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Late Presentation of Tracheobronchial Foreign Body Aspiration In Children

Authors Mohammed Saquib Mallick, FRCS, Abdul Rauf Khan, FRCS Abdulrahman Al-Bassam, FRCSEd,

Correspondence Address: Dr. Abdulrahman Al-Bassam, FRCSEd Associate Professor & Consultant Head Section of Pediatric Surgery Department of Surgery King Khalid University Hospital College of Medicine King Khalid University Hospital P.O. Box 86572, Riyadh 11632 Saudi arabia Fax No. 966 1 467-9493 Tel No. 966 1 467-1575 E-mail: abassam@ksu.edu.sa

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Abstract: Tracheobronchial foreign body (FB) aspiration remains a frequent and serious problem in childhood with significant morbidity and sometime fetal sequelae. The diagnosis is often delayed or overlooked. The aim of this study is to examine the causes of delay (> 1 month) in the diagnosis and to study the complications of late presentation and their

management. During the period between July 1993 to August 2002, 128 patients with suspected FB aspiration were admitted to KKUH, Riyadh, Saudi Arabia. 28 patients out of 128 patients were presented late (>1month). The medical records of those 28 patients presented late were review in respect to: history of FB aspiration, symptoms physical signs, reason for delay presentation, radiological investigation, complications and their management and follow-up. There were 16 males and 12 females. Average age was 3.28 years (range 1-11 years). The average time between the onset of the symptoms All of them

and bronchoscopy was 5.5 months (range 1-60 months).

experienced chronic cough at presentation. Thirteen (48%) children had a history suggestive of FB aspiration. Seventeen (63%) children presented with the complications that included pneumonia (n-13), bronchiectasis (n-3), and broncho-oesophageal fistula (n-1). The diagnostic delay was attributed to

physician misdiagnosis (n=9) and partially failure by parents to seek early medical advice (n=4) and patients left against medical advice (n=1), and cause of delay was unknown in the remaining 14 children. Rigid

bronchoscopy was performed in all patients. FB was found in all of cases except 4. Complications were treated as follows: Pneumonia with intravenous

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antibiotics, bronchiectasis conservatively and broncho-oesophageal fistula repaired surgically. Follow-up ranged from 6-48 months. We conclude that diagnostic delay of tracheobronchial FB aspiration has significant morbidity in children. A high index of suspicion and early

referral to higher center are essential in preventing such complications. Public awareness and education to primary care physicians may help in avoiding such complications. Keywords: Foreign body, tracheobronchial aspiration, bronchoscopy.

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Introduction: Tracheobronchial foreign body aspiration continues to be a very serious and vital problem in childhood. FB aspiration is one of the leading cause of death at home in children under 6 years of age in United State of America.1 Despite the modern methods of bronchoscopy extraction available nowadays, inhaled FB can be fetal if it results in acute respiratory failure or if it remains for a long time unrecognized. Extraction of chronic FB can be difficult due to intense reaction of mucous membrane. In this study, we report our experience with 28 patients with FB aspiration presented late (> 1 month).

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Materials and Methods: During the period between July 1993 to August 2002, 128 patients with suspected FB aspsiration were admitted to KKUH Riyadh, Saudi Arabia. Twenty eight children (21.8%) were presented later than one month and they are the subject of this study. History of witnessed choking, chronic cough, dyspnea and strider were recorded. Signs of inhalation included decreased breath sounds, cyanosis, chest wall retraction and temperature were documented. The cause of delay in presentation was searched for in every case Radiological investigation included of plain chest radiography, expiration/inspiration films, and lateral decubitus in younger children, CT scan, ventilation perfusion (V/Q) scan and chest flouroscopy. Bronchoscopy was performed in operating room under general anesthesia and using ventilating bronchoscope. A rigid pediatric

bronchoscopic system with optical telescope (Storz, Germany) was used in all cases. Once the FB removed completely, the telescope was reinserted to check the retained FB, to take sectretions for culture and assess the severity of mucosal reaction and damage. Bronchial biopsy from the site of suspected FB were taken in 5 children. Postoperatively the children were stayed in the hospital for 2 to 14 days (average 7 days) depending upon, recovery from respiratory distress and strider, requirement of brochodilator nebulizer and intravenous antibiotic. Steroid therapy were used in half of patients. All

patients required chest physiotherapy post-operatively. from 6-48 months.

Follow-up ranged

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Results: Sixteen children were male and twelve children were female. Their age ranged between 1 to 11 years (mean 3.28 years) and more than half of them (n=15) were younger than 2 years of age. All of the patients had chronic cough at the time of presentation. Other symptoms included history of

witnessed choking (n=11), fever (n=13), dyspnea (n=14), strider (n=3). On auscultation there was rhonchi with or without crepitation in 14 children. The interval between suspected aspiration and bronchoscopy was 1 to 60 months (range 5.5 months). Radiological findings included hyperinflation of lung in 11 (39.2%) atelectasis II, mediastinal shift in 3 (10.7), radio-opoque foreign body in 2 (7.11%) and normal in 1 (3.5%). In 24 patients, one or several foreign bodies were removed, 13 (54%) were located in main left bronchus, 6 (25%) in main right bronchus, 2 (8.3%) in right distal bronchus, 1 (4.1%) in carina, 1 (4.1%) trachea and 1 (4.1%) in both bronchus. Bronchoscopy showed no foreign body in 4 (14.2%) cases, however, signs of FB inflammation (granulation tissue, bleeding to touch, localized thickening of the bronchus) were there. The majority of FBs recovered were organic (n=17; 70.8%) and included mainly watermelon seeds, peanuts, seed shells. Non-organic FBs were found in 7 (29.2%) cases that consisted of plastic toy piece, nail and bone (Table 1). All the FB were successfully removed with the help of optical forceps. There was no morbidity. Longer than 4 weeks delay in diagnosing FB aspiration resulted significant incidence of complications. Seventeen

children (60.7%) presented with the complications that included pneumonia

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(n=13) (Fig. 1), bronchiectasis (n=3) and broncho-oesophageal fistula (n=1) (Fig. 2). All the complications except broncho-oesophageal fistula were

treated conservatively with antibiotics and chest physiotherapy after removing the FB. Broncho-oesophageal fistula was treated surgically by left posterolateral thoracotomy, division and repair of fistula. FB (nut shell) was found sitting in the fistula. This child developed oesophageal stricture later on which was managed successfully by oesophageal dilations. The diagnostic delay was due to misdiagnosis by physician in 9 cases, due to parents negligence in 5 and cause was unknown in 14 children.

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DISCUSSION: Although public awareness of the dangers of FB aspiration has increased, there is significant morbidity due to delay diagnosis. The age

distribution of our patients is similar to that reported in other series where the majority of patients were below 3 years of age2,3. More than 50% (n=14) children were younger than 2 years of age in our series. The following

reasons have been suggested for the high frequency of such inhaled foreign bodies in children. The tendency of the infants and toddlers to put everything into their mouth, immaturity of the neural mechanisms that coordinate swallowing and respiration4 and playing running and laughing while eating. The incidence of a definite history of foreign body aspiration has been reported to range from 45.7 to 80%.4,5 Most of the foreign bodies encountered in our patients were organic in origin and consisted mainly of variety of seeds (Table 1). Unlike Western countries where peanuts are the most commonly encountered foreign body (24% - 37%).6,7 Our findings agree with those of Ashoor et al 8 and Fadl et al 9 who found that in the Middle East watermelon seeds (fusfus) are the most common foreign body. These differences are due to eating habits in these countries. Watermelon is commonly eaten fruit in this region. Its seeds also saved and dried, salted and roasted, and the Kernel is eaten after removal of the shell. Episode of inhalation in smaller children happened either during eating the watermelon or putting the dried seeds with shell in the mouth. It seems that watermelon seed cause less inflammatory changes in respiratory tract that is why it stays longer in tracheobronchial tree with minimal symptoms. The overall M:F sex ratio of 1.2 : 1 is similar to that of other

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studies series.

The commonest site of lodgment was left main bronchus in our

There are no symptoms specifically diagnostic of a tracheobronchial FB. Diagnostic delays and misdiagnosis are common. FB aspiration can mimic other disease process, leading to a misdiagnosis of croup, asthma, pneumonia or bronchitis. The common clinical symptoms are cough,

dyspnea, wheezing, fever and stridor. Coughing is most common symptoms in late presentation of tracheobronchial FB. In our series, all the children had chronic cough at the time of presentation. Late symptoms are characterised by complications caused by the FB such as obstructions, erosions or infection. Chronic cough, recurrent or persistent penumonia, lung abscess, haemoptysis, unexplained fever and general malaise are common presentations of chronic airway FB. Choking crisis is the most sensitive clinical parameter with highest specificty. Barrios et al the
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suggested that bronchoscopy should be performed in all children with of choking crisis. A substantial number of negetive

history

bronchoscopies will be required to ensure that no FB has been overlooked. In our series there were 4 negative (14.2%) bronchoscopies. According to

some authors, the incidence of negative bronchoscopies ranges from 9% to 16.5%.13 An accurate history and high index of clinical suspicion are at paramount importance in the diagnosis. Late presentation or delay in the diagnosis of tracheo-bronchial FB can be attributed to the misdiagnosis by the physicians. Parents failure to seek early medical advice, late referral from peripheral hospitals or clinic, or family members may not be present when the

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choking crisis occurs. In our series, late presentation was due to physician failure to diagnose FB aspiration in 9 cases (32.1%). Parents negligence in 5 and cause was unknown in 14. The average time between the onset of the symptoms and bronchoscopy was 5.5 months (range 1-60 months) in our series. Review of literatures showed 2-23% of cases presented longer than one month duration after aspiration of FB.12,14,15 In our study, 28 patients (21.8%) presented longer than one month. After initial episode of choking, patient may present by complication like obstruction, infection or erosion. Although only 6% to 16% of aspirated FB are radiopaque, the nonspecifically lung abnormalities are usually detectable in children who had symptoms for longer than 2-4 weeks. These include obstructive emphysema, mediastinal shift, atelectasis, pneumonia. 10-25% of chest radiographs are normal in early cases as reported in literature.14 Retained tracheobronchial FB carries high risk of complications such as pneumonia (16 to 27%), consolidation (5%), abscess (<1%) and bronchiectasis (<1%).12,16 Bronchoectasis can lead to pulmonary resection. In our series, 17 (60.7%) children presented with complications. Pneumonia (n-13), bronchiectasis (n-3) and broncho oesophageal fistula (n-1). Apart

from one of the patients with bronchoesophageal fistula which was repaired surgically, all other were treated conservatively.

Conclusion: We conclude that delay in diagnosis of tracheo-bronchial FB aspiration has significant morbidity in children. A high index of suspicion and early

referral to higher center are essential in preventing such complications.

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Public awareness and education to primary care physicians may help in avoiding such complications.

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REFERENCES: 1. Majd NS, Mofenson HC, Greenshen J: Lower airway foreign body aspiration in children: An analysis of 13 cases. Clin Pediatr 1977; 16: 13-16. 2. Banergee A, Subba Rao KSVK, Khanna SK, et al: Laryngotracheo-bronchial foreign bodies in children. J Laryngol Otol 1988; 102: 1029-1032. 3. Kim IG, Brummitt WM, Humphrey A, et al: Foreign body in the airway: A review of 202 cases. Laryngoscope 1973; 83: 347-354. 4. Wolach B, Raz A, Weinberg J, et al: Aspirated foregin bodies in the respiratory tract of children: Eleven years of experience with 127 patients. Int J Pediatr Otorhinolaryngol 1994; 30: 1-10. 5. Sobocyznski A, Skuratowicz A, Grzegorowskim, et al: The

problem of lower respiratory tract foreign bodies in children. Acta Otorhinolaryngol Belg 1993; 47: 443-7. 6. Burton Em, Brick WG, Hall JD, et al: Tracheobronchial foreign body aspiration in children. South Med J 1989; 8: 195-198. 7. Blck RE, Johnson DG, Matlak Me, et al: Bronchoscopic removal of aspirated foreign bodies in chidlren. J Pediatr Surg 1994; 682-684. 8. Ashoor AA, Barakan M, Kholani A: Foreign bodies in the

pediatric tracheobronchial tree. Saudi Med J 1987; 8: 499-501. 9. Fadl FA, Omer MIA: Tracheobronchial foreign bodies: A review of children admitted for bronchoscopy at King Fahd Specialist

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Hospital, Al-Gassim, Saudi Arabia. 309-313. 10.

Ann Trop Paed 1997; 7:

Florendo RB, Al Jassim AA. Laryngotracheobronchial foreign bodies. Ann Saudi Med 1990; 10:29-32

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Inhalation of foreign bodies in chinese

children: A review of 400 cases. Laryngoscope 1991; 101:65760. 12. Barrios JE, Gutierrez C, Llana J, et al : Bronchial foreign body : Should bronchoscopy be perfromed in all patents with a choking crisis. Pediatr Surg Int 1997; 12: 118-120. 13. Montor PC, tuggle DW, Tunnel WP: An appropriate negative bronchoscopy rate in suspected foreing body aspiration. Surg 1989; 158: 622-624. 14. Wiseman NE, Schwartz I: The diagnpsis of foreign body Am J

aspiration in childhood. J Pediatr Surg 1984; 19: 531-535. 15. Aytac A, Yurdakuly Y et al: Inhalation of foreign bodies in

children. J Pediatr Surg 1977 74; 145-151. 16. Black RE, Johnson DG, Matlak ME et al: Bronchoscopic

removal of aspirated foreign bodies in children. J Pediatr Surg 1994; 15: 234-238.

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TABLE 1:

Nature of Foreign Body

Type of FB Organic Watermelon seeds Peanuts Miscellaneous Non-organic Plastic toy pieces Nail Bone

No. of Patients 17 9 4 4 7 3 2 2

Total

24*

* FB not found in 4 patients

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Legend:

Figure 1:

This is part of water soluble contrast swallow examination demonstrating bronchoesophageal fistula.

Figure 2:

Portable chest x-ray showing non-homogenous specification of the left hemithorax with cystic changes and a screw projecting over medial aspect of same side.

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