Aspiration of foreign bodies that allow air passage through

doi:10.4236/ojped.2011.14021

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Open Journal of Pediatrics, 2011, 1, 90-93

doi:10.4236/ojped.2011.14021 Published Online December 2011 (http://www.SciRP.org/journal/ojped/

OJPed

)

Published Online December 2011 in SciRes. http://www.scirp.org/journal/OJPed

Aspiration of foreign bodies that allow air passage through

Demet Can1, Ozge Yilmaz2*, Suna Asilsoy1, Saniye Gulle1, Hasan Yuksel2

1Department of Pediatric Allergy, Behcet Uz Children’s Hospital, Izmir, Turkey;

2Department of Pediatric Allergy and Pulmonology, Medical Faculty, Celal Bayar University, Manisa, Turkey.

Email: *[email protected]

Received 6 September 2011; revised 17 October 2011; accepted 3 November 2011.

ABSTRACT

Foreign body aspiration is commonly encountered in

children. In cases that foreign body does not disturb

respiratory physiology, clinical and radiological di-

agnosis may be delayed leading to severe complica-

tions. Four cases with aspiration of a foreign body

not obstructing ventilation and without typical clini-

cal and radiological findings are discussed.

Keywords: Foreign Body; Aspiration; Children; Ventila-

tion; Air Passage

1. INTRODUCTION

Foreign body aspiration is commonly encountered in

children particularly less than three years age. Fourty

eight patients were diagnosed with foreign body in the

Emergency department of our hospital in 2005 and for-

eign body was removed in 44. Among 50% these cases,

foreign body was located in left main bronchus. History

was suggestive in 67% of the children while radiological

findings supported the diagnosis in 83% [1,2].

Although history and radiological findings leads to

early diagnosis in many cases, delay in diagnosis leading

to severe complications is not rare either. Delay is espe-

cially prominent when the foreign body does not cause

airway obstruction therefore not disturb respiratory

physiology. Four cases with aspiration of a foreign body

that allow passage of air and therefore not obstructing

ventilation and not causing significant clinical and ra-

diological findings are discussed below.

2. CASE REPORT

2.1. Case 1

Twelve year old boy followed up for allergic asthma for

three years had presented with cough and dyspnea to the

Emergency department a month ago. He had been play-

ing with a pen cap before the symptoms started and told

this to the Emergency Department physician. Physical

findings during that visit included bilateral ronchi, pro-

longed expirium and tachpnea. His findings disappeared

in short time after initiation of bronchodilator treatment.

Both the chest X-ray and lung CT did not suggest for-

eign body aspiration. Upon fast resolution of clinical

findings and absence of radiological findings, diagnosis

of foreign body aspiration was ruled out and he was dis-

charged with the diagnosis of an acute asthma exacerba-

tion. However, the patient reported coughing up the pen

cap three weeks after discharge. The foreign body that

was coughed up had a hole inside that allowed air pas-

sage.

2.2. Case 2

Thirteen year old boy was hospitalized with symptoms

of fever, productive cough and dyspnea. Past history

revealed hospitalization due to pneumonia and pleuritis

one year ago. Respiratory sounds were absent on the

left side and decreased on the right side of the chest.

Bronchial (tubular) breath sounds and fine rales were

heard. White blood cell count (WBC) was increased to

21,900/mm3 and erythrocyte sedimentation rate was 70

mm/hour. CRP was 15.5. Plain chest radiography sug-

gested bronchiectasis and lung CT demonstrated left

sided bronchiectasis (Figure 1). Immunoglobulin levels,

tuberculin skin test and alpha1 anti-trypsin levels were

normal. Sputum and blood cultures failed to reveal an

infectious etiology. A piece of a whistle was seen in the

left main bronchus during bronchoscopy and removed.

The parents then remembered that he had had sudden

cough and cyanosis when trying to blow out the plastic

part inside the whistle. They had presented to a health

care center where plain chest radiography was found to

be normal. The foreign body that was removed allowed

air passage at the midline.

2.3. Case 3

Two year old girl was hospitalized three times before she

was sent for rigid bronchoscopy to another hospital. First

hospitalization was at the age of 13 months with the di-

agnosis of acute bronchiolitis when she first had fever

D. Can et al. / Open Journal of Pediatrics 1 (2011) 90-93 91

Figure 1. Lung CT of case 2 demonstrating left sided bronchiectasis.

and dyspnea. Past history revealed hospitalization in

another hospital for a week at the age of 36 days with the

diagnosis of bronchopneumonia. Body weight was 10.7

kg (50% - 75%, height was 74 cm (50% - 75%). She had

tachycardia (162/minute), tachypnea (48/minute). Sub-

costal, intercostal retractions and prolonged expiration

time were detected. Bilateral hyperaeration was noticed

in the plain radiograph (Figure 2). Nebulized salbutamol

was administered and she was discharged on fifth day of

hospitalization upon resolving of the clinical findings.

She was hospitalized seven months after this because she

had had four wheezing episodes after the first hospitali-

Figure 2. Bilateral hyperaeration in the plain chest radiograph

of case 3.

zation. Lung auscultation revealed rhonchi. Serum levels

of immunoglobulins, sweat chloride test and gastroe-

sophageal reflux scintigraphy was normal. Plain chest

radiography was normal but thorax CT was taken due to

the persistence of auscultation findings on right side of

chest. Focal area of atelectasis was detected on right

lower lobe. Radiological findings were not found con-

sistent with foreign body aspiration by the Radiologists.

She was discharged and was started on inhaled steroids.

Two months later, she was hospitalized again upon per-

sistence of auscultation findings on the right side of

chest. AngioCT revealed focal areas of narrowing in

right middle and lower lobes that were interpreted in

favor of bronchomalacia. Therefore the patient was sent

to another center for rigid bronchoscopy during which a

foreign body (plastic flower) was removed from right

lung.

2.4. Case 4

Fourteen year old boy presented with cough. He had

been hospitalized for treatment of lower respiratory tract

infection many times for the last 6 months. Past medical

and family histories were non-remarkable. Physical ex-

amination revealed bilateral fine rales and rhonchi that

were more pronounced in the right lower lung fields.

Complete blood count and serum biochemistry were

normal. Immunoglobulin A, G and M values were in the

normal ranges. Plain chest radiography demonstrated

infiltration in the right middle lobe. Lung CT revealed

right middle and lower lobe infiltration and mediastinal

D. Can et al. / Open Journal of Pediatrics 1 (2011) 90-93

shift. Bronchial wall irregularity was seen in the seg-

mental bronchus of the right upper lobe anterior segment

and main bronchus of the right middle lobe. Flexible

fiberoptic bronchoscopy was performed for diagnostic

purposes and foreign body lodged right below enterance

of right middle lobe was suspected. Pediatric surgery

was called in during the same session for rigid broncho-

scopy since the patient had received general anesthesia.

They could not reach the foreign body in that session

and interpreted the image as granulation tissue. However,

upon questioning of the family again for foreign body

aspiration, the child remembered swallowing a plastic

pencil tip seven years ago. They had presented to a phy-

sician but aspiration was not thought at that time because

plain radiography was normal. Upon this information,

rigid bronchoscopy was performed once again and the

foreign body was removed (Fi gure 3).

3. DISCUSSION

Foreign body aspiration that is most commonly encoun-

tered in pre-school children, is a life threatening emer-

gency, however, it may go unrecognized for prolonged

periods of time due to vague clinical and radiological

findings in some cases [3,4]. Considering that most

commonly aspirated foreign bodies in children include

organic material including peanuts not causing complete

obstruction, careful evaluation is especially important

for prompt diagnosis [3].

Aspiration of a foreign body may result in immediate

choking when lodged in larynx or may lead to complete

obstruction of air entry into a lung segment [5,6]. Re-

tained foreign body in the airway leads to local me-

chanical effects, chemical reactions and inflammation.

An animal study has demonstrated that initial reaction to

the presence of foreign body in the airway is polymer-

phonuclear leukocyte infiltration and edema which is

followed by mononuclear leukocyte and macrophage

infiltration. These findings have been interpreted as ini-

tiation of acute inflammation as early as three days after

aspiration and progression to chronic inflammation as

Figure 3. Foreign body aspirated by case 4.

early as ten days. Moreover, bronchiectatic changes were

observed when a month has passed after aspiration [7].

Presenting symptoms of foreign body aspiration may

vary from vague to specific and include cough, wheeze,

dyspnea and fever. Physical examination may reveal

focal wheezing or decreased air entry but the findings

may also reveal generalized wheezing or it may be com-

pletely normal [8]. Similarly plain radiographs of chest

may reveal unilateral hyperinflation, atelectasis, con-

solidation or mediastinal shift if there is complete ob-

struction of airflow by the foreign body or they may be

normal especially if there is no obstruction to airflow [5,

8]. Therefore, it is impossible to exclude diagnosis of

foreign body aspiration with a normal radiograph [9]. In

the presented cases, two of them had findings suggestive

of bronchiectasis in plain radiographs which was con-

firmed by computerized tomography (CT). Two patients

had normal plain radiography findings. One of the latter

two had persistent findings on physical examination and

therefore underwent CT that demonstrated focal atelec-

tasis.

Diagnosis of foreign body aspiration is usually sug-

gested with clinical history and radiological findings [3].

Foreign body is encountered only in 5% of cases that

undergo flexible bronchoscopy without a prior suspicion

of aspiration [3,5]. Considering that early removal of

aspirated foreign bodies is necessary to avoid the patho-

logical progress from inflammation that initiates at third

day to development of bronchiectasis after 30 days, high

suspicion even in cases with vague clinical or radiologi-

cal findings is required [7,8]. Four cases presented in

this report highlight the importance of aspiration of for-

eign bodies that do not cause complete obstruction since

these cases may easily be overlooked and bronchoscopy

may be delayed. In three of these cases clinical findings

were not suggestive of foreign body aspiration due to the

nature of the foreign body that allowed air passage. One

patient was lucky to cough up the aspirated material but

the other three presented with bronchiectasis, pneumonia

or bronchoconstriction findings [8]. Although the clini-

cal findings may be milder without complete airway

obstruction, induction of inflammation is still expected

to progress thus making early and prompt diagnosis es-

sential for prevention of complications. Therefore, high

clinical suspicion and use of flexible bronchoscopy as

the initial technique of evaluation in patients with sus-

pected foreign body aspiration is prompted. Moreover,

Flexible bronchoscopy provides detailed information

about the nature and localization of the foreign body as

well as the characteristics of airway mucosa [3].

Detection of a foreign body aspirated into the airway

should be followed by removal as soon as possible to

prevent the inflammatory reaction and development of

D. Can et al. / Open Journal of Pediatrics 1 (2011) 90-93

granulation tissue [4]. Although, flexible bronchoscopy

is very often used for evaluation of airway in suspected

cases of foreign body aspiration, rigid bronchoscopy

remains the method of choice for removal due to the

wide working channel. There are a limited number of

reports of foreign body removal by flexible broncho-

scopy [3]. With the exception of the case who has

coughed up the foreign body, in all three cases the for-

eign body was removed with rigid bronchoscopy.

OJPed

In conclusion, diagnosis of foreign body aspiration

was delayed in all the cases presented in this report due

to the non-obstructing nature of the foreign body. Air

passage through the foreign body delayed appearance of

radiological clues. These cases were reported to empha-

size the importance of early consideration of broncho-

scopy in cases with persistent findings even in the ab-

sence of supporting clinical and radiological clues of

foreign body aspiration.

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