As with esophageal foreign bodies, airway foreign bodies are much more common in infants and young children. Many deaths from foreign-body aspiration occur in the home before medical intervention can be administered. The most

Figure 19-3 Inspiratory (A) and expiratory (B) radiographs of 8-year-old boy with left airway foreign body (peanut). No foreign object is visible on plain films, but the expiratory film shows overinflation of the left lung with mediastinal shift to the contralateral side.

frequently aspirated foreign bodies are foods, with nuts leading the list. Foreign bodies aspirated into the airway are usually found lodged in the bronchial tree but can also be found in the larynx or trachea. If the event is witnessed and results in complete airway obstruction, a Heimlich maneuver should be administered; however, the event is often not witnessed. Symptoms can include hoarseness, persistent cough, wheezing, or stridor if the foreign body is lodged in the trachea or larynx. Because the potential for morbidity and mortality is substantial, this condition requires urgent diagnosis and timely intervention to prevent catastrophe.

Any time a small child presents with wheezing or noisy breathing without a previous history of reactive airway disease, an airway foreign body should be included in the differential diagnosis. Typically, patients and parents recount a transient episode of coughing during eating that then subsided; the patient might even be symptom free for a time, then later have symptoms such as coughing or wheezing.

The most important diagnostic step for identifying a foreign body is a high index of suspicion. Careful auscultation of the lung fields is essential because subtle asymmetric differences may be found. Because most airway foreign bodies are radiolucent, chest radiographs can be normal, but abnormalities such as hyperinflation, atelectasis, or pneumonia can be present (Fig. 19-3). If plain radiographs are equivocal or normal and the patient is in stable condition, airway fluo-roscopy can be helpful.

Consultation with a physician experienced in foreign body removal is required. Definitive treatment of airway foreign bodies is direct laryngoscopy and rigid bronchoscopy to indentify and remove the object.

hypertension, bleeding dyscrasias (factor deficiencies, hereditary hemorrhagic telangiectasia, lymphoproliferative disorders), anticoagulation therapy (acetylsalicylic acid, heparin, warfarin), and intranasal tumors. Special consideration should be given to adolescent boys with recurrent epistaxis and nasal obstruction, because these symptoms might be the result of a juvenile nasopharyngeal angiofibroma. These are benign but locally aggressive tumors. All these potential risk factors should be considered because they must be addressed to treat the patient appropriately.

Epistaxis is classified according to its location. Bleeding from the anterior nasal cavity is most common and usually originates from a rich plexus of vessels at the anterior septum called Kiesselbach's plexus (Fig. 19-4). Bleeding from this location, although troublesome, is less likely to be severe and is usually easier to control than posterior epistaxis. Posterior epistaxis originates from the posterior two thirds of the nasal cavity and can be quite severe and much more difficult to control.

Initial management of epistaxis includes assessment and stabilization of vital signs. Rarely, severe bleeding can lead to airway compromise or hemodynamic compromise, or both, especially in patients with underlying cardiopulmo-nary dysfunction. The airway should be assessed and stabilized, urgently if necessary. Hypertension, if severe, should be controlled, with care taken to avoid subsequent hypotension. Hematologic studies, including complete blood count (CBC), prothrombin time, and partial thromboplastin time, should be ordered. Intravenous access should be established, allowing administration of fluids as well as IV medications, if necessary during treatment.

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