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How toManage Urgent Problems
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intheNeck: Foreign Bodies in the
Trachea and in the Esophagus in
Children and Adults andOther
Surgical Problems inLow- and
Middle-Income Countries
PhilipVareedAlexander
Be calm and strong and patient.
– William Osler
24
Abbreviations
A-P Anteroposterior
CT Computerized tomography
SCIWORA Spinal cord injury without radio-
logic abnormality
Trachea
Foreign Bodies inChildren
Clinical Vignette
A 6-month-old male infant was brought to the
emergency room with sudden difculty in breathing. He was seen holding a shelled peanut prior
to presentation. On examination, the child was in
severe respiratory distress with use of accessory
muscles of respiration, indrawing of the intercostal muscles and subcostal recession. An X-ray
showed compensatory emphysema of the left side
and some hyperination of the left upper lobe. He
was taken up for bronchoscopy when half a
shelled peanut was extracted from his right
bronchus.
P. V. Alexander (*)
Lady Willingdon Hospital, Manali, India
Foreign body inhalation is life threatening
especially in those under 2 years of age. The
child may present acutely with observed aspiration and choking or they may present insidiously with undetected aspiration. Peanuts and
food items are the usual culprits in children
under 2, whereas non-food items are aspirated
by older children [1]. Balloons, round objects,
failure to disintegrate, and swelling up of irritant vegetable matter complicate extraction and
increase morbidity [2]. Most foreign bodies
lodge in the bronchus, unless they are large and
cause tracheal obstruction [3]. There is no predilection in children for the right bronchus as
there is in adults.
Coins are a commonly ingested or aspirated. An A-P X-ray will differentiate the site
of obstruction, whether in the airway, where
the coin will be seen edge-on (since it sits
sagitally in the trachea) or in the esophagus,
where its face will be visualized on the film
(since it sits coronally in the esophagus)
(Fig.24.1).
Only 15% of aspirated foreign bodies are
radio opaque and identiable on a plain X-ray.
Secondary signs need to be relied upon to diagnose radiolucent object aspiration. Cough,
wheeze, and diminished breath sounds are the
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_24
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P. V. Alexander
Fig. 24.1 Coin in the esophagus (Image courtesy Dr.
Gerald Diaz)
classic triad, but additional subtle signs include
aring of ala nasi, stridor, intercostal recession
on the affected side, and hyperination of the
opposite lung (Fig. 24.2). Distal hyperination
seen on the X-ray is indicative of partial bronchial obstruction, with progressive ination but
inadequate expiration. Complete obstruction can
cause distal collapse with compensatory hyperination of the opposite lung. Mediastinal shift,
obstructive emphysema, and atelectasis are other
secondary signs (Fig.24.2).
If time permits before intervention, a CT scan
is usually conclusive in demonstrating the
obstruction and the offending object. Delayed
presentation or undetected foreign body may primarily present as a pneumonia.
Foreign body aspiration in children is a lifethreatening emergency condition and mandates
bronchoscopic removal [4]. Bronchoscopy has
altered mortality dramatically. In remote areas,
bronchoscopy can present quite a challenge.
Many remote locations lack anesthetists. Close
monitoring and ventilation are precariously balanced during the bronchoscopic extraction.
Most centers lack the rigid or exible bronchoscope needed for this procedure [5]. Referral to
a higher center may take anywhere between 8
and 10h so the attending is caught between a
rock and a hard place and is hard pressed to
Fig. 24.2 Inspiratory chest radiograph in a 12-month-old
boy with a 2-month history of wheezing demonstrates
moderate hyperlucency and hyperexpansion of the right
hemithorax. A mild deviation of the mediastinum toward
the left chest is noted (Courtesy of Brit B.Gay, Jr., MD,
Radiology Department, Egleston Children’s Hospital,
Atlanta, Ga)
Fig. 24.3 Demonstrating use of a rigid nephroscope for
bronchoscopic extraction of foreign bodies. Note the use
of the irrigation port for ventilation using a syringe as a
connector
make the right decision. We describe the use of
a rigid nephroscope in the extraction of a peanut
from the trachea of a 3-year-old child (Fig.24.3),
which is a demonstration of adaptation often
necessary in remote and rural surgery. The side
irrigation port was used for ventilation and a
Dormia basket was used to extract the offending
peanut (Fig.24.3).
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Fig. 24.4 Segments of pulmonary lobes in left and right lungs correlated with the anatomy of the bronchial tree
(source: Sabiston Textbook of Surgery, 17th Ed. Putnam Jr., JB, Chapter 57, p.1765, Elsevier Publisher)
279
Intravenous steroids and antibiotics are always
indicated in management, and delayed presentation or stubborn foreign bodies could be reapproached bronchoscopically after a 5–7-day
course of steroids.
Airway Foreign Bodies inAdults
Unless the foreign body is large, and there is
acute aspiration as in “café coronary” or aspiration of nails or pins held in the teeth during work,
foreign body aspiration in adults is usually more
subtle and undetected and presents late as a
chronic cough or a delayed pneumonia trending
toward a lung abscess. It usually occurs in the
elderly or debilitated who have trouble with their
swallowing reex. The radiologic signs of hyperination are not replicated in the adult lung,
though a CT scan will either demonstrate a pneumonia or suggest the obstruction. The angulation
of the right main bronchus permits objects to
lodge in it (Fig.24.4).
Complete obstruction is usually supraglottic
or pre-carinal tracheal. Supraglottic obstruction
can be relieved with direct laryngoscopic extraction with Magill forceps, while pre-carinal
clearance may be obtained by endotracheal intubation obtaining tracheal clearance by pushing a
tracheal foreign body into the bronchus, converting a complete obstruction into a partial
one, amenable to later elective bronchoscopic
extraction. Though rigid bronchoscopy is still
the most successful, exible bronchoscopy in
skilled hands has been reported with equivalent
success [6]. The rigid nephroscope system we
have described (Fig.24.3) can also be utilized in
adult patients.
Esophagus
Foreign Bodies inChildren
Clinical Vignette
A 1-year-old male child was brought to the emergency room with history of swallowing a coin.
The child was comfortable and in no acute distress and able to swallow and keep down solids
and liquids. An X-ray demonstrated a coin in his
esophagus identied by its coronal presentation.
The child was taken up for endoscopy under
anesthesia and the coin extracted with the help of
a Foley catheter whose balloon was inated distal to the coin to withdraw it back into the
oropharynx.
Foreign body aspiration is not uncommon in
infancy from 6months of age to 3years. At this
age the child is passing through the oral phase of
development when everything goes into his or
her mouth and can be easily inhaled or swallowed
[7]. It is at this age that parents should be careful
to keep small objects away from children. The
ingestion may or may not be witnessed.
Esophageal ingestion is usually asymptomatic, and the offending object may transit through
the gastrointestinal tract uneventfully if it has
negotiated through the pylorus. Those with a
developmental delay may be particularly prone to
recurrent ingestion or inhalation. Death from
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Fig. 24.5 Demonstrating
the use of a cystoscope to
extract a coin from the
esophagus under vision
with a Foley catheter
passed alongside it
P. V. Alexander
ingestion of a foreign body is rare except if the
offending object is a coin battery which mandates
extraction [8].
Children have a predilection to put all objects
into their mouth. Coins are the most frequently
ingested, but then there is a huge variety of other
swallowed objects. Witnessed or reported ingestion usually brings the child to the doctor. The
child is in no acute distress and is usually quite
placid considering the amount of fuss that swirls
around him or her post-ingestion. Large swallowed objects can cause distress and nearcomplete obstruction can cause drooling. Coins
can be easily identied by an X-ray with its
placement in the coronal plane. The recent utility
of coin batteries in a plethora of gadgets make for
a dangerous and critical situation since these can
erode and perforate through the esophageal or
intestinal lumen and mandate extraction. The
denitive management has to be endoscopy
under general anesthesia. Intubation secures the
airway and a pediatric endoscope with an array of
graspers, and snare is an essential armament to
tackle the situation.
We describe the use of an adult cystoscope to
extract a coin with the help of a Foley catheter
passed alongside which permits safe extraction
under vision (Fig.24.5).
The offending object usually lodges at one of
the anatomical esophageal constrictions, the cri-
copharyngeus, aortic indentation, or at the lower
end. If retrieval is difcult, pushing the foreign
body into the stomach usually permits passage
through the gastrointestinal tract with the administration of laxatives to help it along. A Foley
catheter with its bulb inated after passage distal
to the object is a very simple and useful tool to
extract objects which are not easily grasped or
snared and if an endoscope is not available. The
bulb can be lled with radio opaque contrast
material to permit extraction under uoroscopy if
the object is metallic.
Esophageal Foreign Bodies inAdults
The debilitated elderly, and those predisposed to
esophageal obstruction with esophageal strictures and reux esophagitis, are those who present with esophageal obstruction. A bone or a
large piece of ingested meat is the usual offender,
but there can be a variety of other objects in
those with psychiatric illness. In the elderly, dentures have also been swallowed unwittingly and
these do present a formidable challenge to the
endoscopist and are probably best handled at
higher centers. They may require exploration if
lodged further along the GI tract, as in the distal
ileum. Quite often, the foreign body may have
passed into the stomach leaving an ulcer or abrasion in the esophagus which mimics the symptoms from an obstructed foreign body. An X-ray
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or CT scan can provide denition, if the object is
radio- opaque. Endoscopic visualization can lay
the suspicion of a lodged foreign body to rest.
Any object less than 5cm in diameter will usually continue its journey through and out of the
gastrointestinal tract. Pins, razor blades, and
needles can perforate the esophagus spontaneously or during extraction. Tri-prong graspers,
the trapezoid snare, and rat tooth forceps are
very useful in a variety of foreign bodies. The
Foley catheter is also an excellent option to
extract obstinate objects resisting capture or
grasp. The procedure can be performed under
sedation in a cooperative patient, but a combative or restive patient is best intubated to permit
protection of the airway and easy retrieval. The
overtube is protective of the esophagus during
extraction of a sharp object.
Foreign Bodies inEar or Nose
The remote surgeon is often presented with a
plethora of objects that have been thrust into various orices by children as young as 6months to
12 years of age. Erasers, beads, legumes, nuts,
and sharp objects such as pins, paper clips, and
needles have all been introduced into nostrils and
ears. Flying insects may also decide to enter the
auditory canal, to the great discomture of the
individual.
The child may present to emergency room
either calm and quiet or irritable and cranky.
Otoscopic examination or examination of the
nasopharynx usually permits visualization of the
offending object, and though the temptation to
reach out and attempt removal is tantalizing, it
must be overcome and retrieval must be performed under sedation. Attempting to remove the
object without sedation will only cause the child
to jerk and move, complicating the situation with
dislodgment and bleeding driving the object
deeper into the orice. A quiet child, good light,
and suction are prerequisites for a painless extraction. The application of gentle suction often
moves the object upward permitting it to being
grasped and removed with a mosquito clamp.
Though a variety of spoons, forceps, and probes
are available for this purpose, the humble Kelly
clamp is sufcient to grasp and extract the object.
Vegetable matter tends to swell and fragment. A
scoop may come in handy for this situation. A
bead with a hole often resists grasp, revolving
within the cavity. Getting one limb of the clamp
into the central hole or using a probe positioned
within the central hole permits extraction. Insects
can be drowned with saline and then grasped and
extracted. It is unwise to try to irrigate the object
out, particularly nuts or legumes because they
will swell and then be removable only with difculty under general anesthesia.
Prior to extracting foreign bodies in the nasopharynx, packing the throat under sedation is
important, because the object could be pushed
from the nasopharynx into the oropharynx during
the attempt and then be aspirated, which will convert the benign procedure of the removal of a foreign body from the nose into the critical extraction
of the foreign body from the trachea or
bronchus!
Lymph Node Biopsies
Swellings in the neck form a signicant proportion of patients presenting to the outpatient
department. The different diagnoses present a
plethora of conditions, each to be assessed clinically and investigated with appropriate imaging.
Neck masses may be approached considering
their chronology of appearance and their location. That helps classify disease into congenital,
inammatory, traumatic, or neoplastic headings,
which are baskets that permit narrowing down
the differential diagnosis by the conduct of a
good history and clinical examination. These are
cheap and time-tested techniques of whittling
down the differentials yet this is also a fading art
with the advent of advanced and expensive imaging, often unavailable to the rural surgeon. The
details of this are beyond the scope of this chapter
which will mainly focus on the approach to
lymph nodes in various triangles of the neck. One
should remember that following trauma, a small
pseudoanurysm of a vessel in the neck can mimic
a lymph node without obvious pulsations. An
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P. V. Alexander
Fig. 24.6 Anatomy of the distribution of the lymph nodes of the neck: a guide to biopsies
ultrasound, when available, can be very helpful in
the diagnosis (Fig.24.6).
Lymph node swellings are very common in
all ages. Mothers bring their toddlers worried
about swellings in the submandibular or jugulodigastric location that have appeared coincident with a sore throat, or tonsillitis. Older
children can present with nodes in the postauricular or post- occipital location coincident
with ear discharge and otitis media. At a later
age, dandruff is often the culprit for nodes in
level Va, in the preening adolescent or even up to
middle age. A good shampoo is often curative.
Most of these nodes are below 2cm in size, discrete, well dened, non-tender, and mobile. In
low- and middle- income countries, tuberculosis
is ubiquitous and forms up to 30% of all extrapulmonary disease. These nodes tend to be larger
and rmer and coalesce prior to caseating and
becoming uctuant. They may be accompanied
by night sweats and fever. Lymphomas lurk in
the shadows of these nodes, so a good histopath-
ological diagnosis is vital prior to the initiation
of treatment. Being described as rubbery and
discrete are not enough to differentiate them
from the nodes of tuberculosis. Infectious mononucleosis, brucellosis, tularemia, HIV, and parasitic infections are other causes. Tuberculous
nodes in the neck can caseate and burst, leaving
a potential nonhealing sinus. Histopathology
from these nodes can still be obtained by curetting them and suturing the skin closed. The
administration of appropriate antituberculous
medication can prevent the formation of a sinus.
A 6-month course is often curative. Resistant
nodes that do not regress in 6months need to be
biopsied again, sent for culture sensitivity, and
may need change of the treatment regime to a
drug-resistant regime with culture-sensitive
medicines. On rare occasions, obstinate nodes
may need a modied nodal neck dissection,
which decreases the burden of disease and permits clearance of the neck. This may be
approached like a neck dissection exempting the
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jugular vessels but removing all gross nodal
disease.
The traditional investigative approach to a
lymph node swelling in the neck is to approach
it with a ne needle. This may sufce when
positive, but its yield is often inconclusive and
does not provide additional material for subsequent culture-sensitive tests. Our preference is
to subject suspicious swellings to a traditional
biopsy which provides adequate preserved tissue for the pathologists, often located many
miles away.
Though an excision biopsy of the node is most
satisfying when the entire node is removed for
examination, it is wise to err on the side of caution and settle for an incision wedge biopsy for
nodes in levels approaching the base of the neck
or along the carotid sheath, particularly if the
node is partially submerged behind the clavicle.
A suture taken through the substance of the node
provides for traction and permits easy dissection
(Fig.24.7).
Biopsy of nodes in levels IV or IIB should
only be attempted cautiously in the operating
theater with a senior attending available for the
instant need to convert to general anesthesia and
undertake a major procedure if any major bleeding is encountered. It is wiser to settle for a good
incision biopsy rather than ambitiously embark
on an excision biopsy and get into trouble for
very little gain. We have had to resect the clavicle to control bleeding from the subclavian vein
and have also had to establish vascular control
Fig. 24.7 Suture taken through the node and used for
traction during dissection
of the internal jugular vein on occasion. Thus,
the lowly lymph node biopsy is not to be
underrated.
Dicult Airway and Access
The pediatric and adult airway can present formidable challenges to the general surgeon in remote
and rural locations, far away from specialized
help and instrumentation.
The Pediatric Airway
The neonatal airway can be a challenge, but it
can be usually intubated with careful positioning in “snifng position,” a good laryngoscope,
and an endotracheal tube of the appropriate
size. The formula gestational weeks/10 and the
formula (age/4+4) usually works for the neonatal and pediatric age group, respectively.
Typically, a 2.5 tube is appropriate for infants
<1kg weight, a 3.0 tube for infants weighing
1–2kg, a 3.5 tube for infants 2–3kg, and a 3.5
or 4.0 tube for infants over 3kg. The appropriate size for larger children can be calculated
using the formula of (age/4 + 4) for uncuffed
tubes and (age/4 + 3) for cuffed tubes.
Eyeballing the little nger permits an approximation for the size of the appropriate endotracheal tube. The approximate depth of insertion
of the endotracheal tube from the middle of the
upper lip in centimeters can be calculated as
(weight in kg+6cm). The straight blade laryngoscope is usually sufcient, in combination
with a good suction at hand.
The laryngeal mask airway is an excellent
alternative in the patient with a non-intubatable
airway. It provides the ability to ventilate adequately for shorter procedures. The size can be
read off the chart in Table24.1.
Bag mask ventilation is a short-term option
with the disadvantage of gastric distension
despite presence of a nasogastric tube and failure
to protect the airway from aspiration. An I-gel
LMA has an inbuilt aspiration channel to prevent
this.
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LARYNGEAL MASK AIRWAY SIZING
5 Large adult >70 kg
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Table 24.1 LMA sizing
P. V. Alexander
L.M.A Size Patient Size
1 Neonates/Infants < 5 kg
1.5Infants 5-10 kg
2Infants/Children 10-20 kg
3 Children/Small adults 30-50 kg
4 Adults 50-70 kg
Tracheostomy in children is rarely indicated
and beset with the danger of tracheomalacia or
stricture formation in the period following
post-decannulation.
The Adult Airway
Elective surgery can provide the luxury of preanesthetic estimation of airway difculty using
the Mallampati classication [9](Fig. 24.8).
Those with a short thyromental distance or
wide neck allow the operator to be forewarned
and therefore forearmed. An endotracheal bougie
is inexpensive and should be present in all remote
and rural theatres, since it permits the endotracheal tube to be railroaded into the trachea with
minimum fuss. For the anterior larynx not permitting entry of the tip of the bougie, an ordinary
bronchoscope or even a exible endoscope can be
adapted to permit visual intubation along the side
or with the endotracheal tube preloaded onto the
scope prior. An ingenious system has been devised
by one hospital using a mobile phone with a camera attached to the tip of a laryngoscope [10].
Ludwig’s angina, extensive facial trauma,
suprathyroid injury, and severe glottic edema and
spasm all transform an elective situation into an
emergent one to achieve control of the airway,
and it is in these situations that a needle or surgical cricothyroidotomy becomes life-saving. This
is a relatively easy procedure that permits easy
surgical access to the airway through the cricothyroid membrane which can been accessed with
a broad gauge needle or with serial dilators that
permit passage of a small size endotracheal tube
as a temporizing airway.
Tracheostomy: The traditional tracheostomy
though described as an emergency and life-saving procedure should be probably undertaken in a
semi-elective setting, after already having access
in some fashion to the airway by one of the above
methods. Beating the life clock in rushing through
an emergency tracheostomy, without prior airway access, makes for a lot of confusion, with
possibilities of overt bleeding and damage to
neck structures, all the time beset with the possibility of hypoxic brain damage or, even worse,
with death. Airway access, surgical assistance,
good positioning, good light, suction, a responsible person at the head end controlling the airway, and a sedated patient are ideal elements for
an uneventful tracheostomy. Post-procedure, care
should also be taken to deate the bulb periodically to prevent tracheal erosion and also avoid
overlling the bulb to avoid anterior displacement of the balloon and occlusion of the tip.
When connected to a ventilator circuit, undue
traction on the tracheostomy during the rst 48h
while turning the patient or if the patient becomes
combative can predispose to sudden extubation.
Replacement of the tube within the rst 24hours
post-procedure can be harrowing.
Immobilization oftheNeck
Cervical injuries are the insidious cause of mortality and long-term incapacitation, often the
cause of the “second accident” due to unpro-
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Fig. 24.8 The Modied Mallampati classication
tected transfer of the injured accident victim,
both outside and within the hospital setting.
Protection of the cervical spine is not universal as
yet in the initial management of the injured
patient worldwide, both in pre-hospital and hospital settings. A community will do well to train
its populace in BLS inclusive of safe transfer of
the injured patient hospital to mitigate the lifelong consequences of injury to the cervical spine.
In our hospital we had made simple backboards of plywood covered with Rexene and with
handles along the edges and made them available
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