2006 Presidential Citation for Foreign Body Management

Management of a Catastrophic Aerodigestive Foreign Body
Thomas Andrews, MD, FACS*, James Quintessenza, MDÝ, Jeffrey Jacobs, MD, FACSÝ., Richard Harmel, MD, FACS



The patient, A.P, a nine-month-old, was brought to the operating room urgently from the emergency center. The patient could not be adequately ventilated except with a 4.5 cuffed endotracheal tube with external pressure held at the neck to prevent air escape through the esophagus. The patient's history was significant for a foreign body ingestion of a camera battery which was removed three days prior to presentation. At the time of removal the battery was grasped with a basket through flexible esophagoscopy and removed, according to history, without difficulty; however, there was note of erosive esophagitis at the site.

Upon presentation, ventilation was difficult through the existing endotracheal tube and the saturations could only be held in the 80s despite intubation. Because the patient had previously placed IV access, the endotracheal tube was removed and the patient was intubated with a ventilating 3.5 bronchoscope. The examination revealed no supraglottic or glottic abnormality; however, the distal trachea demonstrated a large posterior defect with only a small strand of tissue connecting the distal trachea with the carina. Copious secretions were present in the left bronchus and the right mainstem, when selectively cannulated with the ventilating bronchoscope, could not hold saturations above 80.



We then selectively intubated the right mainstem bronchus with a 3.5 cuffed endotracheal tube over a Storz-Hopkins telescope. Selective intubation on the left was problematic due to copious secretions. However, even with selective intubation on the right, saturations did not rise above 80, and in many instances were down to a low of 47.

The pediatric cardiothoracic service was then called for consideration of emergency cardiopulmonary bypass. The cardiothoracic surgeons placed the patient on cardiopulmonary bypass via a right neck cannulation and the patient was stabilized. Via a right thoracotomy, a large defect in the posterior wall of the trachea distally was demonstrated as well as complete erosion of the esophagus at the same level. Severe mediastinitis including a large abscess was found at the site. The proximal and distal segments of the esophagus were ligated. The posterior tracheal wall was then repaired with a pedicled intercostal muscle flap.

During this, the patient had central lines placed; multiple thoracostomy tubes inserted and a proximal esophageal sump with a decompressive gastrostomy tube were completed. Three days later, the patient underwent bronchoscopy which revealed some dehiscence of the flap. Conservative therapy was initially attempted.

Ten days following the initial procedure, the patient returned with dehiscence of the initial tracheal reconstruction and underwent tracheal resection with end-to-end anastomosis of the intrathoracic trachea and a small resection of distal necrotic tracheal tissue while on cardiopulmonary bypass. The repair was done using an esophageal patch tracheoplasty.

As expected, the patient had significant problems with mediastinitis initially, but the symptoms resolved over the next two weeks. After the second repair of the tracheal injury was completed, the patient underwent a cervical esophagostomy and resection of a blind-ending proximal esophagus.

The patient has continued to do well, was discharged from the hospital and although reconstruction of the esophagus will take place at a later time, the patient has continued to have normal activity without airway symptoms. Follow-up bronchoscopy reveals redundant tissue at the repair site that looks obstructive but has not accompanying symptoms.

This potentially fatal presentation was only averted due to the multidisciplinary work of Pediatric Cardiothoracic Surgery, Pediatric Surgery, Pediatric Anesthesia, Pediatric Intensive Care and Pediatric Otolaryngology.



From: The Department of Otolaryngology & Pediatrics, University of South Florida and Pediatric Otolaryngology, All Children's Hospital*; The Congenital Heart Institute of Florida, University of South Florida and Division of Cardiothoracic Surgery, All Children's HospitalÝ; The Department of Surgery, Division of General Surgery, All Children's Hospital_ St. Petersburg, Florida