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ENT (Ear, Nose, Throat Conditions)

Foreign Body in the Airway

Inhalation of an object into the larynx, trachea, or bronchi. A life-threatening emergency if causing significant airway obstruction. Most common in children <5 years.

Also known as: Inhaled Foreign Body, Aspirated Foreign Body, Choking

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Referral and warning signs

When to refer

IMMEDIATE EMERGENCY REFERRAL/TRANSPORT for: Any child with ongoing respiratory distress after choking event. ANY child with suspected retained foreign body (even if currently asymptomatic). Child requiring bronchoscopy.

Red flags

  • Inability to cough, speak, or cry.
  • Cyanosis.
  • Stridor.
  • Loss of consciousness.
  • Persistent wheezing or cough after a choking episode.

Signs and symptoms

  • Acute Choking Episode: Sudden onset of coughing, gagging, choking, stridor, wheezing, cyanosis, inability to speak or cry, respiratory distress, potential loss of consciousness.
  • Post-Aspiration (If object lodges distally):
  • - Persistent cough.
  • - Unilateral wheezing (may be localized).
  • - Recurrent or persistent pneumonia (often in same lung lobe).
  • - Decreased breath sounds on affected side.
  • - May be asymptomatic initially if object small and non-obstructing.
  • - Hoarseness (if laryngeal FB).

Risk factors

  • Age <5 years (especially 1-3 years).
  • Access to small objects (nuts, seeds, small toys, coins, buttons).
  • Eating while running, playing, laughing, crying.
  • Neurological impairment affecting swallowing/cough reflex.

Diagnosis

Clinical assessment

Acute Choking: Diagnosis based on witnessed event and signs of airway obstruction. Suspected Retained FB: History of choking episode (may be forgotten/unwitnessed) followed by persistent cough, wheeze, or recurrent pneumonia. Physical exam may reveal localized wheeze or decreased air entry.

Investigations

  • Acute Setting: Focus on immediate life support, investigations deferred.
  • Suspected Retained FB:
  • - Chest X-ray (Inspiratory and Expiratory/Lateral Decubitus views): May show radio-opaque FB. May show indirect signs like unilateral hyperinflation (air trapping on expiration), atelectasis/collapse, mediastinal shift.
  • Normal CXR does NOT rule out FB.
  • - Bronchoscopy (Rigid preferred): Gold standard for diagnosis and removal. Performed by specialist under general anaesthesia.

Diagnostic criteria

Witnessed choking event with obstruction OR High clinical suspicion based on history/exam +/- suggestive CXR findings. Definitive diagnosis by bronchoscopy.

Differential diagnosis

  • Asthma exacerbation.
  • Croup.
  • Epiglottitis.
  • Bronchiolitis.
  • Pneumonia.
  • Anaphylaxis.
  • Laryngomalacia/Tracheomalacia.
  • Vocal cord paralysis.
  • External airway compression (tumour, node).

Management

Non-pharmacological management

  • Acute Complete Airway Obstruction (Child unable to cough/speak/cry):
  • - Infant (<1 year): 5 Back Slaps followed by 5 Chest Thrusts. Repeat cycle.
  • - Child (>1 year) / Adult: Heimlich Maneuver (Abdominal Thrusts). Repeat until object expelled or patient becomes unresponsive.
  • - If Unresponsive: Start CPR. Check mouth for visible object ONLY before giving rescue breaths - remove if easily seen (NO blind finger sweeps).
  • Acute Partial Airway Obstruction (Child coughing effectively):
  • - Encourage coughing.
  • - Do NOT interfere with back slaps/thrusts.
  • - Monitor closely, be prepared to intervene if obstruction worsens.
  • After Successful Dislodgement or if Retained FB Suspected:
  • - Transport to hospital for assessment (even if object seemingly expelled) to rule out complications or retained fragments.
  • Removal of Retained FB:
  • - Requires Bronchoscopy (usually rigid) under general anaesthesia by ENT or Thoracic surgeon.

Pharmacological treatment

  • Oxygen therapy if hypoxic.
  • Antibiotics may be needed if secondary pneumonia develops.

Monitoring

Monitor respiratory status closely after choking event or removal.

Complications

  • Hypoxia, Brain damage.
  • Respiratory arrest, Cardiac arrest.
  • Death.
  • Pneumonia (post-obstructive).
  • Bronchiectasis.
  • Lung abscess.
  • Pneumothorax / Pneumomediastinum.
  • Airway trauma from FB or removal attempts.

Prevention

  • Keep small objects (foods like whole nuts/grapes, toys, batteries, coins) out of reach of young children (<3-4 years).
  • Supervise children while eating.
  • Discourage running/playing while eating.
  • Cut food into small pieces for young children.
  • Age-appropriate toys.
  • Caregiver education on choking hazards and first aid.

Patient education

  • Choking prevention strategies (food safety, toy safety, supervision).
  • Basic choking first aid (back blows, chest/abdominal thrusts).
  • Importance of seeking medical evaluation after any significant choking episode, even if object seems expelled.
  • Signs of retained foreign body (persistent cough/wheeze).

Uganda-specific notes

Common emergency, especially with groundnuts, beans, maize seeds. High risk of mortality/morbidity if not managed promptly. Access to bronchoscopy limited to referral hospitals. Prevention through caregiver education is key.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 21, Section 21.3.1

  • Basic Life Support / Pediatric Advanced Life Support Guidelines

    (Standard choking algorithms)

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