Hot Seat #154: 16mo concern for foreign body ingestion

Posted on: June 5, 2020, by :

Marci Fornari, MD, Children’s National Medical Center

CC: Foreign Body Aspiration

HPI: 16 month old ex-FT female with no PMHx presents with concern for foreign body aspiration. Parents were feeding her dinner when she seemed to choke on a piece of apple. She coughed a few times but did not spit up any food or vomit. She had no respiratory distress or cyanosis during the episode. No stridor or drooling since the episode occurred. After the coughing episode resolved, her parents noticed that she could take small sips of liquids, but she could not eat solids.  When she was given solid foods she would spit them out. Due to this concern, parents took her to an OSH ED where she had a CXR that showed tracheal deviation. She was transferred to the CNMC ED for further workup. On arrival to the CNMC ED her vital signs were stable and she had no signs of respiratory distress. The OSH CXR was uploaded and the tracheal deviation was confirmed by our radiologist.

PMHx: born full term with no complications, no hospitalizations, no medications

Immunizations: UTD

Family Hx: no asthma, no airway anomalies, no congenital heart disease

Social Hx: Lives at home with mom and dad, no daycare

ROS:

Constitutional: no fevers, tolerating small sips of liquids but no solid foods

Skin: no rashes

ENMT: no nasal congestion, no drooling, no change in voice or cry

Respiratory: +coughing episode, no SOB, no wheeze, no stridor, no cyanosis

Gastrointestinal: no vomiting, no diarrhea

Neuro: no AMS, no LOC

Allergies: no seasonal, food or medication allergies

Physical Exam:

T 36.8 C, HR 106, RR 26, BP 101/50, SpO2 99%

General: sitting in mom’s lap smiling, no acute distress

Skin: warm, dry, no rash

Head: normocephalic, atraumatic

Neck: supple, tracheal midline, no lymphadenopathy

ENT: TMs normal, no drooling, no foreign objects or lesions visible in the oropharynx

CV: regular rate and rhythm

Respiratory: no increased WOB, lungs clear to auscultation bilaterally, no wheeze, no stridor

GI: soft, non-tender, non-distended

Neuro: developmentally normal, moves all extremities, walks independently, says ma-ma and da-da

You decide to keep the patient NPO and obtain a repeat CXR (AP & Lateral views) to re-assess the airway. The repeat CXR shows persistent rightward tracheal deviation.

ENT was consulted due to concern for tracheal deviation. ENT recommended admission for bronchoscopy to evaluate the airway. General surgery was consulted due to concern for foreign body in the esophagus. given that she was so well appearing they recommended a PO trial, however, initially they recommended admission for EGD.

GI was consulted who recommended an esophagram. The general surgery resident then called back to say that the surgery attending recommended a CT neck and chest with IV contrast to evaluate the airway and assess for foreign body.

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Marci Fornari

Marci was born and raised right outside of NYC, but she is now a self-proclaimed Philadelphia (and Eagles fan) thanks to her husband. Over the past decade she has been making her way down the East Coast, and she is very excited to take advantage of all DC has to offer during her fellowship. Her academic interest include quality improvement, intimate partner violence screening, social determinants of health, as well as a goal to obtain an MPH. When she is not in the emergency department, you can find her on the beach, the ski slopes, at the dog park with her labradoodle, or at Orange Theory Fitness.

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2 thoughts on “Hot Seat #154: 16mo concern for foreign body ingestion


  1. too many cooks in this kitchen. Your suspicion is FB in the airway, given tracheal deviation. ENT wants to admit for bronchoscopy. request that surgery or GI join so they can do an EGD if the foreign body is not visualized. If you need to admit them to the hospitalist team for coordination of care, so be it.


  2. I think the heart of the matter is figuring out if the piece of apple is in the airway (“aspiration”) or in the esophagus (“ingestion”). There are many clues from the H&P that suggest that this child has a partial obstruction of her esophagus that is resulting in a tracheal deviation. Most importantly, she presents with no respiratory symptoms (no current cough, no stridor, no wheeze, no dyspnea). Also, an aspiration of a solid lodged in the lumen of the trachea would typically not cause trachea deviation, but it would cause significant airway symptoms. Remember that the trachea is very pliable in young, young children. In this case, it is likely being deviated by something external to it. And that something is likely the esophagus…with a chunk of apple in it! Also, the child is handling her secretions and can swallow small amounts of liquids but not solids. This suggests a partial obstruction of the esophagus. Hence, my first step would have been to obtain an esophagram BEFORE consulting anyone. Also, 16 month-olds are notorious for not chewing their food well.

    A question for everyone, would a piece of apple stuck in the esophagus be labeled a “foreign body”. I always thought foreign bodies were things we don’t typically ingest like screws, coins, or batteries. Or is this just semantics?

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