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Potpourri aspiration presenting as tension pneumothorax
Potpourri Aspiration Presenting as Tension Pneumothorax Jeffrey D. Carron, MD, and Craig S. Derkay, MD Foreign body aspiration in children is a relatively common occurrence, with peanuts, seeds, or other food particles representing the most common items. Because radiological findings such as mediastinal shift, postobstructive emphysema, and pneumonia are notoriously inconsistent, diagnosis hinges on an accurate history, which may be correlated by physical examination and radiography. We present the case of a 2-year-old girl with delayed treatment of a bronchial foreign body who presented with tension pneumothorax before endoscopy. After chest tube removal, her pneumothorax recurred, thereby bringing about the question of bronchial erosion. Furthermore, an uncommonly reported aspirated object, household potpourri, was encountered. (Am J Otolaryngol 2000;21:349-351. Copyright r 2000 by W.B. Saunders Company)
(Editorial Comment: The authors highlight the danger of pleasant-smelling potpourri in a household with small children.)
CASE REPORT A 2-year-old girl was taken to the urgent care center of a rural community for a 1-day history of right-sided chest pain and a 1-week history of fevers up to 102°F. On questioning, her mother related a history of chronic, occasionally paroxysmal, dry cough for over 1 year after a possible aspiration of household potpourri; she had no distress on initial evaluation and subsequently missed her follow-up visit. The remainder of the history was unremarkable. Physical examination revealed a well-developed, well-nourished girl in mild distress. Examination of the head and neck was unremarkable. No stridor was appreciated. Chest examination was significant for decreased breath sounds in the right lower lobe. Chest radiograph showed a 50% right-sided pneumothorax with no obvious infiltrate or mediasti-
From the Department of Otolaryngology—Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, VA. Address reprint requests to Jeffrey D. Carron, MD, Department of Otolaryngology—Head and Neck Surgery, 825 Fairfax Ave, Suite 510, Norfolk, VA 23507. Copyright r 2000 by W.B. Saunders Company 0196-0709/00/2105-0014$10.00/0 doi:10.1053/ajot.2000.16171
nal shift (Fig 1A). Complete blood count showed a mild leukocytosis at 19,100 cells/mL (82% PMNs, 12% bands), hemoglobin 10.2 mg/dL, and hematocrit of 32%. Tube thoracostomy was performed and the patient was transferred to our facility, where a postexpansion roentgenogram showed a right lower lobe (RLL) infiltrate (Fig 1B). A purified protein derivative (PPD) was placed (and later found to be negative), and she was started on intravenous cefuroxime. Flexible bronchoscopy by a pediatric pulmonologist found the RLL bronchus to be occluded by a white plug that could not be aspirated. Otolaryngologic consultation was obtained, and the patient was taken to the main operating room for rigid bronchoscopy. Endoscopy confirmed hard, white debris occluding the RLL bronchus. Optical forceps were used to extract 2 large pieces and 2 smaller ones. The fragments were firm and had a woody consistency; the largest measured 0.5 by 0.5 cm (Figs 2A and B). A small amount of purulent fluid was suctioned from the right lower lobe. Postoperatively, the patient had immediate resolution of her RLL infiltrate and no air leak from her chest tube. The tube was removed 2 days later when no pneumothorax recurred after 24 hours of water seal. A delayed film done 6 hours later, however, showed a 50% right-sided pneumothorax; reinsertion of a chest tube failed to re-expand her lung. Because of concern over chronic inflammation restricting lobar inflation or obstruction from
American Journal of Otolaryngology, Vol 21, No 5 (September-October), 2000: pp 349-351
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retained foreign body, she was taken the next day for a second-look rigid bronchoscopy. At the time of repeat endoscopy, a mild amount of granulation tissue was seen, but there was no evidence of retained foreign body or bronchial erosion. Her chest tube was repositioned and postoperative films showed complete reexpansion of the right lung. Her chest tube was successfully removed 2 days later and she was discharged.
Fig 2. (A) Initial view of potpourri occluding right lower lobe bronchus. (B) Removal with optical forceps.
DISCUSSION
Fig 1. (A) Chest roentgenogram at presentation showing 50% pneumothorax. (B) Right lower lobe infiltrate seen after thoracostomy.
Foreign body aspiration in children can be a life-threatening event, with death usually secondary to hypoxemia and respiratory failure before arrival to the hospital.1,2,3 The most commonly aspirated items in younger children are peanuts and other food items.1-5 Household potpourri is a blend of herbs, flower petals, and wood chips, which are usually soaked in fragrances that may contain oils or other, aromatic chemicals; significant inflammation can conceivably result from these compounds. An extensive review of the literature revealed 1 other case of potpourri aspiration in which the child coughed out the debris while in the ambulance.6 The actual number is
POTPOURRI ASPIRATION
undoubtedly higher, as foreign bodies are often unidentifiable and described as ‘‘organic or vegetable matter.’’3,4,5 Although several cases have been reported,8-11 tension pneumothorax is an infrequent occurrence with foreign body aspiration. In the presented patient, the RLL infiltrate was only apparent after reinflation of the lung; additionally, her history was suggestive of a chronic bronchial irritation after a possible aspiration event. This case emphasizes the importance of thorough history taking and prompt management. REFERENCES 1. Murray AD, Mahoney EM, Holinger LD: Foreign bodies of the airway and esophagus, in Otolaryngology— Head and Neck Surgery (ed 3). St. Louis, MO, Mosby-Year Book, 1998 2. Steen KH, Zimmerman T: Tracheobronchial aspiration of foreign bodies in children: A study of 94 cases. Laryngoscope 100:525-530, 1990 3. Mu L, He P, Sun D: Inhalation of foreign bodies in
351
Chinese children: A review of 400 cases. Laryngoscope 101:657-660, 1991 4. Reilly J, Thompson J, MacArthur C, et al: Pediatric aerodigestive foreign body injuries are complications related to timeliness of diagnosis. Laryngoscope 107:1720, 1997 5. Black RE, Johnson DG, Matlak ME: Bronchoscopic removal of aspirated foreign bodies in children. J Pediatr Surg 29:682-684, 1994 6. Hopkins RL, Kiernan MP: Aspiration of potpourri. Chest 104:985-986, 1993 (letter) 7. Newson TP, Parshuram CS, Berkowitz RG, et al: Tension pneumothorax secondary to grass head aspiration. Pediatr Emerg Care 14:287-289, 1998 8. Wilkinson KA, Beckett W, Brown TC: Pneumothorax secondary to foreign body inhalation in a 20 month old child. J Paediatr Health 28:67-68, 1992 9. Thomas R, Gaillard de Collogny L, Gaillard A, et al: [A case of pneumothorax preexistent to the extraction of a bronchial foreign body]. J Fr Otorhinolaryngol 14:581585, 1965 10. Samokhval V: [Spontaneous left pneumothorax and atelectasis of the right lung resulting from occlusion of the right main bronchus by a foreign body]. Klin Khir 8:43-44, 1968 11. Kozitskaia KN, Tyshko FA: [Foreign body of the respiratory tract complicated by spontaneous pneumothorax]. Zh Ushn Nos Gorl Bolezn 26:65-66, 1966
(Editorial Comment: The authors highlight the danger of pleasant-smelling potpourri in a household with small children.)
CASE REPORT A 2-year-old girl was taken to the urgent care center of a rural community for a 1-day history of right-sided chest pain and a 1-week history of fevers up to 102°F. On questioning, her mother related a history of chronic, occasionally paroxysmal, dry cough for over 1 year after a possible aspiration of household potpourri; she had no distress on initial evaluation and subsequently missed her follow-up visit. The remainder of the history was unremarkable. Physical examination revealed a well-developed, well-nourished girl in mild distress. Examination of the head and neck was unremarkable. No stridor was appreciated. Chest examination was significant for decreased breath sounds in the right lower lobe. Chest radiograph showed a 50% right-sided pneumothorax with no obvious infiltrate or mediasti-
From the Department of Otolaryngology—Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, VA. Address reprint requests to Jeffrey D. Carron, MD, Department of Otolaryngology—Head and Neck Surgery, 825 Fairfax Ave, Suite 510, Norfolk, VA 23507. Copyright r 2000 by W.B. Saunders Company 0196-0709/00/2105-0014$10.00/0 doi:10.1053/ajot.2000.16171
nal shift (Fig 1A). Complete blood count showed a mild leukocytosis at 19,100 cells/mL (82% PMNs, 12% bands), hemoglobin 10.2 mg/dL, and hematocrit of 32%. Tube thoracostomy was performed and the patient was transferred to our facility, where a postexpansion roentgenogram showed a right lower lobe (RLL) infiltrate (Fig 1B). A purified protein derivative (PPD) was placed (and later found to be negative), and she was started on intravenous cefuroxime. Flexible bronchoscopy by a pediatric pulmonologist found the RLL bronchus to be occluded by a white plug that could not be aspirated. Otolaryngologic consultation was obtained, and the patient was taken to the main operating room for rigid bronchoscopy. Endoscopy confirmed hard, white debris occluding the RLL bronchus. Optical forceps were used to extract 2 large pieces and 2 smaller ones. The fragments were firm and had a woody consistency; the largest measured 0.5 by 0.5 cm (Figs 2A and B). A small amount of purulent fluid was suctioned from the right lower lobe. Postoperatively, the patient had immediate resolution of her RLL infiltrate and no air leak from her chest tube. The tube was removed 2 days later when no pneumothorax recurred after 24 hours of water seal. A delayed film done 6 hours later, however, showed a 50% right-sided pneumothorax; reinsertion of a chest tube failed to re-expand her lung. Because of concern over chronic inflammation restricting lobar inflation or obstruction from
American Journal of Otolaryngology, Vol 21, No 5 (September-October), 2000: pp 349-351
349
350
CARRON AND DERKAY
retained foreign body, she was taken the next day for a second-look rigid bronchoscopy. At the time of repeat endoscopy, a mild amount of granulation tissue was seen, but there was no evidence of retained foreign body or bronchial erosion. Her chest tube was repositioned and postoperative films showed complete reexpansion of the right lung. Her chest tube was successfully removed 2 days later and she was discharged.
Fig 2. (A) Initial view of potpourri occluding right lower lobe bronchus. (B) Removal with optical forceps.
DISCUSSION
Fig 1. (A) Chest roentgenogram at presentation showing 50% pneumothorax. (B) Right lower lobe infiltrate seen after thoracostomy.
Foreign body aspiration in children can be a life-threatening event, with death usually secondary to hypoxemia and respiratory failure before arrival to the hospital.1,2,3 The most commonly aspirated items in younger children are peanuts and other food items.1-5 Household potpourri is a blend of herbs, flower petals, and wood chips, which are usually soaked in fragrances that may contain oils or other, aromatic chemicals; significant inflammation can conceivably result from these compounds. An extensive review of the literature revealed 1 other case of potpourri aspiration in which the child coughed out the debris while in the ambulance.6 The actual number is
POTPOURRI ASPIRATION
undoubtedly higher, as foreign bodies are often unidentifiable and described as ‘‘organic or vegetable matter.’’3,4,5 Although several cases have been reported,8-11 tension pneumothorax is an infrequent occurrence with foreign body aspiration. In the presented patient, the RLL infiltrate was only apparent after reinflation of the lung; additionally, her history was suggestive of a chronic bronchial irritation after a possible aspiration event. This case emphasizes the importance of thorough history taking and prompt management. REFERENCES 1. Murray AD, Mahoney EM, Holinger LD: Foreign bodies of the airway and esophagus, in Otolaryngology— Head and Neck Surgery (ed 3). St. Louis, MO, Mosby-Year Book, 1998 2. Steen KH, Zimmerman T: Tracheobronchial aspiration of foreign bodies in children: A study of 94 cases. Laryngoscope 100:525-530, 1990 3. Mu L, He P, Sun D: Inhalation of foreign bodies in
351
Chinese children: A review of 400 cases. Laryngoscope 101:657-660, 1991 4. Reilly J, Thompson J, MacArthur C, et al: Pediatric aerodigestive foreign body injuries are complications related to timeliness of diagnosis. Laryngoscope 107:1720, 1997 5. Black RE, Johnson DG, Matlak ME: Bronchoscopic removal of aspirated foreign bodies in children. J Pediatr Surg 29:682-684, 1994 6. Hopkins RL, Kiernan MP: Aspiration of potpourri. Chest 104:985-986, 1993 (letter) 7. Newson TP, Parshuram CS, Berkowitz RG, et al: Tension pneumothorax secondary to grass head aspiration. Pediatr Emerg Care 14:287-289, 1998 8. Wilkinson KA, Beckett W, Brown TC: Pneumothorax secondary to foreign body inhalation in a 20 month old child. J Paediatr Health 28:67-68, 1992 9. Thomas R, Gaillard de Collogny L, Gaillard A, et al: [A case of pneumothorax preexistent to the extraction of a bronchial foreign body]. J Fr Otorhinolaryngol 14:581585, 1965 10. Samokhval V: [Spontaneous left pneumothorax and atelectasis of the right lung resulting from occlusion of the right main bronchus by a foreign body]. Klin Khir 8:43-44, 1968 11. Kozitskaia KN, Tyshko FA: [Foreign body of the respiratory tract complicated by spontaneous pneumothorax]. Zh Ushn Nos Gorl Bolezn 26:65-66, 1966