Only one-fourth of patients who have aspirated a foreign body present within 24 h of the event. A high index of suspicion is required to diagnose this disorder. Foreign-body aspiration should always at least be considered in a young child with respiratory symptoms. If the clinical scenario clearly indicates the presence of a foreign body or airway obstruction, the hospital's protocol for obstructed airway should be implemented immediately. When a diagnosis is considered in a stable child, plain radiographs may be helpful if positive. Clinicians should never rule out a foreign-body aspiration based only on plain radiographs, as they may be entirely normal in up to one-third of bronchoscopically proven cases of foreign-body aspiration. Friedman's review found that only 7 percent of aspirated foreign bodies were radiopaque.30

Nonradiopaque foreign bodies at the laryngeal or tracheal locations may be identified by looking for telltale air contrast of the foreign body in relation to the surrounding normal soft tissues. Computed tomography (CT) may be helpful. In most cases, however, additional radiologic procedures are not ideal, and laryngoscopy and rigid bronchoscopy are indicated.

In cases of complete obstruction, segmental atelectasis may be seen on plain radiographs. In other cases, intermittent or partial obstruction occurs, creating a ball-valve effect (Fig 12.9-4). In these cases, additional radiographs or fluoroscopy may be helpful. Partial obstruction, most commonly of the right mainstem bronchus, may cause obstructive emphysema of the involved lung by allowing air past the obstruction on inhalation but preventing its passage on exhalation. In cooperative, stable children, inspiratory and expiratory PA chest radiographs looking for hyperinflation of the involved lung with contralateral mediastinal shift and decreased excursion of the ipsilateral diaphragm may be indicated. Forced expiration by having a parent gently push on the child's lower abdomen during expiration may increase the sensitivity, but this has not been adequately studied. In young or uncooperative children, the ball-valve phenomenon may best be demonstrated by fluoroscopy. Bilateral decubitus PA chest radiographs may also be used but are less sensitive than fluoroscopy. The obstructed side will remain fully inflated with the ipsilateral diaphragm inferiorly displaced when the involved side is down. When the unobstructed side is down, it will show the normal findings of diaphragmatic elevation, rib splinting, and decreased relative volume compared to the upside ( Fig 129-5 and Fig 129-6) . Series have demonstrated that bronchoscopically proven cases of foreign-body aspiration were definitively diagnosed preoperatively in only 60 percent of cases. Clinically suspected foreign-body aspiration should ultimately be ruled out by bronchoscopy.

be ruled out by bronchoscopy.

Although uncommon, esophageal foreign bodies may cause stridor. Esophageal foreign bodies more commonly are radiopaque and are, therefore, more easily seen on plain radiography. In general, narrow, flat foreign bodies such as coins will be oriented in the coronal plane if they are in the esophagus. The tracheal cartilages with the exception of the cricoid ring are incomplete and horseshoe-shaped, with the opening directed posteriorly. These anatomic characteristics cause most narrow, flat radiopaque tracheal foreign bodies to be sagittally oriented on radiography. Certainly exceptions to these generalities do occur. Radiolucent foreign bodies in the esophagus may be suspected in many cases due to an air-fluid level or soft tissue changes in the area just cephalad to the obstruction. Older children may complain of something stuck in the throat. Discussion of esophageal foreign-body management is found in Chap 72,

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