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Transcutaneous migration of foreign body into thorax in children: A report of two cases
J Ped Surg Case Reports 14 (2016) 32e34
Contents lists available at ScienceDirect
Journal of Pediatric Surgery CASE REPORTS journal homepage: www.jpscasereports.com
Transcutaneous migration of foreign body into thorax in children: A report of two cases Bothra Jyoti*, A. Narendra Kumar, Jayaram Harish Department of Pediatric Surgery, Rainbow Children’s Hospital, Hyderabad, India
a r t i c l e i n f o
a b s t r a c t
Article history: Received 19 August 2016 Accepted 26 August 2016
Inhalation and ingestion of foreign bodies is common in pediatric age group. However transcutaneous migration of sharps into the lung parenchyma is rarely reported and can be hazardous. We report two such cases with details on the diagnosis and the treatment modalities used for the management. Ó 2016 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Key words: Transcutaneous Sharp foreign body Thoracoscopy
Aspiration is a common cause of tracheobronchial foreign bodies (FBs). However, foreign bodies in lung parenchyma can be migrated through the airway or rarely transcutaneous. We present two such cases where a needle foreign body with suspected route of entry being transcutaneous were evaluated and managed by thoracoscopy in one and thoracotomy in the other and relevant literature reviewed.
adherent to the thoracic wall with fibrotic tissue around (Fig. 3). The fibrotic tract was opened and a bent sewing needle was seen with the tip piercing parenchyma and the eye of the needle in the intercostal space suggesting the subcutaneous entry of the needle. The needle was grasped and delivered through the port site. Child recovered uneventfully and was discharged on post op day 2 and is doing well on follow up.
1. Case 1
2. Case 2
A 4 year old boy was referred to us in view of recurrent episodes of hemoptysis. Patient was on oral anticoagulants for the past 3 months for an acute onset right hemiparesis due to an infarct of left cerebral cortex. Child underwent an upper GI endoscopy for suspected hematemesis initially which was normal. HRCT thorax was then done which showed a linear radio-opaque foreign body in the left paraspinal muscles extending into the lower lobe of left lung in the para-cardiac region (Fig. 1). Patient was optimized and a diagnostic rigid bronchoscopy revealed extensive inflammation and blood clots in the left lower lobe bronchus (Fig. 2). However, no intrabronchial foreign body could be visualized. C-Arm guided localization of needle was done followed by thoracoscopy which showed left lower lobe parenchyma
A 50 days old male infant was antenatally diagnosed with bilateral hydronephrosis. Child was in the NICU of a different hospital for 17 days for neonatal septicemia, oliguric AKI. A Micturating Cystourethrogram (MCUG) was later done which confirmed the diagnosis of posterior urethral valves. The MCUG plate showed in addition the presence of a linear radio-opaque foreign body in the left perihilar region which appeared intraparenchymal on fluoroscopy (Fig. 4). After parental counselling, thoracoscopy was done which did not reveal any FB. Hence a thoracotomy was done, the needle FB felt intraparenchymal and retrieved. This was followed by cystoscopy for valve fulguration. A hypodermic needle without hub generally used for venous sampling in neonates was the FB and the route of entry was most probably transcutaneous. The infant had an uneventful recovery and is doing well on follow up.
Source of support: None. Presentation at a meeting: None. We present this case series to reemphasize the importance of safe disposal of sharps and use of advanced techniques for retrieval of foreign bodies. * Corresponding author. E-mail address: [email protected] (B. Jyoti).
3. Discussion Foreign body ingestion or aspiration is commonly seen in pediatric age group [1,2]. Sharp foreign bodies are rare in children
2213-5766/Ó 2016 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). http://dx.doi.org/10.1016/j.epsc.2016.08.009
B. Jyoti et al. / J Ped Surg Case Reports 14 (2016) 32e34
33
Fig. 3. Thoracoscopic image with bent needle entering parenchyma.
Fig. 1. Plain chest X-ray showing the foreign body.
diligent care is not taken a sharp object present in the wraps may then pierce the skin and may not announce itself for a long time as seen in our cases. These foreign bodies found incidentally or after symptoms as seen in our two cases needs to be removed as they can cause serious complications if left in vivo.
[3,4]. The transcutaneous route of entry for foreign body is relatively uncommon or under-reported. Tightly wrapping an infant in a baby-cloth is a usual custom in many countries. However, if
Fig. 2. Under fluoroscopy.
Fig. 4. MCUG showing foreign body.
34
B. Jyoti et al. / J Ped Surg Case Reports 14 (2016) 32e34
In a literature review, only four cases of intrapulmonary needles similar to this case have been reported in children [1]. One case was complicated by an abscess formation and required lobectomy for removal [5]. Two other were asymptomatic, the route of entry was unknown and bronchoscopic extraction was possible [6]. A venous sampling needle in the thorax removed by thoracotomy was reported in one of the case [7]. Pins and needles in the airway passages may migrate into the periphery but usually are symptomatic [8,9]. Complication that may arise due to intrapulmonary needles are abscess formation or pneumothorax [3,10]. The use of minimally invasive techniques i.e. thoracoscopy makes it easy to localize the foreign body without much dissection and decreases the surgical morbidity [11]. Transcutaneous route of venous sampling needles has been reported earlier and is of major concern for healthcare industry. It has both medical and medicolegal liabilities on the hospital and should be dealt with seriously. We, at our institute have abandoned the practice of drawing venous sample by this method and reinforced the rules of strict and diligent disposal of sharps around the infant. We report this case to emphasize the importance of proper disposal and need of precaution while handling sharps near children and the role of thoracoscopy in the retrieval of such foreign bodies with least morbidity in children. Conflict of interest None.
Acknowledgement None. References [1] Miura H, Taira O, Hiraguri S, Hirata T, Kato H. Successful surgical removal of an intrapulmonary aberrant needle under fluoroscopic guidance: report of a case. Surg Today (Japan) 2001;31:55e8. [2] Hart BL, Newell JD, Davis M. Pulmonary needle embolism from intravenous drug abuse. Can Assoc Radiol J 1989;40:326e7. [3] Vane DW, Pritchard J, Colville CW, West KW, Eigen H, Grosfeld JL. Bronchoscopy for aspirated foreign bodies in children. Arch Surg 1988;123:885e8. [4] Kosloski A. Bronchoscopic extraction of foreign bodies in children. AJDC 1982; 136:924e7. [5] Yamaguchi K, Esashi N. Three clinical cases with intrapulmonary foreign bodies. Kyoubo Geka (J Thorac Surg) 1960;13:162e6 [in Japanese]. [6] Nishida Y, Arai M, Muratani M, Miyawaki H, Kuribara T, Nakamura T. Guuzen hakkensareta hainhaifukushin no 3. Geka 1982;44:546e9 [in Japanese]. [7] Saleem MM. Transcutaneous migration of a foreign body (needle) into the hilum of the lung of an infant. Ann Saudi Med 2004 MareApr;24(2):127e8. [8] Pyman C. Inhaled foreign bodies in childhood: a review of 230 cases. Med J Aust 1971;9:620e8. [9] Hight DW, Phillipart AL, Hertzler JH. The treatment of retained peripheral foreign bodies in the pediatric airway. J Ped Surg 1981;16:694e9. Ann Saudi Med 24(2) MarcheApril 2004, www.kfshrc.edu.sa/annals. [10] Reinmuth N, Foster R, Sheld H. From the neck to the lung: pneumothorax caused by a lost needle. Eur J Cardio-Thorac Surg 1995;9:216e7. [11] Yoshida H, Sugita M, Saito R, Sato N, Hasumi T, Matsumura S, et al. An experience of video-assisted thoracoscopic surgery for an intrapulmonary needle under CT-guide marking. Kyoubu Geka 1998;51(9): 781e4 [in Japanese].
Contents lists available at ScienceDirect
Journal of Pediatric Surgery CASE REPORTS journal homepage: www.jpscasereports.com
Transcutaneous migration of foreign body into thorax in children: A report of two cases Bothra Jyoti*, A. Narendra Kumar, Jayaram Harish Department of Pediatric Surgery, Rainbow Children’s Hospital, Hyderabad, India
a r t i c l e i n f o
a b s t r a c t
Article history: Received 19 August 2016 Accepted 26 August 2016
Inhalation and ingestion of foreign bodies is common in pediatric age group. However transcutaneous migration of sharps into the lung parenchyma is rarely reported and can be hazardous. We report two such cases with details on the diagnosis and the treatment modalities used for the management. Ó 2016 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Key words: Transcutaneous Sharp foreign body Thoracoscopy
Aspiration is a common cause of tracheobronchial foreign bodies (FBs). However, foreign bodies in lung parenchyma can be migrated through the airway or rarely transcutaneous. We present two such cases where a needle foreign body with suspected route of entry being transcutaneous were evaluated and managed by thoracoscopy in one and thoracotomy in the other and relevant literature reviewed.
adherent to the thoracic wall with fibrotic tissue around (Fig. 3). The fibrotic tract was opened and a bent sewing needle was seen with the tip piercing parenchyma and the eye of the needle in the intercostal space suggesting the subcutaneous entry of the needle. The needle was grasped and delivered through the port site. Child recovered uneventfully and was discharged on post op day 2 and is doing well on follow up.
1. Case 1
2. Case 2
A 4 year old boy was referred to us in view of recurrent episodes of hemoptysis. Patient was on oral anticoagulants for the past 3 months for an acute onset right hemiparesis due to an infarct of left cerebral cortex. Child underwent an upper GI endoscopy for suspected hematemesis initially which was normal. HRCT thorax was then done which showed a linear radio-opaque foreign body in the left paraspinal muscles extending into the lower lobe of left lung in the para-cardiac region (Fig. 1). Patient was optimized and a diagnostic rigid bronchoscopy revealed extensive inflammation and blood clots in the left lower lobe bronchus (Fig. 2). However, no intrabronchial foreign body could be visualized. C-Arm guided localization of needle was done followed by thoracoscopy which showed left lower lobe parenchyma
A 50 days old male infant was antenatally diagnosed with bilateral hydronephrosis. Child was in the NICU of a different hospital for 17 days for neonatal septicemia, oliguric AKI. A Micturating Cystourethrogram (MCUG) was later done which confirmed the diagnosis of posterior urethral valves. The MCUG plate showed in addition the presence of a linear radio-opaque foreign body in the left perihilar region which appeared intraparenchymal on fluoroscopy (Fig. 4). After parental counselling, thoracoscopy was done which did not reveal any FB. Hence a thoracotomy was done, the needle FB felt intraparenchymal and retrieved. This was followed by cystoscopy for valve fulguration. A hypodermic needle without hub generally used for venous sampling in neonates was the FB and the route of entry was most probably transcutaneous. The infant had an uneventful recovery and is doing well on follow up.
Source of support: None. Presentation at a meeting: None. We present this case series to reemphasize the importance of safe disposal of sharps and use of advanced techniques for retrieval of foreign bodies. * Corresponding author. E-mail address: [email protected] (B. Jyoti).
3. Discussion Foreign body ingestion or aspiration is commonly seen in pediatric age group [1,2]. Sharp foreign bodies are rare in children
2213-5766/Ó 2016 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). http://dx.doi.org/10.1016/j.epsc.2016.08.009
B. Jyoti et al. / J Ped Surg Case Reports 14 (2016) 32e34
33
Fig. 3. Thoracoscopic image with bent needle entering parenchyma.
Fig. 1. Plain chest X-ray showing the foreign body.
diligent care is not taken a sharp object present in the wraps may then pierce the skin and may not announce itself for a long time as seen in our cases. These foreign bodies found incidentally or after symptoms as seen in our two cases needs to be removed as they can cause serious complications if left in vivo.
[3,4]. The transcutaneous route of entry for foreign body is relatively uncommon or under-reported. Tightly wrapping an infant in a baby-cloth is a usual custom in many countries. However, if
Fig. 2. Under fluoroscopy.
Fig. 4. MCUG showing foreign body.
34
B. Jyoti et al. / J Ped Surg Case Reports 14 (2016) 32e34
In a literature review, only four cases of intrapulmonary needles similar to this case have been reported in children [1]. One case was complicated by an abscess formation and required lobectomy for removal [5]. Two other were asymptomatic, the route of entry was unknown and bronchoscopic extraction was possible [6]. A venous sampling needle in the thorax removed by thoracotomy was reported in one of the case [7]. Pins and needles in the airway passages may migrate into the periphery but usually are symptomatic [8,9]. Complication that may arise due to intrapulmonary needles are abscess formation or pneumothorax [3,10]. The use of minimally invasive techniques i.e. thoracoscopy makes it easy to localize the foreign body without much dissection and decreases the surgical morbidity [11]. Transcutaneous route of venous sampling needles has been reported earlier and is of major concern for healthcare industry. It has both medical and medicolegal liabilities on the hospital and should be dealt with seriously. We, at our institute have abandoned the practice of drawing venous sample by this method and reinforced the rules of strict and diligent disposal of sharps around the infant. We report this case to emphasize the importance of proper disposal and need of precaution while handling sharps near children and the role of thoracoscopy in the retrieval of such foreign bodies with least morbidity in children. Conflict of interest None.
Acknowledgement None. References [1] Miura H, Taira O, Hiraguri S, Hirata T, Kato H. Successful surgical removal of an intrapulmonary aberrant needle under fluoroscopic guidance: report of a case. Surg Today (Japan) 2001;31:55e8. [2] Hart BL, Newell JD, Davis M. Pulmonary needle embolism from intravenous drug abuse. Can Assoc Radiol J 1989;40:326e7. [3] Vane DW, Pritchard J, Colville CW, West KW, Eigen H, Grosfeld JL. Bronchoscopy for aspirated foreign bodies in children. Arch Surg 1988;123:885e8. [4] Kosloski A. Bronchoscopic extraction of foreign bodies in children. AJDC 1982; 136:924e7. [5] Yamaguchi K, Esashi N. Three clinical cases with intrapulmonary foreign bodies. Kyoubo Geka (J Thorac Surg) 1960;13:162e6 [in Japanese]. [6] Nishida Y, Arai M, Muratani M, Miyawaki H, Kuribara T, Nakamura T. Guuzen hakkensareta hainhaifukushin no 3. Geka 1982;44:546e9 [in Japanese]. [7] Saleem MM. Transcutaneous migration of a foreign body (needle) into the hilum of the lung of an infant. Ann Saudi Med 2004 MareApr;24(2):127e8. [8] Pyman C. Inhaled foreign bodies in childhood: a review of 230 cases. Med J Aust 1971;9:620e8. [9] Hight DW, Phillipart AL, Hertzler JH. The treatment of retained peripheral foreign bodies in the pediatric airway. J Ped Surg 1981;16:694e9. Ann Saudi Med 24(2) MarcheApril 2004, www.kfshrc.edu.sa/annals. [10] Reinmuth N, Foster R, Sheld H. From the neck to the lung: pneumothorax caused by a lost needle. Eur J Cardio-Thorac Surg 1995;9:216e7. [11] Yoshida H, Sugita M, Saito R, Sato N, Hasumi T, Matsumura S, et al. An experience of video-assisted thoracoscopic surgery for an intrapulmonary needle under CT-guide marking. Kyoubu Geka 1998;51(9): 781e4 [in Japanese].