Tracheobronchial Foreign Body Aspiration in Children EDWARD M. BURTON, MD, WENDY. BRICK, BS, JOHN D, HALL, BS, WEBSTER RIGGS, JR, MD, and GC. STEPHEN HOUSTON, MD, Memphis, Tenn ABSTRACT: In this retrospective study, we reviewed the demographic and radiographic findings of 155 children with bronchoscopy-proven tracheobronchial foreign body aspiration (FRA), Two thirds of the patients were male, and most were children between 1 and 2 years of age. An aspirated peanut accounted for one third of all cases. Foreign body location was distributed nearly evenly to the right and left primary bronchi; tracheal foreign body was noted in 16 patients. The most frequent symptoms of FBA were cough (85 patients)'and wheezing (60 patients). Although most patients were seen within 1 day of aspiration, 30 patients had symptoms that lasted at least 1 week before diagnosis. The most common radiographic findings were unilateral or segmental hyperlucency (59) or atelect (88). The trachea was the site of the foreign body in one half of children with a normal chest radiograph and FBA. FOREIGN BODY ASPIRATION (FBA) is a common, sometimes fatal problem in childhood. In the United States, aspiration is the most important cause of accidental death in the home among children less than 6 years of age.’ Although most patients are seen within 1 day of aspira- tion, some have symptoms that last weeks to months before diagnosis. Early diagnosis is prompted by recognition of the signs and symptoms of FBA and an accurate evaluation of chest radiographic findings. The purpose of our study was to provide detailed epidemio- logic and radiographic data concerning for- eign body aspiration in children, PATIENTS AND METHODS We retrospectively reviewed 155 childhood cases of bronchoscopy-proven tracheo- bronchial FBA that occurred from 1952 through 1988 at LeBonheur Children’s Medical Center, Memphis, Tenn. We included all patients who had chest radiographs and a tracheobronchial foreign body diagnosed at bronchoscopy. We evaluated the cases for loca- tion of the foreign body, type and duration of symptoms, and chest radiographic findings. When available, the original radiographs were reviewed by a trained pediatric radiologist. Fluoroscopic examinations, if done, were not included in this study. From the Department of Radiology, LeBonheur Children’s Medical Center, Memphis, Tenn. Reprints requests to Edward M, Burton, MD, Department of Radiology, Medical College of Georgia, Augusta, GA 80912-3900, TABLE 1. Foreign Body Aspiration—Epidemiologic Data Ne : Na. 16 ‘ale 108 (66%) 54 Female 52 (34%) 44 18 4 9 iss RESULTS Of these 155 children with FBA, 108 were male and 52 were female. Most of the children were 1 to 2 years old (63%); 16 patients were younger than 1 year of age, and 19 were older than 6. Boys outnumbered girls by a ratio of almost 2 to 1 (Table 1). Peanuts were the for- cign body inhaled most often (34%), followed other vegetable matter (21%) and other nuts (12%) (Table 2). The foreign body was found nearly as often in the right primary bronchus as the left. Of the total, 43% were found in the right main bronchus and 47% in the left main bronchus. The foreign body was found in the trachea in 16 patients (10%) TABLE 2. Type of Foreign Body Found at Bronchoscopy Fong Dod Na Peanut 3 (34%) Other nut 18 (12%) Vegetable 33 (21%) Metal 21 (14%) Bone 10 (0%) Miscellaneous. 20 (18%) To Burlon etal + FOREIGN BODY ASPIRATION IN CHILDREN 195“TABLE 3. Incidence of Symptoms and Tigi Primary ‘Signs Relatod fo Location of Foreign Body si iia Signor Spm ace rhs dren tt Gough 3 % 6 Him Where 6 2 2 0%) Choting : 2 2 mae) Storrs of breath 3 io : 21048) Fever . q 103) Camo 1 (3) eprator are ‘ ioe ‘Abn rch ond i 3 4 8@ tant oven bay 2 3 Gm Seine 2 1 3 Ge Stir 2 3 up Fretmonia 1 1 2 08) Hemp i 1 2 Gm) Rhona 1 1 2 OB Yomting 1 1 2 08) Bron 1 i 2 Om The signs and symptoms associated with these foreign body aspirations are shown in Table 3. The most common symptoms noted were cough (54%), wheezing (40%), and choking (32%). Cough, wheezing, and chok- ing were not specific for a site of FBA. Stridor was identified only in patients with tracheal FBA. All four cases of respiratory arrest were associated with a foreign body lodged in the right main bronchus. All four patients with cyanosis had left bronchial FBA. The interval between the time of inhalation and the time of diagnosis (range, 0 to 120 days) is shown in Table 4: 71 cases (46%) were diagnosed within 1 day of development of symptoms; 88% were diagnosed before 14 days elapsed. In the 27 cases of delayed diagnosis (14 to 120 days), 13 foreign bodies were in the right main bronchus and 14 were in the left main bronchus. The most common clinical findings in this group included cough (18), wheezing (1), fever (7), and diagnosis of recurrent pneumonia or bronchitis (3). Radiographic findings in FBA of prolonged duration included atelectasis (11), hyperlucency (9); normal appearance (4), effusion (2), consoli- dation (2), and abscess (1). Nuts were the most frequently found foreign body (16/27 cases). ‘The radiologic findings are summarized in Table 5. The most common x-ray findings TABLE 4. Duration of Symptoms Daye o- vA 71 (16%) 23 29 (19%) 47 25 (16%) a3 3 (2%) a 27 (17%) were hyperlucency (88%), atelectasis (25%), and normal appearance (19%). Table 6 corre- lates hyperlucency and atelectasis with the site of obstruction. ‘Typically, the side of either atelectasis or hyperlucency was ipsilateral to the main bronchus in which the foreign body became lodged. The clinical information concerning patients who had a normal chest radiograph is. Shown in Table 7. Of the patients with a rig! sided foreign body, 17% had a normal radi- ograph; of those with a left-sided foreign body, 15% had a normal radiograph. Interestingly, 50% of all patients with a tracheal foreign body had a normal radiograph. DISCUSSION The highest incidence of foreign body aspi- ration occurs in children between the ages of 1 and 3.** Boys predominate by a margin of 2:1 and nuts are the most commonly inhaled foreign bodies (38% to 58%)?" In our study, nuts of all types accounted for 46% of cases of FBA; peanuts were the single most frequently inhaled foreign body 34%). Several investigators have reported that EBA. is more common in the right main bronchus than the left.** It is assumed that the more ‘TABLE 5, Ratiographio Findings in All 155 Cases of Foreign Body Aspiration Fincing No Typeriucency 39 (8%) Atelecusis 38 (25%) Normal 30 (19%) ‘Opaque foreign body 33.15%) Pheumomediastinumn 10 (6%) Consolidation 7 (58) EMusion 30%) Peumothorax 20%) Abscess 1 (1%) 196 February 1996 + SOUTHERN MEDICAL JOURNAL + Vol 80, No.2‘TABLE 6, Relationship Between Foreign Body Location and Finding of Hyperlucency or Atelectasis on Chest Radiograph ‘TABLE 7. Duration of Symptoms and Location and “Type of Foreign Body in Patients With Normal Chest Radiographs Tipertuceng eketsis Length ofsympioms Oto 21 days, mean 4.0, Tait Left Right Let Site of foreign body No. Foreign Body Site Lag _Lavg_iltoral__Lang_Lang Right primacy bronchus 12 (17% ofall ightsidd foreign bodies) Rightbronchus ‘18 2 BR Lett primary bronchus 11 (15% ofall letsided foreign bodies) Leftbronchs 0-2 8B 1 9 ‘Trachea 8 (50% oF al trachea foreign bodies) Trachea 1 0 2 aoa ‘Type of foreign body Peanut 9 Other ni 3 Vegetable 10 Other 9 obtuse angle of the right main bronchus pre- disposes to rightsided FBA.* However, others have noted an equal distribution between right and left bronchial FBA," an observation in agreement with our study, This equal distribu- tion may be explained by Cleveland," who stated that “symmetry of bronchial angles is found until approximately 15 years of age. ‘After that age, an aortic indentation is noted on the trachea with an increased left bronchial angle.” The reason for the difference among the various studies regarding the most fre- quent site of FBA is not clear. ‘The most common signs and symptoms of FBA include cough (59% to 98%), wheezing (24% to 57%), and choking (5% to 87%).2** In our study, three signs or symptoms corre- lated with a specific site of FBA: (1) stridor, in patients with tracheal FBA; (2) cyanosis, in patients with left bronchial FBA; and (3) respi- ratory arrest, in patients with right bronchial FBA. Although this may be coincidental, we suspect that FBA into the right main bronchus may elicit a vagal response because the vagus nerve is in contact with the right main bronchus. The most common radiologic findings are hyperlucency (26% to 60%), atelectasis (12% to 22%), and normal (8% to 24%).” Hyper- lucency, found in 38% of our cases, occurs as a result of air trapping in FBA or is due to reflex vasoconstriction.’ The site of hyperlucency or atelectasis usually indicates the site of the foreign body. In patients who had either hyperfucency or atelectasis and FBA into the right main bronchus, the site of the bronchial foreign body could be correctly identified in 48 of 47 instances. In patients who had either hyperlucency or atelectasis and FBA into the left main bronchus, the site of the bronchial foreign body could be correctly identified in 37 of 41 instances. Only 2 of 5 children with tracheal FBA had bilateral hyperlucency. Chest radiographs were normal in 17% of our cases. Whereas radiographic findings were normal in 17% and 15% of cases of right and left bronchial FBA respectively, 50% of patients with tracheal FBA had a normal chest film, A delay in diagnosis of FBA is not unusual. In 17% of our patients, the diagnosis was made at least 2 weeks after aspiration. Other investi- gators have reported a similar incidence of delayed diagnosis. With prolonged duration of symptoms (214 days), the most common radiographic findings were atelectasis (41%), hyperlucency (38%), and normal appearance (15%). Of our total number, 10 patients had pneu- momediastinum and 2 had pneumothorax. In each instance, atelectasis and/or hyperlu- cency accompanied the pneumomediastinum or pneumothorax. Three of these patients had a previous history of asthma, but the pheumomediastinum was produced by FBA rather than by mucous plugging. The associa- tion of air block phenomena in children with FBA has been reported previously." In a child between 1 and 8 years of age, a radi- ographic finding of pneumomediastinum or pneumothorax with no history of trauma should prompt further investigation for RBA" References 1. Majd NS, Mofenson HC, Greenshen J: Lower airway for. eign body aspiration in children: an analysis of 13 eases Clin Picts 197; 1613-16 2, Banerjee A, Subba Rao KSVK, Khanna SK, et alk Laryngor tracheo-bronchial foreign bodies in children. J Laryngol ‘ol 1988; 109:1029-1082 8. inn IG, Brummit WM, Humphrey A xa: For body the airway: a review of 209 eases. Laryngoscope 1973; 88:347- 354 4, Aytae A, Yurdukul ¥, Coskumn 1, et al: Inhalation of foreign ‘bodies in children: report of 500 cases, J Thorac Cariooase Surg 1977; 74:145-181 5, Rothmann BF, Boeckman CR: Foreign bodies in the larynx and tracheobronchial tree in children: a review of 225 tases, Ann Otol Binal Laryngol 1980; 89:484-436 6, Lianeai M, Ping H, Degiang S: Inhalation of foreign bodies inv Chinese children: & review of 400 cases. Laryngoscope 1991; 101:657.660 Burton et al + FOREIGN BODY ASPIRATION INCHILDREN 1977. Reed MH: Radiology of airway foreign bodies in children J Can Assoe Radiol 197; 293111118 8. Tooley WH: Expiratory obstruction. Padiatries, Rudolph AX (ed), Norwalk, Cann, Appieion & Lange, 18th Ed, 3987, p 1413, 9. Cohen SR, Herbert WI, Lewis GB, etal: Foreign bodies the airway: fveyenr retrospective study with special reer fence to management. Ann Oo 1980; B9:497-442 10, Cleveland RH; Symmetry of bronchial angles in children, Radiology 1979; 198:88.93. 11, Potchen EJ, Evens RG: The physiologic factors affecting 2 13, 14 regional ventilation and pexfsion. Senin Nucl Mad 19715 153.160 Rudavsky AZ, Leontds JG, Abramson AL: Lung sean Autry hexceton st ehdobronchil foreign bodies infantsand sildren, Railay 1973, 108:625 88 Darton EM, Riggs W, Kaufman RA, et al: Pneumo- ‘hatin eased by foreign body aspiration in ehiren, Padiatr Rio 1980; 2045-17 Berdon WE, Dee Gj, Abraunson Sf, eta: Localized pnewe fotlorat adjacent toa collpred Tobe: a sign of bronchial Sbuuricton. Rating 1984; 1803097694 4198 February 1996 + SOUTHERN MEDICAL JOURNAL * Vol. 89, No. 2