 months) and toddlers (1–3 years) are at the highest risk. This is due to the children’s tendency to explore the world using their mouth, their tendency to eat and play simultaneously, their relatively smaller airway, and their limited ability to differentiate edible from inedible materials. Children also do not have fully developed posterior dentition, nor is their cough reflex mature. Children with behavioral disorders such as ADHD and hyperactivity disorder are further predisposed to FB incidents [1].

In adults, poor eating habits, loss of dentition, alcohol consumption, and old age are the factors predisposing patients to FB pathology. It should be noted that adults presenting with FB must be inspected for underlying pathology, such as some neurological conditions or malignancies [2].

Higher levels of housing instability and material deprivation are associated with more common FB ingestion and more common complications related to FB ingestion. The odds of complications related to FB ingestion are also much higher in children with comorbidities [3].

History can be helpful, but the clinician should not rely on history too much when considering diagnostic approaches. Regarding aural and nasal foreign bodies, parents often witness the actual event or come to a physician after seeing the foreign body in the nose or the ear canal. If these things do not happen, patients will present with nasal/aural discharge and pain due to mucosal swelling. Regarding esophageal FB, aside from witnessing the event, history often consists of sudden-onset dysphagia/aphagia and drooling. Aspirated FBs are almost always accompanied by an initial choking and coughing event. Children who are verbal can often report where the foreign body is sensed.

Radiograph imaging is usually performed when there is a suspicion of FB. However, it has low sensitivity and specificity for nonmetallic objects. A systematic review and meta-analysis of eighteen articles (4178 patients) showed that the sensitivity of chest CT scans in detecting foreign bodies in children was 99%, while the specificity of chest CT scans was 92%. The authors concluded that while CT can be used to help reduce the number of unnecessary rigid bronchoscopies, it should not be a replacement for gold standard bronchoscopy, especially in cases with a clear history and positive symptoms [4].

Any history of witnessed choking accompanied by gagging, coughing, or cyanotic episodes should be investigated further via flexible laryngoscopy and bronchoscopy, regardless of radiographic findings.

The first described foreign body extraction was performed by Verduc in 1717 and consisted of a bronchotomy. Bronchotomy remained a procedure of choice for the next one and a half centuries, despite having a higher mortality rate than observation (23%). In 1876, Killian changed the approach by removing a pork bone from the patient’s airway using an esophagoscope, giving rise to the era of endoscopy in FB management. The early twentieth century gave rise to modern rigid bronchoscopes. The fiber-optic bronchoscope was first developed in 1967 by Shigeto Ikeda, thus beginning the new era. Today, fiber-optic bronchoscopy is the gold standard for the diagnosis and management of aspirated foreign bodies [5].

Foreign bodies in the ear, nose, and throat can frequently be managed in the emergency department, especially if the patient provides a history consistent with the foreign body and is calm and cooperative during the examination and removal procedures. On the other hand, many studies point to the problem that arises when an unsuccessful attempt at FB removal is made in the emergency department. Namely, the risk of FB removal failure by an ENT specialist increases significantly following a failed prior removal attempt by a non-ENT specialist. Therefore, each case must be carefully evaluated to minimize the odds in this scenario. More difficult cases should always be referred to an ENT specialist [6].

2. Incidence

In the European Union, the yearly incidence of FBs is around 50.000 for children aged 0–14 years. Out of those, around 1% end up being fatal. This makes choking the 4th leading cause of death in children under 5 years [7, 8].

As people’s habits change, so do the types of foreign bodies. Nowadays, safety pins and marbles have been replaced with batteries and plastic toy pieces.

The Susy Safe project is the largest registry of FB incidents. It started collecting data in 2007, at first in the EU and later getting reports from other parts of the world. As of March 6, 2023, there are 35,891 cases registered in the database. According to the database, boys are more likely than girls (53 vs. 47%) to present with a foreign body. Most FB incidents happen at home (83%), and most happen in the presence of an adult (72%). The incidence by region was: ear (19%), nose (26%), mouth and esophagus (25%), pharynx and larynx (10%), and tracheobronchial tree (15%). However, one should bear in mind when looking at this statistical data that it is collected by means of reporting on a case-by-case basis. Also, the project started with the collection of only nonfood foreign bodies and only later incorporated food foreign bodies. The proportion may also vary depending on the region because of different cultures and food types [8].

A large retrospective study of 829 patients in 7 years identified the following relative proportions: nose (58.7%), ear (20.2%), mouth/pharynx/tonsil (12.3%), esophagus (6.2%), and laryngotracheobronchial tree (2.4%). The most common FBs by location were beads in the nose (30.8%); beads in the ear (32.1%); fishbones in the mouth, pharynx, or tonsil (56.8%); nuts and peanuts in the laryngotracheobronchial tree (70%); and coin/disc batteries in the esophagus (80.7%) [9].

A big step forward was made in 1979 (Consumer Product Safety Act), which introduced the cylinder test to reduce the risk of choking in children. The cylinder has an inner diameter of 31.7 mm and a truncated askew with an upper dimension of 51.7 mm and a lower dimension of 25.4 mm. Any toy entering the cylinder without pressure is considered unsuitable for children younger than 3 and is legally banned. For all toys intended for children under 3 years old, the batteries must be secured in compartments with screws [10].

3. Classification of foreign bodies

Foreign bodies can be classified by type and by localization.

By type, FB can be broadly classified as organic or inorganic (Figure A1). Special attention must be devoted to batteries, as these are the only FBs that require immediate intervention regardless of the anatomic site that they are in. Around 80% of FBs in the upper aerodigestive tract are organic in nature [8].

In general, metallic objects cause minimal inflammatory response, while organic foreign bodies tend to be more irritating to the upper aerodigestive tract mucosa and tend to cause symptoms much earlier. FBs with high starch content can absorb water and enlarge, subsequently causing even bigger obstruction. Some FBs are potentially toxic to the body (lead objects, drug packets) [11].

By location, FBs are most commonly classified as aural, nasal, pharyngeal, ingested, and aspirated FBs. According to the literature, aural and nasal foreign bodies are more common than aspirated or ingested foreign bodies, but this was dealt with more in the previous chapter. There is reporter bias regarding this matter, as the literature on aural and nasal foreign bodies is much scarcer, due to them being much less of a threat to a patient’s well-being, and tertiary centers dealing with aspirated and ingested FBs never come into contact with some of the aural and nasal FBs that are removed in the emergency department.

4. Ear foreign bodies

The external auditory canal (EAC), along with the nose, is the most common site of FB encounter. The majority of ear FBs are found in children; however, adults also frequently present with foreign bodies in this region. Children most commonly insert beads, plastic toy pieces, popcorn kernels, and paper. Adults present with cotton pieces from ear swabs and insects [12].

The EAC is a narrow tube of cartilage and bone, lined with perichondrium and periosteum, and overlying skin that is tightly adherent to the surface. The narrow point of the EAC is the bony-cartilaginous junction, the place at which FB can become impacted, which most commonly happens with unsuccessful removals. Most FBs are found lateral to the isthmus. Additionally, the tympanic membrane is at risk of perforation if further displacement of the FB happens [13].

While many FBs can be removed in the emergency department, careful evaluation must be done prior to the first attempt. Non-graspable foreign bodies are better removed by otolaryngologists with fewer complications compared to emergency department staff removal [13, 14]. Other indications for referral include patients with trauma to the canal or tympanic membrane, a foreign body suspected of touching the tympanic membrane, foreign bodies with sharp edges, or unsuccessful removal attempts. Children have narrow external auditory canals and relatively greater amounts of earwax compared to adults. The risk of eardrum damage increases if a foreign body is in its proximity. Because of this, especially if paired with a noncooperative child, general anesthesia is relatively commonly required for aural FB [15]. In most cases, though, FB can be removed as an outpatient procedure using a combination of instruments, most notably suction, alligator forceps, and a right-angled hook [16]. The procedure is done under microscopic visualization with adequate positioning of the patient. Many aural foreign bodies will spontaneously migrate out of the ear. This is what commonly happens with grommets.

A few rules of thumb can be applied when it comes to dealing with aural foreign bodies [17]:

• Batteries require immediate removal.

• If the foreign body is inorganic, then syringing can be a good option.

• If the foreign body is organic matter, it is best to avoid syringing, as the foreign body could swell and make the extraction more difficult.

• If the foreign object is an insect, the patient’s head should be tilted so that the ear with the insect is upward. It is usually a good practice to kill the insect using an alcohol or lidocaine solution, unless there is a suspicion that the tympanic membrane is perforated. After a few minutes, the insect is removed like any other FB.

Complications caused by extraction are lacerations and excoriations to the ear canal and rarely tympanic membrane perforation with or without ossicular chain damage [9].

5. Nasal foreign bodies

Commonly encountered in the pediatric population, nasal foreign bodies comprise around ¼ of FB incidents worldwide. The most common items extracted from the nose are beads, paper slices, food particles, and button batteries [8].

Nasal foreign bodies are most frequently located on the floor of the nasal passage, just below the inferior turbinate, or in the upper parts, anterior to the middle turbinate [17].

A nasal foreign body must be considered in any child with unilateral nasal discharge, even without a history of FB. The discharge usually occurs 4 days after the insertion, but with button batteries, discharge occurs immediately [18].

Most of the nasal foreign bodies can be removed in the emergency department, but doing so requires a careful clinical evaluation. Unsuccessful attempts at nasal FB removal may cause physical harm, such as lacerations of the nasal mucosa or nasal mucosa edema, as well as induce or worsen patient or parent anxiety. All of those factors can complicate subsequent removal attempts and sometimes even necessitate the use of general anesthesia, which is a further risk for the patient [19].

Early plain film X-rays should be justified for unwitnessed foreign body insertions, suspected unknown metallic foreign bodies, and disproportionate discharge or pain [20].

Some FBs are inert and can remain in the nasal cavity for a long time, causing no harm or even causing no major symptoms. Other FBs cause mucosal edema and subsequent erosions, ulcerations, and bleeding. Over time, due to chronic inflammation, these FBs absorb minerals, thus hardening and turning into rhinoliths.

Before the FB removal, a decongestant and local anesthetic should be applied to minimize edema and discomfort during the procedure. The commonly used instrument is a hook or a bent Jobson-Horne probe over and behind a foreign body. In around 60% of the cases, a technique referred to as “mothers kiss” can successfully expel the FB in children too small to blow their nose. The technique is performed by sealing the unaffected nostril and blowing the air gently from mouth to mouth. Balloon catheters (Fogarty) can also be placed intranasally behind the foreign body, partially inflated, and pulled out of the nose. In intubated patients, FB can be pushed into the nasopharynx and removed from there [17].

6. Pharyngeal foreign bodies

The pharynx is the most common localization of FB in the adult population [12, 21]. The most common subsite is the palatine tonsil and the lymphoid tissue at the base of the tongue. The most frequent type of FB is, by far, a fish bone, with its one end stuck in the tonsillar crypt.

Removal of pharyngeal FBs is usually done in outpatient settings. Most of these FBs are easily visualized during oropharyngoscopy using a headlight and proper patient positioning. Most of these FBs can be easily grasped using Magill forceps. In rare cases, as with the posterior pole of the palatine tonsil, vallecula, or pyriform sinus, the FB may not be visualized directly. Flexible endoscopes can be used to visualize the FB and extract it using flexible grabbing forceps passed down the instrument channel. In rare circumstances, this removal can require general anesthesia and a rigid endoscopy.

A rare but serious complication regarding pharyngeal foreign bodies is a migrating foreign body. The FB can migrate to the mucosa, to the soft tissue, or even to adjacent organs, forming abscesses and fistulae. A case series describes pharyngeal FBs migrating to the floor of the mouth, tongue, retropharyngeal region, and soft tissues of the neck [22]. One case study even shows migration of the fish bone to the mediastinum [23].

7. Ingested foreign bodies

Foreign body ingestion is a common occurrence in ENT practice. Foreign bodies can pass through gastrointestinal tract without causing any problems (80%) and may need endoscopic extraction (10–20%) or even surgical removal (<1%) [24]. Outcome depends on the nature of the FB, as well as the patient’s clinical and anatomical characteristics. In this chapter, we will be discussing esophageal foreign bodies, as the lower parts of the gastrointestinal tract are not within the domain of the ENT specialist.

A majority of patients with FB ingestion are children between 6 months and 3 years of age [25]. At this age, children regularly put foreign objects in their mouths as a mean of exploring the surroundings. By doing so, they sometimes accidentally swallow these objects. The American Association of Poison Control Centers recorded 83,412 FB ingestions in 2022 among all age groups (55,803 in children under 5 years and 7886 in adults above 20 years). There were no recorded fatal outcomes [26]. Most of them were unintentional [26, 27]. However, there is a substantial portion of adult population in which FB ingestion was intentional. Groups that have greater risk of foreign body ingestion are older people and people with gastrointestinal obstruction, intellectual disability, or secondary gain [27, 28, 29].

Impaction place of the FB depends on its morphology. The most common place where FBs get lodged are upper esophageal sphincter (70%), followed by aortic notch (20%) and lower esophageal sphincter (10%) [27]. Most commonly ingested FBs are coins, batteries, magnets, pieces of toys, and pieces of food. Button batteries are one of the most dangerous ingested FBs (refer to Section 9. Special considerations) [30].

Patients with esophageal FB can be asymptomatic or can develop dysphagia, odynophagia, FB sensation, hypersalivation, refusal to eat, retrosternal pain, respiratory distress [24, 27]. As in many other instances, detailed anamnesis and physical examination are in order. Witness statements are of great value. It is important to find out when the incident occurred, what is the FB, how many are there, were there any symptoms at the time of ingestion, is it the first time that FB ingestion occurred, has food or drink been ingested since the incident. It is helpful if the similar object as the FB can be presented to the physician. All of this can sometimes be challenging, especially when working with young children and the incident was not witnessed.

Laboratory tests are often unremarkable when a patient is stable [25]. Both anteroposterior and lateral radiographs are strongly suggested whenever there is a suspicion of the FB ingestion, even with asymptomatic patient (Figure A2). It gives additional information about the position and the shape of the FB. However, some FBs are radiolucent and cannot be seen on plain radiograph. Recent meta-analysis has showed that radiographs have 58% sensitivity and 94% specificity for detecting upper digestive tract FBs [31]. In some cases, radiographs have 100% positive predictive value (metallic objects) but 0% for others (wooden objects) [24]. CT scans can be used for radiolucent objects [2, 32]. They are particularly helpful when there is a suspicion of FB-related complication [33]. Contrast swallow studies are not routinely recommended, because they can be the cause of increased risk of aspiration in patients with complete obstruction, can delay treatment, and make the extraction of FBs more challenging by impairing visualization [33].

Ingested FB requires emergent (within 2 h) or urgent (within 24 h) endoscopy. Button batteries, sharp-pointed objects, magnets, and FB with complete obstruction demand emergent endoscopy. All other FBs with incomplete obstruction warrant urgent endoscopy [33].

The question whether to use flexible or rigid endoscopy greatly depends on the institutional policies. Flexible endoscopy is the first choice, as it is cost-effective and can be performed under sedation and local anesthesia. On the other hand, rigid endoscopy is superior for extraction of sharp objects and has the benefit of protected airways as it is always performed in general anesthesia [33, 34]. They are considered complementary techniques, equally effective for the removal of ingested FBs [35, 36].

Foley catheter can also be used for removal of FBs. It is used by inflating the balloon behind the FB and removing it with the extraction of the catheter. Although it has high success rate, it also has major disadvantages (no control of the FB and no airway control) [30, 37]. The use of this technique has been decreasing in recent years.

Esophageal bolus impaction can be treated by gently pushing it toward the stomach (90% success rate); however, extraction of the FB is preferred [33].

Surgical extraction of FB is usually reserved for irretrievable FBs and ones with complications such as perforation of the esophagus, fistula, extensive bleeding, and mediastinitis [33]. This is often a multidisciplinary endeavor and can be performed only in institutions of higher rang.

If the recurrent or unusual FB ingestion is observed, a mental health professional should be involved.

8. Inhaled foreign bodies

Foreign body aspiration is potentially one of the most urgent and the most stressful situations that can happen in a physician’s career. Even a patient that presents as asymptomatic can quickly find itself in a life-threatening situation.

It occurs more often in children, particularly younger than 3 years of age [11, 38, 39], and is one of the leading causes of accidental death in this population [7]. Foreign body aspiration is less common in adults [40]. Risk factors in adult population include older age, neurological and mental disorders, alcoholism, sedative abuse, and tracheostomy cannula handling [39, 40, 41]. In most cases, aspiration happens accidentally; however, iatrogenic aspirations are also possible.

Inhaled FB are typically classified as organic or inorganic, with organic being the ones causing more complications. The most common organic FBs are bones and seeds, and the most common inorganic FBs are teeth, metallic and plastic objects [39, 40]. Teeth are one of the most prevalent iatrogenic FBs that can get broken off and displaced into the tracheobronchial tree during intubation or several ENT procedures [38].

FBs can be found in any part of tracheobronchial tree. Right bronchial tree is more often the place where FBs end up, due to its size and angle to the trachea. Lodgement in the trachea and especially larynx is far less common [42]. Localization of the FB greatly affects clinical presentation.

Symptoms range from acute respiratory distress to asymptomatic patients that do not even recall having aspirated an FB [38]. Cough is the most commonly occurring symptom, as it is a natural protective reflex of the body. Other common symptoms are dyspnea, stridor, wheezing, choking, hemoptysis, and chest pain [38]. Complications arise when the FB gets undetected for a longer period. Some of the possible complications are pneumonia, bronchiectasis, emphysema, empyema, and so forth. For that reason, in every patient with recurrent or long-standing pneumonia, FB must be considered [43, 44].

Detailed anamnesis and physical examination are in order. It is important to notice that ability to speak, cough, or breathe usually indicates that the patient has mild obstruction, while weakening of these parameters implies a severe airway obstruction [41]. If a conscious patient has a severe obstruction, back blows, abdominal, and chest thrusts can be of help. Efficacy of these measures increases if the patient is placed in a prone or a head-down position [45]. These treatments should not be used if the obstruction is mild since they can worsen the obstruction. If the patient is unresponsive, CPR should be started promptly [41].

In stable patients, posteroanterior and lateral chest radiographs are to be obtained when there is a suspicion of FB aspiration (Figure A2). However, not all FB can be seen on the radiograph; only 26% can be identified. Besides direct visualization, physician should be on the lookout for indirect radiograph findings of the FB, such as consolidation, atelectasis, air trapping, and mediastinal shift. It is important to note that normal radiograph finding does not exclude FB aspiration [39, 46]. CT scans are superior in detecting FB aspiration and providing information about the surrounding tissue, but they are not considered as a routine procedure for FB detection [46].

Bronchoscopy is a mainstay for treatment of inhaled FBs. Rigid bronchoscopy was first introduced by Gustav Killian in 1897 [47] and since then was used for FB extraction. With the improvement of flexible endoscopes, flexible bronchoscopy has become the standard tool in FB aspiration management [38]. Rigid bronchoscopy is usually preferred in children, while flexible bronchoscopy is considered as the first choice in adults, where it accounts for about 80–90% of retrieved FBs [39, 40]. As mentioned, when discussing ingested FBs, flexible and rigid endoscopies are considered complementary. The same applies for bronchoscopies. Flexible bronchoscopy provides better visualization, can be performed in the setting of local anesthesia and sedation, and is cheaper and faster to perform. On the other hand, rigid bronchoscopy provides better ventilation, has wide array of instruments that can be used during the extraction of FB, and is necessary in some cases (impacted, sharp, or large foreign bodies; cases with extensive granulation tissue or scaring; and several failed attempts of FB removal with flexible endoscopy) [38, 40].

When bronchoscopy fails to retrieve the FB, open surgery procedures may be necessary. It is particularly important in cases with recurrent complications. In some cases, tracheostomy needs to be performed to establish airway control. There have been a few cases in literature, where tracheostomy was performed to extract the FB since it was too big to pass through subglottis [48].

Complications of the extraction of inhaled FB include bleeding, trauma, asphyxiation, and so on. Granulation tissue often accompanies late-diagnosed FBs. Damage to this tissue leads to bleeding that is usually easily managed with cauterization. Trauma can occur at any part of the airway path during the management of the FB and may be the cause of later scaring. Even when the FB is secured by the instrument and extraction is in place, there is a danger of losing the grip and dropping the FB in the airway. If FB is big enough, it can get lodged into the trachea and cause a life-threatening situation. In this case, FB must be pushed into the distal parts of the airway to maintain partial ventilation. Once the ventilation is stabilized, attempt of extracting the FB must be repeated [38].

To his day, there are no valid clinical prediction models for FB aspiration. The decision relies on the astute clinical care tailored for each patient by an experienced clinician [49].

9. Special considerations

Button batteries, as an FB, are a medical emergency regardless of the localization. They are increasingly more present in every household device, such as toys, watches, remote controls, hearing aids, and so forth. Even though cylindrical batteries are also common FB, button batteries have significantly higher morbidity [27]. Because of their size and shape, button batteries get lodged in esophagus in such a way that both poles of the battery are touching the esophageal wall, establishing electrical current, which generates hydroxide radicals at the negative pole. Contrary to the assumption, thermal damage, pressure necrosis, and leakage of battery’s internal substances (alkaline or lithium electrolytes) do not play a significant role in tissue damage [50, 51, 52]. Lithium batteries of ≥20 mm diameter pose the biggest risk. Damage to the mucosa of the esophageal wall occurs within 30 minutes and can be the cause of serious complications: esophageal perforation, tracheoesophageal fistula, aortoesophageal fistula, mediastinitis, and so on. This FB gives a characteristic finding on plain radiograph, similar to a coin, but with additional double halo rims. Button batteries are a clear indication for emergent endoscopic extraction [27, 34]. The application of oral honey (10 ml every 10 min) prior to extraction has recently been proposed by the National Capital Poison Center in the USA and in an ESPGHAN position paper in Europe, particularly for esophageal foreign bodies. Honey should be avoided in infants [52, 53]. After extraction, endoscopy should be repeated to assess the condition of esophagus and determine the risk for potential complications. Damage to the tissue may continue even after the extraction of the buttery if the site is not irrigated and environment neutralized. Ex vivo studies suggest that irrigating with mildly acidic beverages, such as lemon juice and soda or 50–150 mL of 0.25% sterile acetic acid, as early and frequently as possible may be most beneficial for pH neutralization [50, 52]. After removal of the button battery, patients should be on NPO (nil per os) and on careful observation since the above mentioned complications can happen several weeks after the FB removal. MRI is an important prognostic tool during this period [54].

The number of magnetic FB has been rising in the recent years. There is an increasing number of strong magnets (neodymium) in everyday objects. The attracting force of these magnets is many times stronger than that of conventional ones. When two magnets or a magnet and a metal object are ingested, they attract each other through the intestinal walls and can cause ischemia and tissue necrosis and consequentially obstruction, ulceration, perforation, fistulae, peritonitis, sepsis, and death. Symptoms depend on the size and the localization of the FBs. Patient may be asymptomatic or have abdominal pain and vomiting as the most common symptoms. Abdominal radiograph is essential for early diagnosis. Magnetic FB must be addressed promptly because every delay increases the risk of complications. Treatment is by endoscopic or surgical removal. If there is only one FB, observation may be considered with daily abdominal radiographs [25, 55].

Key points

• FB incidents are common and more prevalent in children.

• High level of suspicion is essential for FB diagnosis.

• Normal physical exam does not exclude FB diagnosis.

• Frontal and lateral plain radiographs are helpful, but normal findings do not exclude FB diagnosis.

• Button battery FB requires urgent removal.

• The majority of ingested FB are low-risk objects and pass through gastrointestinal tract without causing any problems.

• Bronchoscopy should be performed whenever there is a reasonable suspicion of aspirated FB.

• Recurrent or long-standing pulmonary problems warrant FB consideration.

Appendix

Figure A1.

Organic foreign bodies (A-E): A – bone form oesophagus; B – lamb bone from oesophagus; C – seed in glottis; D – tooth from right bronchus; E – corn from right bronchus. Inorganic foreign bodies (F-J): F – denture from oesophagus; G – magnet from oesophagus; H – coin from oesophagus; I – Q-tip in trachea; J – mouthpiece from left bronchus.

Figure A2.

Radiographs and extracted foreign bodies. A-B: needle in oesophagus; C-D: Tooth in right bronchus; E-F: lamb bone in oesophagus; G-H: oin in esophagus.