Tracheobronchial foreign body aspiration represents a life-threatening condition especially in young children. It carries a great amount of mortality and morbidity through the possibility of obstructing the airway and thus resulting in acute respiratory failure. The diagnostic challenges are brought by the great variability of clinical presentation which sometimes only consists of subtle symptoms. For an optimal therapeutic outcome, only a high index of clinical suspicion can ensure a prompt treatment. The mainstay of both diagnostic and therapeutic algorithm resides in bronchoscopy. The article reports the multidisciplinary management of two young children with organic foreign body aspiration, outlining the importance of a step-wise diagnostic approach.
Tracheobronchial foreign body aspiration is one of the commonest causes of death in young children under the age of 3(1). Acute aspiration of a foreign body is considered an emergency and, therefore, requires immediate treatment. Regardless of the possibility of lodging in the bronchus, it could be easily dislodged into the trachea or the larynx, causing complete obstruction(2). In young children, the event is suspected only when a chocking episode is witnessed by an adult. In contrast, unwitnessed foreign bodies often present with atypical or subtle symptoms, representing a demanding challenge for the clinician(1).
Needless to say the diagnosis and treatment of foreign body aspiration in young children require a multidisciplinary team comprising of a general pediatrician, a pediatric pulmonologist and an ENT specialist with a strong experience in bronchoscopy. The article presents two challenging cases of foreign body aspiration in two young children who differ in clinical presentation and management. The emphasis is put on the fundamental role played by bronchoscopy both in diagnosis and treatment.
Case 1. A 2.5-year-old girl was admitted on the Pediatric Otolaryngology Department at “Grigore Alexandrescu” Emergency Clinical Hospital for Children, for a 6-month history of persistent dry cough alternating with episodes of productive cough and purulent sputum, accompanied by high fever. There was no history either of foreign body aspiration or swallowing, or of a witnessed chocking event.
The medical history revealed recurrent episodes of infectious pneumonia in the previous 6 months. Repeated pulmonary radiological studies gradually revealed infiltration, condensation, and opacification of the left lower lobe. The imaging findings, along with the clinical findings were interpreted as lobar pneumonia for which she had previously received extensive wide-spectrum antibiotic cures along with bronchodilators and steroid courses in other three pediatric hospitals with only temporary favourable evolution.
On admission, physical examination was relevant for localized sibilant wheezes on the base of the left lung. The chest X-ray revealed diffuse infiltration along with interstitial oedema predominantly in the left lower lobe (Figure 1a). Given the persistence of the cough, along with the history of recurrent left lower lobe pneumonia, a bronchoscopy with rigid bronchoscope under general anaesthesia was performed.
The investigation revealed the partial obstruction of the left inferior bronchus by fragments of sunflower seed surrounded by purulent secretion. The fragments were safely removed and the secretion was positive for Klebsiella pneumoniae and Haemophillus influenzae. After another cure of antibiotics, all the symptoms resolved and the chest X-ray normalised (Figure 1b).
Case 2. A 1.7-year-old boy presented to the Emergency Department at “Grigore Alexandrescu” Emergency Clinical Hospital for Children in Bucharest for recent-onset stridor. The parents have witnessed him choking with a peanut, followed by facial cyanosis and stridor. He was immediately transferred on the Pediatric Otolaryngology Department.
Physical examination revealed respiratory distress, stridor and asymmetric breath sounds with diminished vesicular murmur on the left hemithorax upon lung auscultation. The chest X-ray showed a hyperinflated left lung (Figure 2a). An emergency bronchoscopy with rigid bronchoscope under general anaesthesia was performed. Initially, the peanut was identified in the left main bronchus (Figure 3a), but during manipulation it moved in the left inferior lobar bronchus (Figure 3b). The peanut was eventually fragmented and entirely removed with no further complications. After bronchoscopy, the symptoms resolved and the chest X-ray normalized (Figure 2b).
Foreign body aspiration in children brings many diagnostic challenges. The anamnesis is vital for establishing a high index of clinical suspicion. Extremely relevant information from parents consists in the moment of ingestion and the presence of any respiratory symptoms since then. The clinical presentation could be an episode of choking, gagging, and cyanosis followed by coughing, wheezing, or stridor(3). However, if the foreign body allows the air flow, the patient may be even asymptomatic which results in severely delayed diagnosis. In early presentations, physical examination varies from normal lung auscultation to signs of airway obstruction such as asymmetric breath sounds or wheezing(4).
The case reports described outline the importance of carefully reviewing the patient’s history. While the second patient was immediately rushed to the hospital in respiratory distress after parents had witnessed the chocking event, the first patient suffered from the consequences of a delayed diagnosis. Actually, failure to consider foreign body aspiration is one of the commonest causes for delay(1). Even though recurrent pneumonia could be a sign of an aspirated foreign body, the diagnosis was repeatedly overlooked. In an era where antibiotic resistance is a global health issue, the patient received at a young age various cures of antibiotics.
Besides a careful history and a complete physical examination, the diagnosis requires performing imaging studies (posteroanterior and lateral plain films of the neck and chest) followed by bronchoscopy(2,5). In addition to the identification of a radiopaque foreign body, suggestive radiological features include: hyperinflation, localized infiltration or even localized atelectasis(4,5). The chest X-rays were valuable resources in establishing the diagnosis for the two patients. They identified suggestive radiological features (localized infiltration, and hyperinflation). On the other hand, as far as organic foreign bodies are involved, imaging studies could be non-contributory, and are sometimes regarded as controversial, the mainstay remaining the bronchoscopy(3,5). The indication for this intervention is sustained by the deterioration of respiratory status along with specific clinical findings such as unilateral wheeze, chronic cough or haemoptysis(1). In the second case, due to the respiratory distress, an emergency bronchoscopy was performed, which ensured a rapidly favourable clinical course. For both patients bronchoscopy held both a diagnostic and a therapeutic role. Both foreign bodies were localised in the left bronchial tree. 50-60% of foreign bodies in children lodge in the left bronchus and foods count for the most frequently aspirated(4,6).
There still remains a controversy concerning the choice between flexible and rigid endoscopy(6,7). For both cases, a rigid bronchoscope was used for a better controlled respiration and for an easier retrieval of the foreign body. While in adults flexible bronchoscope is the elective method, being performed under local anaesthesia, in young children rigid bronchoscopy is the preferred method(6,7). An important advantage is the forceps which enables an easier extraction for both the foreign body and its remaining fragments(6). In addition, being performed under general anaesthesia with controlled ventilation, it lowers the risk for complications(7).
In the past few years, advances in endoscopy techniques offered new therapeutic opportunities for flexible bronchoscopy. It has been reported to be successfully used for the management of foreign bodies in children(7,8). The main advantage outlined is the possibility to reach distal airways (segmental, and subsegmental ones)(6,9). Other significant benefits are the worldwide increasing availability in medical centers and the possibility of being performed under local anaesthesia with deep sedation(9). However, it is widely used especially as a diagnostic tool for a better localization, rather than a therapeutic procedure(7).
Rigid bronchoscopy remains much more reliable in children(8,10). Its reliability is ensured by the larger working channel for instruments and the greater variability of tools for foreign bodies retrieval(9). In selected cases, when distal airways are affected, guidelines recommend a combination of techniques between rigid and flexible methods(2,4). This kind of therapeutic approach requires experienced pediatric otolaryngologists and pulmonologists with adequate training, highlighting the paramount importance of a multidisciplinary team(1,11,12).
Beyond choosing the type of bronchoscopy, the most important step is to perform it in optimal time. The greater the delay, the greater the complications(1,6,7). The first patient was diagnosed after 6 months. Besides suffering from recurrent pneumonia, she could also have developed pulmonary abscesses, atelectasis or bronchiectasis(1,13). To make matters worse, she had to face the adverse effects of repeated courses of steroids, bronchodilators and antibiotics. Ideally, for an optimal therapeutic outcome, the bronchoscopy should be performed in the first 24 hours after the aspiration event(12,13).
Tracheobronchial foreign body aspiration represents a serious pediatric emergency which poses many diagnostic challenges in young children. The diagnosis relies on a careful history review for finding a choking event, imaging studies for identifying key radiological features and bronchoscopy performed by an experienced medical team. The central element of both diagnostic and therapeutic algorithm consists of bronchoscopy. While flexible bronchoscope is preferred for diagnosing distal foreign bodies, the rigid one is preferred for extraction. Whenever there is a suspicion of an aspiration event accompanied either by a clinical, or a radiological context, a bronchoscopy should be performed as soon as possible. Needless to say it is better to have a negative bronchoscopy than to confront with the consequences of a delayed diagnosis.
- Ruiz F. Airway foreign bodies in children. UpToDate 2016.
- Muntz H. Foreign Body Management In R.B. Mitchell and K.D. Pereira Pediatric Otolaryngology for the Clinician, pages 215-222, Humana Press ,1st Ed, 2009.
- Rosbe K. Aerodigestive Tract Foreign Bodies, In Schoem S, Pediatric Otolaryngology American Academy of Pediatrics, 2012, Chapter 19, pages 401-410.
- Passali D, Gregori D, Lorenzoni G. Foreign body injuries in children: a review. Acta Otorhinolaryngologica Italica. 2015;35(4):265-271.
- Orji, F.T. and Akpeh, J.O. Tracheobronchial foreign body aspiration in children: how reliable are clinical and radiological signs in the diagnosis? Clinical Otolaryngology, 2010, 35: 479–485.
- Korlacki, W., Korecka, K., Dzielicki. Foreign body aspiration in children: diagnostic and therapeutic role of bronchoscopy. J. Pediatr Surg Int (2011) 27: 83.
- Passàli D, Lauriello M, Bellussi L, Passali G, Passali F, Gregori D. Foreign body inhalation in children: an update. Acta Otorhinolaryngologica Italica. 2010; 30(1):27-32.
- Boufersaoui, A, Benhalla K, Boukari R, Smail S, Anik R, Aouameur R. Foreign body aspiration in children: Experience from 2624 patients. International Journal of Pediatric Otorhinolaryngology, 2013, Volume 77, Issue 10, 1683-1688.
- Lowe D, Vasquez R, Maniaci V. Foreign body aspiration in children. Clinical Pediatric Emergency Medicine, Vol 16, Issue 3, September 2015, 140–148.
- Arif, Nighat, et al. Rigid bronchoscopy for tracheobronchial foreign bodies in children: experience at Holy Family Hospital Rawalpindi. Gomal Journal of Medical Sciences, April-June 2014, Vol. 12, No. 2; 101-105.
- Gursu K, Gocmen B, Tugtepe H, Karakoc F, Dagli E. Foreign body aspiration in children: The value of diagnostic criteria. International Journal of Pediatric Otorhinolaryngology, 2009, Volume 73, Issue 7, 963-967 .
- Haddadi S, Marzban S, Nemati S, Ranjbar kiakelayeh S, Parvizi A, Heidarzadeh A. Tracheobronchial Foreign-Bodies in Children; A 7-Year Retrospective Study. Iranian Journal of Otorhinolaryngology. 2015; 27(82):377-385.
- Bodart E, Gilbert A, Thimmesch M. Removal of an unusual bronchial foreign body: rigid or flexible bronchoscopy? Acta Clinica Belgica Vol. 69, Iss. 2, 2014.