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Christmas surprise: The unnoticed journey of a needle—from bronchus to intestine
ARTICLE IN PRESS Respiratory Medicine (2005) 99, 1600–1602
CASE REPORT
Christmas surprise: The unnoticed journey of a needle—from bronchus to intestine H. Graffsta ¨dta, B. Dieckowa, C. Gru ¨berb, B. Sto ¨verc, B. Niggemannb, a
Department of Pediatric Surgery, University Children’s Hospital Charite´, Berlin, Germany Department of Pediatric Pneumology and Immunology, University Children’s Hospital Charite´, Augustenburger Platz 1, 13353, Berlin, Germany c Division of Pediatric Radiology, University Children’s Hospital Charite´, Berlin, Germany b
Received 4 March 2005; accepted 14 March 2005
KEYWORDS Aspiration; Foreign body; Migrating; Needle; Wandering
Summary We report on a 14-year-old Arabian girl who suddenly developed coughing after having aspirated a needle used for fixing her headscarf. The chest Xray showed the needle located in the right main bronchus. However, subsequent flexible bronchoscopy could not detect any foreign body. A further X-ray of the abdomen showed the needle now behind the diaphragm. Gastro-oesophageal endoscopy was also uneventful. On the third day, the needle was excreted naturally. Astonishingly, this journey of the wandering needle from bronchus to intestine was not realised by the patient at any time. Our case highlights that children and adolescents should be warned repeatedly about the risks of putting needles between their teeth. It also reminds the physician to diagnose aspirated foreign bodies as early as possible to prevent wandering and migrating, which may induce new risks and unnecessary diagnostic and therapeutic procedures. & 2005 Elsevier Ltd. All rights reserved.
Introduction While nuts are the most commonly aspirated foreign body in small children, needles become a risk in older children and adolescents. The risk is particularly high when people hold needles between their teeth while using their hands for other Corresponding author. Tel.: +49 30 450 566 643; fax: +49 30 450 566 931. E-mail address: [email protected] (B. Niggemann).
things. Further rare situations of needle aspiration include inhalation therapy: an 11-year-old boy aspirated an injection needle during inhalation for his asthma via a nebuliser; the needle could be removed by flexible bronchoscopy.1 Migration of foreign bodies within the lung has been reported, e.g. a piece of an almond from one main bronchus to the other in a 1-year-old child.2 Sharp foreign bodies, such as needles, may migrate into other organs, even into the pericardium, as observed in a 2-year-old boy.3 We report on an adolescent who ingested a needle secondary to
0954-6111/$ - see front matter & 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.rmed.2005.03.022
ARTICLE IN PRESS Wandering needle
1601
aspiration, without having noticed when or how the needle took its way from bronchus to intestine.
Case report On Christmas Eve, the 14-year-old Arabian girl suddenly developed coughing after having aspirated a needle used for fixing her headscarf. At the emergency department she presented with moderate cough and mild thoracic pain, but no dyspnoea. The chest X-ray showed the needle located in the right main bronchus (Fig. 1). Flexible bronchoscopy, performed a few hours later (she had no empty stomach on entering the emergency department), could not detect any foreign body—even using a very small device. The mucosa of the airways was totally normal. X-ray examination in the operating room revealed that the needle was now projecting behind the diaphragm. Immediate gastro-oesophageal endoscopy during the same anaesthetic procedure was also uneventful, showing an intact mucosa. It was decided to let the patient wake up and to wait for the next day. The day after, the X-ray of the abdomen showed the needle projecting in the small pelvis (Fig. 2). On the third day, the needle was excreted naturally.
Discussion Although aspiration or ingestion of sharp needles may lead to profound injury including perforation, in our adolescent patient the needle caused no local injury—the mucosa of the bronchi and the gastro-intestinal tract was completely normal. This is especially remarkable because there is no explanation other than that the needle must have been brought up by coughing into the mouth with concomitant ingestion into the oesophagus and intestine. However, this procedure was not realised by the patient. There was no pain or discomfort at any time. In the literature, there is one report of an 8-yearold boy who must have expectorated a needle without noticing, because the bronchoscopy performed a little later also revealed no foreign body after chest-film confirmed aspiration of a needle into his right main bronchus.4 However, there is no other report of a needle aspiration with concomitant ingestion without this being suspected by the patient. The risk of aspiration of needles is high, due to the habit of putting needles between the teeth, for example when putting up posters or fixing turbans.5–7 The situation is very similar in patients with needle aspirations: they occur while talking,
Figure 1 Chest X-ray showing a needle located in the right main bronchus.
ARTICLE IN PRESS 1602
H. Graffsta ¨dt et al.
Figure 2 X-ray of the abdomen showing the needle projecting to the small pelvis.
References 1. Oshio T, Hino M. An injection needle as a foreign body in the trachea resulting from asthma inhalation therapy. Pediatr Int 2001;43:98–9. 2. Singhal P, Sonkhya N, Srivatava SP. Migrating foreign body in the bronchus. Int J Pediatr Otolaryngol 2003;67: 1123–6. 3. Nambirajan L, Chandrasekharam VVSS, Bhatnagar V. Pericardial foreign body. J Pediatr Surg 2001;36:936–8. 4. Brand PLP, Rosingh HJ. The Wandering Needle’’. Pediatr Pulmonol 2003;35:152–4. 5. Kaptanoglu M, Dogan K, Onen A, Kunt N. Turban pin aspiration; a potential risk for young Islamic girls. Int J Pediatr Otorhinolaryngol 1999;48:131–5. 6. Al-Lawaty AAMAB, Al-Delaime TY, Sajwani MJ. Aspiration of pins. A hazard of tradition in Oman. Pediatr Surg Int 1996;11:316–7. 7. Uc- an ES, Tahaoglu K, Mogolkoc N, Dereli S, Basozdemir N, Basok O, Turktas H, Akkoclu A, Ates M. Turban pin aspiration syndrome: a new form of foreign body aspiration. Respir Med 1996;90:427–8. 8. Causey AL, Talton DS, Miller RC, Warren ET. Aspirated safety pin requiring thoracotomy: report of a case and review. Pediat Emerg Care 1997;13:397–400. ’’
laughing, breathing deeply or coughing when holding the needles between the teeth.5 The risk of aspiration of needles may be greater in Islamic girls using needles to attach a headscarf regularly. However, the risk of a needle as an inhaled foreign body does not seem to be restricted to this group. Several years ago, we had a case of a German adolescent girl, who had aspirated a needle held between her teeth while putting up a poster in her room, where she began laughing while sitting on the shoulders of a girl-friend. Our cases highlight that children and adolescents should be warned repeatedly about the risks of putting needles between their teeth. Usually, these foreign bodies can be extracted by bronchoscopy, but in some cases thoracotomy is required.5,6,8 The case of the wandering needle from bronchus to intestine may also remind the physician to diagnose aspirated foreign bodies as early as possible to prevent wandering and migrating, which may induce new risks and unnecessary diagnostic and therapeutic procedures.
CASE REPORT
Christmas surprise: The unnoticed journey of a needle—from bronchus to intestine H. Graffsta ¨dta, B. Dieckowa, C. Gru ¨berb, B. Sto ¨verc, B. Niggemannb, a
Department of Pediatric Surgery, University Children’s Hospital Charite´, Berlin, Germany Department of Pediatric Pneumology and Immunology, University Children’s Hospital Charite´, Augustenburger Platz 1, 13353, Berlin, Germany c Division of Pediatric Radiology, University Children’s Hospital Charite´, Berlin, Germany b
Received 4 March 2005; accepted 14 March 2005
KEYWORDS Aspiration; Foreign body; Migrating; Needle; Wandering
Summary We report on a 14-year-old Arabian girl who suddenly developed coughing after having aspirated a needle used for fixing her headscarf. The chest Xray showed the needle located in the right main bronchus. However, subsequent flexible bronchoscopy could not detect any foreign body. A further X-ray of the abdomen showed the needle now behind the diaphragm. Gastro-oesophageal endoscopy was also uneventful. On the third day, the needle was excreted naturally. Astonishingly, this journey of the wandering needle from bronchus to intestine was not realised by the patient at any time. Our case highlights that children and adolescents should be warned repeatedly about the risks of putting needles between their teeth. It also reminds the physician to diagnose aspirated foreign bodies as early as possible to prevent wandering and migrating, which may induce new risks and unnecessary diagnostic and therapeutic procedures. & 2005 Elsevier Ltd. All rights reserved.
Introduction While nuts are the most commonly aspirated foreign body in small children, needles become a risk in older children and adolescents. The risk is particularly high when people hold needles between their teeth while using their hands for other Corresponding author. Tel.: +49 30 450 566 643; fax: +49 30 450 566 931. E-mail address: [email protected] (B. Niggemann).
things. Further rare situations of needle aspiration include inhalation therapy: an 11-year-old boy aspirated an injection needle during inhalation for his asthma via a nebuliser; the needle could be removed by flexible bronchoscopy.1 Migration of foreign bodies within the lung has been reported, e.g. a piece of an almond from one main bronchus to the other in a 1-year-old child.2 Sharp foreign bodies, such as needles, may migrate into other organs, even into the pericardium, as observed in a 2-year-old boy.3 We report on an adolescent who ingested a needle secondary to
0954-6111/$ - see front matter & 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.rmed.2005.03.022
ARTICLE IN PRESS Wandering needle
1601
aspiration, without having noticed when or how the needle took its way from bronchus to intestine.
Case report On Christmas Eve, the 14-year-old Arabian girl suddenly developed coughing after having aspirated a needle used for fixing her headscarf. At the emergency department she presented with moderate cough and mild thoracic pain, but no dyspnoea. The chest X-ray showed the needle located in the right main bronchus (Fig. 1). Flexible bronchoscopy, performed a few hours later (she had no empty stomach on entering the emergency department), could not detect any foreign body—even using a very small device. The mucosa of the airways was totally normal. X-ray examination in the operating room revealed that the needle was now projecting behind the diaphragm. Immediate gastro-oesophageal endoscopy during the same anaesthetic procedure was also uneventful, showing an intact mucosa. It was decided to let the patient wake up and to wait for the next day. The day after, the X-ray of the abdomen showed the needle projecting in the small pelvis (Fig. 2). On the third day, the needle was excreted naturally.
Discussion Although aspiration or ingestion of sharp needles may lead to profound injury including perforation, in our adolescent patient the needle caused no local injury—the mucosa of the bronchi and the gastro-intestinal tract was completely normal. This is especially remarkable because there is no explanation other than that the needle must have been brought up by coughing into the mouth with concomitant ingestion into the oesophagus and intestine. However, this procedure was not realised by the patient. There was no pain or discomfort at any time. In the literature, there is one report of an 8-yearold boy who must have expectorated a needle without noticing, because the bronchoscopy performed a little later also revealed no foreign body after chest-film confirmed aspiration of a needle into his right main bronchus.4 However, there is no other report of a needle aspiration with concomitant ingestion without this being suspected by the patient. The risk of aspiration of needles is high, due to the habit of putting needles between the teeth, for example when putting up posters or fixing turbans.5–7 The situation is very similar in patients with needle aspirations: they occur while talking,
Figure 1 Chest X-ray showing a needle located in the right main bronchus.
ARTICLE IN PRESS 1602
H. Graffsta ¨dt et al.
Figure 2 X-ray of the abdomen showing the needle projecting to the small pelvis.
References 1. Oshio T, Hino M. An injection needle as a foreign body in the trachea resulting from asthma inhalation therapy. Pediatr Int 2001;43:98–9. 2. Singhal P, Sonkhya N, Srivatava SP. Migrating foreign body in the bronchus. Int J Pediatr Otolaryngol 2003;67: 1123–6. 3. Nambirajan L, Chandrasekharam VVSS, Bhatnagar V. Pericardial foreign body. J Pediatr Surg 2001;36:936–8. 4. Brand PLP, Rosingh HJ. The Wandering Needle’’. Pediatr Pulmonol 2003;35:152–4. 5. Kaptanoglu M, Dogan K, Onen A, Kunt N. Turban pin aspiration; a potential risk for young Islamic girls. Int J Pediatr Otorhinolaryngol 1999;48:131–5. 6. Al-Lawaty AAMAB, Al-Delaime TY, Sajwani MJ. Aspiration of pins. A hazard of tradition in Oman. Pediatr Surg Int 1996;11:316–7. 7. Uc- an ES, Tahaoglu K, Mogolkoc N, Dereli S, Basozdemir N, Basok O, Turktas H, Akkoclu A, Ates M. Turban pin aspiration syndrome: a new form of foreign body aspiration. Respir Med 1996;90:427–8. 8. Causey AL, Talton DS, Miller RC, Warren ET. Aspirated safety pin requiring thoracotomy: report of a case and review. Pediat Emerg Care 1997;13:397–400. ’’
laughing, breathing deeply or coughing when holding the needles between the teeth.5 The risk of aspiration of needles may be greater in Islamic girls using needles to attach a headscarf regularly. However, the risk of a needle as an inhaled foreign body does not seem to be restricted to this group. Several years ago, we had a case of a German adolescent girl, who had aspirated a needle held between her teeth while putting up a poster in her room, where she began laughing while sitting on the shoulders of a girl-friend. Our cases highlight that children and adolescents should be warned repeatedly about the risks of putting needles between their teeth. Usually, these foreign bodies can be extracted by bronchoscopy, but in some cases thoracotomy is required.5,6,8 The case of the wandering needle from bronchus to intestine may also remind the physician to diagnose aspirated foreign bodies as early as possible to prevent wandering and migrating, which may induce new risks and unnecessary diagnostic and therapeutic procedures.