Foreign body

How should patients with foreign body ingestion be evaluated?

A careful history and physical examination are the keystones in diagnosing an esophageal foreign body and to the prevention of its complications. If symptoms are present, they may suggest a likely location of the foreign body. Imaging should be used to confirm the findings and to localize the site of the foreign body.

Upon auscultation of a patient's lungs, there are harsh, hollow breath sounds which have a long inspiratory component in the region of the suprasternal notch. Throughout the periphery of the lung fields, softer breath sounds are heard. Which of the following best describes these findings? A. Normal B. Asthmatic C. Atelectasis D. Foreign body explanations

A. Normal Bronchial breath sounds are normally heard near the sternum and vesicular breath sounds are heard over the periphery of the lungs in a healthy, normal patient.

A foreign body lodged in the trachea that is causing partial obstruction will most likely produce what physical examination finding? A. Stridor B. Aphonia C. Inability to cough D. Progressive cyanosis

A. Stridor An inspiratory wheeze is called stridor, which indicates a partial obstruction of the trachea or larynx.

Which of the following is accurate about foreign body aspiration? A. The location of an aspirated foreign body inside a patient may depend on the patient's age. B. The likelihood of complications decreases after 24-48 hours. C. Inflammatory changes are completely reversible. D. Foreign body aspiration is more commonly seen in females than in males.

A. The location of an aspirated foreign body inside a patient may depend on the patient's age. Near-total obstruction of the larynx or trachea can cause immediate asphyxia and death. Should the object pass beyond the carina, its location depends on the patient's age and physical position at the time of the aspiration. Because the angles made by the mainstem bronchi with the trachea are identical until age 15 years, foreign bodies are found on either side with equal frequency in persons in this age group. After age 15 years, the right main stem bronchus is straighter, allowing most aspirated foreign bodies to enter the right lower lobe of the lung. Bronchoscopically, the object may appear as a tumor. Even if the object is removed, the inflammatory changes may not be completely reversible. Some investigators believe that scar carcinoma may develop over time. The likelihood of complications increases after 24-48 hours, making expeditious removal of the foreign body imperative. The male-to-female ratio of foreign body aspiration is 2:1, depending on the study.

What is the epidemiology of FBA?

FBA is a common cause of mortality and morbidity in children, especially in those younger than two years of age. Death caused by suffocation following FBA is the fifth most common cause of unintentional-injury mortality in the United States, and the leading cause of unintentional-injury mortality in children younger than one year.

What are techniques for removal of ingested foreign bodies?

Flexible endoscopy Rigid endoscopy Magill forceps Bougienage Foley catheter Penny pincher techique

What is flexible endoscopy?

Flexible endoscopy is preferred in most circumstances because the foreign body can be directly visualized and manipulated, and the surrounding gastrointestinal tract can be examined for potential complications. This procedure is usually performed under general anesthesia with an endotracheal tube in place to ensure that the foreign body does not slip into the airway.

How should suspected FBA be evaluated?

All children with suspected FBA who are stable should undergo a focused history and physical examination, followed by plain radiography of the chest. The caregivers should be specifically asked about a history of a choking episode in the hours or days prior to symptom onset.

In what age groups is FBA most common?

Approximately 80 percent of pediatric FBA episodes occur in children younger than three years, with the peak incidence between one and two years of age. At this age, most children are able to stand, are apt to explore their world via the oral route, and have the fine motor skills to put a small object into their mouths, but they do not yet have molars to chew food adequately.

How can FBA be prevented?

As a general rule, primary passive intervention strategies to reduce the risk of foreign body aspiration (FBA; eg, legislation that eliminates choking hazards from the market) are more effective than active intervention strategies (strategies that require constant parental supervision).

Which of the following is accurate regarding the imaging studies of foreign bodies in soft tissue injuries? A. Radiography is the recommended imaging study in all foreign body soft tissue injuries. B. Fluoroscopy allows for real-time visualization and allows precise location of the foreign body using skin markers. C. Ultrasonography use is generally discouraged in foreign body soft tissue injuries. D. MRI is commonly used for foreign body detection upon initial presentation and is less valuable in nonacute presentations.

B. Fluoroscopy allows for real-time visualization and allows precise location of the foreign body using skin markers. Fluoroscopy can be useful in foreign body removal if a C-arm or other appropriate imaging equipment is accessible. This technique allows for real-time radiographic visualization of the foreign body and affords the clinician the opportunity to precisely locate the foreign body using skin markers. X-rays are most useful in detecting radiopaque foreign bodies with sensitivities above 95% with adequate penetration and multiple views (anteroposterior and lateral). However, for the detection of nonradiopaque foreign bodies (eg, wood, rubber, plastic, and other plant-based foreign bodies), the sensitivity of radiography is low. The use of bedside ultrasonography to detect and localize soft tissue foreign bodies in the emergency department (ED) is gaining in acceptance and popularity because of its ease of use, increased availability, lack of radiation exposure, safety, and sensitivity with detection of certain types of foreign bodies. MRI is rarely used for foreign body detection during the initial ED visit. However, MRI can provide detailed information regarding tissue inflammatory reactions, osteoblastic or osteolytic changes, and secondary tissue reactions that can aid in determining the presence and location of an otherwise occult foreign body.

Which of the following is accurate regarding treatment of foreign body ingestion? A. Flexible bronchoscopy is generally preferred to rigid bronchoscopy in removing tracheobronchial foreign bodies. B. The bougienage method should only be performed if ingestion of a blunt object by a child was witnessed within 24 hours of the procedure. C. Foley catheter removal is indicated for patients who have foreign bodies present for longer than 72 hours. D. Relaxation of the LES with glucagon is recommended more than watchful waiting for foreign bodies confirmed by imaging studies to be lodged at the LES.

B. The bougienage method should only be performed if ingestion of a blunt object by a child was witnessed within 24 hours of the procedure. Blunt esophageal foreign bodies may be advanced into the stomach with a bougie. While the child is sitting upright, the lubricated instrument is gently passed down the esophagus, dislodging the object. The object is then expected to pass through the rest of the GI tract; thus, this procedure should not be performed on children with known lower GI tract abnormalities. A brief observation period and a repeat x-ray should follow any removal procedure to rule out retained foreign bodies and other complications (eg, pneumomediastinum). Because any esophageal foreign body may pass spontaneously, chest x-ray should be performed immediately prior to any removal procedure. Again, only experienced personnel should perform this procedure, and it should be reserved for healthy children whose ingestion of a blunt object was witnessed less than 24 hours prior to the procedure. The rigid bronchoscope has important advantages over the flexible bronchoscope. The larger diameter of the rigid bronchoscope facilitates the passage of various grasping devices, including a flexible bronchoscope. A better chance of quick, successful extraction and better capabilities of suctioning clotted blood and thick secretions are offered by the rigid bronchoscope. Foley catheter removal is contraindicated in patients with foreign bodies that have been present for more than 72 hours, those with a history of esophageal disease or surgery, those who are experiencing respiratory distress, and those who are uncooperative. Foreign bodies lodged at the LES can be managed by relaxation of the LES, although in some studies, success rates associated with this technique are no greater than those associated with watchful waiting.

What is bougienage?

Bougienage (passage of a dilator) has been used to push objects into the stomach. The procedure is less costly than endoscopy and can be performed without anesthesia or sedation. However, it does not retrieve the foreign body and should only be considered for blunt and small objects that are likely to pass along the esophagus and into the stomach without causing significant mucosal injury (eg, coins).

Which of the following is accurate about the presentation of GI foreign bodies? A. Direct examination typically provides better information than indirect laryngoscopy. B. The most common cause of GI foreign bodies in adults involves accidental swallowing of small objects like toothpicks. C. In children, tracheal compression and stridor suggest a large foreign body at the upper esophageal sphincter. D. In adults, dysphagia is associated with foreign bodies in the oropharynx but not in the esophageal regions.

C. In children, tracheal compression and stridor suggest a large foreign body at the upper esophageal sphincter. In children, tracheal compression and stridor suggest a large foreign body at the upper esophageal sphincter. In cooperative patients, indirect laryngoscopy or fiberoptic nasopharyngoscopy provides better information than a direct examination. The most common cause of GI foreign bodies in adults involves food that does not pass through the esophagus because of underlying mechanical problems. Dysphagia is the norm in adults with esophageal foreign bodies. If the obstruction is complete, an inability to handle secretions is common.

A 4 year-old boy presents with pain and irritation of his left ear. Otoscopic examination reveals an insect in the left auditory canal. The tympanic membrane is not completely visualized. Which of the following is the most appropriate management of this patient? A. Debrox insertion with suction removal B. Irrigation with room temperature saline C. Insertion of 2% lidocaine solution with suction or forceps removal D. Polymyxin drop insertion via wick

C. Insertion of 2% lidocaine solution with suction or forceps removal Two percent lidocaine solution will paralyze the insect and provide topical anesthesia for suction or forceps removal.

How does FBA present clinically?

Children who present with severe respiratory distress, cyanosis, and altered mental status have a true medical emergency that demands prompt recognition, life support, and rigid bronchoscopic removal of the foreign body (FB). More commonly, children with FBA present with partial airway obstruction. The most common symptom is cough, followed by tachypnea and stridor, often with focal monophonic wheezing or decreased air entry.

What are the most commonly aspirated foreign bodies?

Commonly aspirated FBs in children include peanuts (36 to 55 percent of all FBs in Western society), other nuts, seeds (particularly watermelon seeds in Middle Eastern countries), popcorn, food particles, hardware, and pieces of toys. Food items are the most common items aspirated by infants and toddlers, whereas nonfood items (eg, coins, paper clips, pins, pen caps) are more commonly aspirated by older children.

What are the most commonly ingested foreign bodies?

Commonly ingested objects include coins, button batteries, toys, toy parts, magnets, safety pins, screws, marbles, bones, and food boluses. Coins are by far the most common foreign body ingested by children.

A 2-year-old presents with sudden onset of cough and stridor. On examination the child is afebrile and appears non- toxic with a respiratory rate of 42 breaths per minute. What is the next step in the evaluation of this patient? A. Lateral soft tissue x-ray of the neck B. Indirect laryngoscopy C. Finger sweep D. Chest x-ray

D. Chest x-ray Chest x-ray should be done first when foreign body aspiration is suspected.

A 4 year-old boy presents with purulent, foul-smelling nasal discharge for three days. He has not had any other symptoms of respiratory illness, cough, wheeze, or fever. His activity level and appetite has been normal. On exam, he is afebrile. TM's have normal light reflex, canals are clear. Left nare is clear; there is considerable amount of purulent exudate from the right nare, and a bright reflection of light is noticed. Oropharynx is without inflammation or exudate. Neck is supple, without lymphadenopathy. Lungs are clear, with equal breath sounds and no wheezing. Heart has regular rhythm without murmurs. Which of the following is the most likely diagnosis? A. Viral URI B. Acute sinusitis C. Allergic rhinitis D. Nasal foreign body

D. Nasal foreign body Nasal foreign body is suggested by unilateral nasal obstruction or discharge.

Which of the following is accurate about complications of pediatric foreign body ingestion? A. The most common site of esophageal impaction is at the lower esophageal sphincter (LES) at the gastroesophageal junction. B. Most complications occur once the foreign body reaches a child's stomach. C. Migration of a foreign body from the esophagus most often leads to aortoenteric fistula. D. Swallowed button batteries may cause substantial mucosal injury within just 2 hours.

D. Swallowed button batteries may cause substantial mucosal injury within just 2 hours. Esophageal button batteries may cause substantial mucosal injury in as few as 2 hours. Once a swallowed foreign body reaches the stomach of a child with a normal gastrointestinal (GI) tract, it is much less likely to lead to complications. Most complications of pediatric foreign body ingestion are due to esophageal impaction, usually at one of three typical locations. The most common site of esophageal impaction is at the thoracic inlet. Defined as the area between the clavicles on chest x-ray, this is the site of anatomic change from the skeletal muscle to the smooth muscle of the esophagus. The cricopharyngeus sling at C6 is also at this level and may "catch" a foreign body. About 70% of blunt foreign bodies that lodge in the esophagus do so at this location. Another 15% become lodged at the mid esophagus, in the region where the aortic arch and carina overlap the esophagus on chest x-ray. The remaining 15% become lodged at the LES at the gastroesophageal junction. A foreign body lodged in the GI tract may have little or no effect; cause local inflammation leading to pain, bleeding, scarring, and obstruction; or erode through the GI tract. Migration from the esophagus most often leads to mediastinitis but may involve the lower respiratory tract or aorta and create an aortoenteric fistula.

How are nasal foreign bodies diagnosed?

Diagnosis is clinical.

How are otic foreign bodies diagnosed?

Diagnosis is made by history and physical exam with visualization of foreign body. Removal of foreign body which requires direct visualization prior to removal either via warm irrigation with syringe, or instruments like an alligator forceps.

What is the appropriate initial imaging for patients with foreign body ingestion?

For all patients with suspected foreign body ingestion, the initial diagnostic test should be biplane radiographs (anteroposterior and lateral) of the neck, chest, and abdomen. We suggest including each of these sites even if symptoms suggest a location (eg, esophageal or respiratory symptoms). This is to evaluate for the possibility of other swallowed objects, for indirect evidence of the radiolucent foreign body (such as an air-fluid level in the esophagus), and for free air representing a perforation.

How should long object ingestion be managed?

For older children and adolescents, objects 5 cm or longer that are in the stomach should be removed because they have a high probability of becoming impacted in the ileocecal area if they pass the pylorus. For younger children with a long object in the stomach, a lower threshold might be more appropriate.

What is the most appropriate initial imaging for FBA?

For patients with suspected FBA who are asymptomatic, or symptomatic but stable, the first step in the evaluation is to perform plain radiography of the chest. However, most objects aspirated by children are radiolucent (eg, nuts, food particles), and are not detected with standard radiographs unless aspiration is accompanied by airway obstruction or other complications. As a result, normal findings on radiography do not rule out FBA, and the clinical history is the main determinant of whether to perform a bronchoscopy.

What is expectant management for foreign body ingestion?

For patients without any of the above characteristics (eg, a coin lodged in the esophagus of a patient who can swallow and has no respiratory symptoms), observation for 12 to 24 hours is reasonable because spontaneous passage often occurs.

What is a Foley catheter?

For this technique, a deflated Foley catheter is passed beyond the foreign body. The balloon is then inflated using a radiopaque contrast dye, and the catheter is slowly drawn back under fluoroscopic guidance to remove the foreign body through the mouth. The technique can be successful with proximal esophageal foreign bodies when performed by an experienced operator.

What percentage of foreign bodies require removal?

Fortunately, most ingested foreign bodies pass spontaneously. Only 10 to 20 percent require endoscopic removal, and less than 1 percent require surgical intervention.

How are aspirated foreign bodies removed?

If FBA is known to have occurred or is strongly suspected, rigid bronchoscopy is the procedure of choice to identify and remove the object. Rigid bronchoscopy permits control of the airway, good visualization, manipulation of the object with a wide variety of forceps, and ready management of mucosal hemorrhage. Bronchoscopy is successful in removing the FB in about 95 percent of cases, with a complication rate of less than 1 percent.

How should patients with life-threatening FBA be evaluated?

If a child presents with complete airway obstruction (ie, is unable to speak or cough), dislodgement using back blows and chest compressions in infants, and the Heimlich maneuver in older children, should be attempted. In contrast, these interventions should be avoided in children who are able to speak or cough since they may convert a partial to a complete obstruction. For the same reason "blind" sweeping of the mouth should be avoided.

How should coin ingestion be managed?

If a coin is visualized in the esophagus and the patient can swallow and has no respiratory symptoms or other distress, the child can be observed for up to 24 hours after ingestion of the coin. Coins that reach the stomach can be managed expectantly. Coins are unlikely to cause a complication because they lack sharp edges, the metal is not toxic, and most will pass out uneventfully within one to two weeks. For these patients, most providers check the location of the coin with a plain radiograph approximately once a week.

How should sharp-pointed object ingestion be managed?

If the object is in the esophagus, it should be removed immediately. If the object is in the stomach or proximal duodenum, it also should be removed promptly using a flexible endoscope. If the object has passed into the small intestine and the patient is asymptomatic, it may be followed with serial radiographs to document its passage. Surgical intervention should be considered for objects that fail to progress for three consecutive days.

What is the next appropriate imaging for patients with foreign body ingestion, if radiographs are inconclusive?

If the patient is symptomatic, or if the suspected foreign body has any dangerous characteristics (large [>2 cm width], long [>5 cm length], or sharp), or if the type of foreign body is not definitively known by the caretakers, we suggest using CT with three-dimensional reconstruction as the next diagnostic procedure.

What imaging findings are consistent with FBA?

In children with lower airway FBA, the most common radiographic findings in lower airway FBA are: ●Hyperinflated lung (lucency distal to the obstruction) - This is caused by partial airway obstruction with air trapping, such that air passes with inspiration, but not with exhalation. ●Atelectasis - This is usually caused by complete obstruction of an airway, since air is resorbed from the distal alveoli over time. ●Mediastinal shift - The mediastinum tends to shift away from the lung field containing the foreign body (FB). ●Pneumonia - Infection often develops distal to an obstructed airway. Therefore, a consolidated infiltrate is also a possible finding.

How should magnet ingestion be managed?

Ingestion of even a single high-powered magnet has some risk as the magnet may attach to external metallic clothing, such as a belt buckle, naval body jewelry, or metallic button. Endoscopic removal should be considered if the magnet is accessible (ie, in the esophagus or stomach). Ingestion of multiple high-powered magnets has a high risk of complications and warrants preemptive removal.

How does the clinical presentation of FBA help determine anatomic location?

Inspiratory stridor if high in the airway. Wheezing and decreased breath sounds if low in the airway.

What are risk factors for FBA?

Institutionalization, advanced age, poor dentition, alcohol, and sedative use.

How are otic foreign bodies treated?

Irrigation of the external ear can be uncomfortable for the child. Aggressive flushing can cause perforation of the tympanic membrane, so caution is advised while irrigating. After each flush, it is prudent to recheck the external canal for retained foreign body (FB) fragments, which can occur with an insect. After irrigation, if the child is uncomfortable, consider treating with topical pain agents such as benzocaine-anti-pyrene. Insects must be immobilized prior to removal. Drown insects with mineral oil or viscous lidocaine before attempting removal.

What are Magill forceps?

Magill forceps can be used to extract foreign bodies impacted in the oropharynx at or above the cricopharyngeus.

How do patients with foreign body ingestion present clinically?

Most children with esophageal foreign bodies are brought to medical attention by their parents because the ingestion was witnessed or reported to them. Such children are often asymptomatic.

Anatomically, where FBAs most commonly located?

The majority of aspirated FBs in children are located in the bronchi. The right main bronchus is the most common location (45 to 55 percent of FBs), followed by left bronchus (about 30 to 40 percent of FBs), and bilateral bronchi (1 to 5 percent). The most common lobe for FBA is the right middle lobe.

How do intestinal foreign bodies present clinically?

Objects that pass beyond the pylorus and into the intestines are usually asymptomatic and pass spontaneously. Occasionally, they may be retained in the distal gastrointestinal tract where they can cause delayed complications.

How do gastric foreign bodies present clinically?

Objects that reach the stomach are typically asymptomatic, unless they are large enough to cause gastric outlet obstruction, which could present with vomiting and/or feeding refusal.

How should FBA be managed?

Once the diagnosis of foreign body aspiration (FBA) has been established by imaging and/or flexible bronchoscopy, the object should be removed as quickly as possible. Laryngeal or tracheal foreign bodies (FBs) require particularly urgent management.

What are risk factors for retention of an ingested foreign body?

Patient risk factors for retention of an ingested foreign body in the esophagus include: ●Younger age (because objects are more likely to be retained in a smaller esophagus). ●Congenital malformations. ●Prior surgery of the esophagus. ●Gastroesophageal reflux or eosinophilic esophagitis (particularly for food bolus impaction). ●Neuromuscular disease.

How do patients with nasal foreign bodies present?

Patient will present as → a 4-year-old boy with unilateral purulent, foul-smelling nasal discharge for three days. The child has no other respiratory symptoms.

How do patients with otic foreign bodies typically present?

Patient will present as → an 18-month-old with ear pain and otorrhea. Otoscopic examination reveals a small insect impacted in the ear canal which is still moving. The tympanic membrane appears intact.

How do esophageal foreign bodies present clinically?

Patients with an esophageal foreign body may be asymptomatic or may present with refusal to eat, dysphagia, drooling, or respiratory symptoms including wheezing, stridor, or choking. Older children may be able to localize the sensation of something stuck in the neck or lower chest, suggesting irritation in the upper or lower esophagus, respectively.

What is a nasal foreign body?

Persistent foul smelling purulent unilateral nasal discharge in a young child without other respiratory symptoms should raise suspicion for a retained nasal foreign body, even without a history of witnessed foreign body insertion.

What is the epidemiology of foreign body ingestion?

The majority of foreign body ingestions occur in children between the ages of six months and three years. Ingestion of multiple foreign objects and repeated episodes are uncommon occurrences and usually occur in children with developmental delay or behavioral problems.

How are nasal foreign bodies treated?

Prior to removal, the provider may consider using oxymetazoline drops to shrink the mucous membrane. Indications for otolaryngology referral may include non-visualized posterior FBs, impacted FBs, or unsuccessful initial attempts at FB removal.

Where are foreign bodies commonly stuck in the esophagus?

When a foreign body is retained in the esophagus, it tends to lodge in areas of physiologic narrowing, such as the upper esophageal sphincter (cricopharyngeus muscle), the level of the aortic arch, and the lower esophageal sphincter.

What is rigid endoscopy?

Rigid endoscopy utilizes a nonflexible channeled device that is introduced into the esophagus under general anesthesia. It is most useful for impacted sharp objects that are located proximal to the esophagus, at the level of the hypopharynx and cricopharyngeus muscle.

Why is ingestion of button batteries significant?

Serious sequelae (eg, esophageal burn, perforation, or fistula) occurs in approximately 3 percent of all button battery ingestions. In addition to direct pressure necrosis, contact of the flat esophageal wall with both poles of the battery conducts electricity, resulting in liquefaction necrosis and perforation of the esophagus. Retained batteries also can cause problems through leakage of caustic material (generally, batteries contain a heavy metal like mercury, silver, lithium, and a strong hydroxide of sodium or potassium).

What is the "classic triad" of FBA?

The classic triad of wheeze, cough, and diminished breath sounds is not universally present.

What are the most commonly ingested sharp-pointed objects?

The most common sharp-pointed objects ingested by children are straight pins, needles, straightened paper clips, and fish bones; these represent 10 to 15 percent of swallowed objects. Sharp objects have a high risk of perforation (15 to 35 percent). When lodged in the hypopharynx, they can cause a retropharyngeal abscess. Ingested toothpicks and bones are likely to perforate.

What is the penny pincher technique?

The penny pincher technique involves insertion of a grasping forceps through a nasogastric tube, under fluoroscopic guidance and usually without anesthesia or endotracheal intubation. This approach is an improvement over the Foley catheter method because it permits direct control of the object, reducing the risk of dropping it into the airway. However, it also does not allow inspection of the esophagus and should only be used for objects that can be firmly grasped and controlled by the forceps.

What is the definitive imaging modality for FBA?

The tracheobronchial tree should be examined in all cases with a moderate or high suspicion of FBA, typically using rigid bronchoscopy so that the object can be safely removed.

How are aspirated foreign bodies removed, if not retrievable by rigid bronchoscopy?

Thoracotomy is occasionally indicated in the rare cases in which FBs are visualized but cannot be removed through a rigid bronchoscope.

How should superabsorbent polymer ingestion be managed?

Toys and household products made of superabsorbent polymers present a risk for bowel obstruction if ingested. These objects can expand 30 to 60 times in volume when hydrated. If ingestion of a superabsorbent object is suspected, it should be removed immediately.

What is tracheobronchial foreign body aspiration (FBA)?

Tracheobronchial foreign body aspiration (FBA) is a potentially life-threatening event because it can block respiration by obstructing the airway, thereby impairing oxygenation and ventilation.

What are indications for urgent removal of an ingested foreign body?

Urgent intervention (ie, removal of the foreign body via endoscopy or other technique) is indicated if any of the following warning signs are present: ●When the patient shows signs of airway compromise. ●When there is evidence of near-complete esophageal obstruction (eg, patient cannot swallow secretions). ●When the ingested object is sharp, long (>5 cm), or a superabsorbent polymer and is in the esophagus or stomach. ●When the ingested object is a high-powered magnet or magnets. ●When a disk battery is in the esophagus (and, in some cases, in the stomach). ●When there are signs or symptoms suggesting inflammation or intestinal obstruction (fever, abdominal pain, or vomiting).

What are possible complications of FBA?

When FBA is diagnosed soon after the event, there is usually little damage to the airway or lung parenchyma. The longer the FB is retained, the more likely are complications (eg, atelectasis, postobstructive pneumonia). A FB that causes chronic or recurrent distal infection may lead to bronchiectasis. Cultures should be obtained if pneumonia is suspected.

How should battery ingestion be managed?

When batteries become lodged in the esophagus, they represent a medical emergency. Like coins, most disk or cylindrical batteries pass harmlessly once they reach the stomach. However, because of the potential for direct mucosal injury and toxicity, batteries should be removed from the stomach under certain conditions.