Endobronchial cockroach: An unusual foreign body aspiration

Endobronchial cockroach: An unusual foreign body aspiration

The Journal FLSEVIEK - of I;merpency .Med~c~nc. Vol IS. No 1. pp Itc” -JW. 1997 Copyright 0 I997 Elswer Sc~encc Inc Printed in the (‘SA. All right...

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The Journal

FLSEVIEK

-

of I;merpency

.Med~c~nc. Vol IS. No 1. pp Itc” -JW. 1997 Copyright 0 I997 Elswer Sc~encc Inc Printed in the (‘SA. All right, rescrvcd 0736.3679/Y 5 I?.of) i .orl

PII So736-4679(~-3

CMnid ENDOBRONCHIAL

Communicatkun COCKROACH:

Troy J. Marlow,

Stephen

AN UNUSUAL I. Schabel,

MD,

FOREIGN

BODY

ASPIRATION

and David D. Goltra, Jr., MD

Department of Radiology, Medical University of South Carolina, Charleston, South Carolina Reprint Address: Stephen 1. Schabel, MD, Department of Radiology, Medical UniversQ of South Carokn:+. 171 Ashley Avenue, Charleston, SC 28425

CASE REPORT

0 Abstract-Foreign-body aspiration is a frequent and potedialIy Lethal occurrence in chlIdren. It is associated with a variety of symptoms including choking, coughing, and wheezing. These symptoms differ in severity and are sometimes absent, and chest rHograph fIndings are often nonspeci% Thus, the diagnosis of foreign body aspiration is occas&naUy missed or ddayed. A multitude of aspirated objects have been reported in the literature. In the present report, we describe the a@ration of a cockroach by a child with a delay in diagnosis of 3 d. 0 1997 Elsevier Science Inc. I7 Keywords-foreign diagnosis

body aspiration;

A 2-yr-old child was vacationing with his parents. They checked into a local hotel, and soon thereafter the child began coughing. His parents immediately took him to the emergency department (ED). Vital signs were: temperature of 37.3”C (99.2”F). respiration rate of 32 breaths/min, pulse of 102 beats/ min, and blood pressure of 108/62 mmHg. The child was in mild respiratory distress and unable to answer questions. The parents were not present at the onset of the coughing and contributed little to the present history. The child suffered from no major illness and had only three mild viral upper respiratory infections in the prior year. Physical examination and a PA chest film were normal. Antitussive medications were prescribed, and the child was released from the ED. Three days later, the child’s cough was still uncontrolled, and his breathing was labored. The parents brought him back to the ED for further evaluation. The child was in mild respiratory distress, and chest films on inspiration showed air trapping in the left lung. with mediastinal shift toward the right (Fig. IA). Expiratory films showed further hyperaeration and mediastinal shift. suggesting a ball-valve effect (Fig. IB). Fiberoptic bronchoscopy was performed. and a cockroach (Fig. 2), which was partially decomposed but clearly recognizable, was removed from the left main stem bronchus. The child’s symptoms resolved after bronchoscopy.

cockroach; delayed

INTRODUCTION Foreign body (FB) aspiration is a frequent, serious, and potentially life-threatening occurrence in young children. Ilsually, the object is expelled spontaneously by coughing immediately following aspiration, but endoscopy is sometimes required to secure the airway and remove the FB. Occasionally, the initial diagnosis of FB aspiration is missed, and the patient presents later with chronic symptoms ( 1). Different objects have been recovered from the respiratory tract of children. We encountered a case of missed cockroach (Peripkzneru umericana) aspiration in a 2-yrold child and can find no prior documentation of this apparently rare occurrence.

RECEIVED: ACCEPTED..

16 September 1996; FINAL SUBMISSION RECEIVED: 4 February 1997: 21 February 1997 487

488

T. J. Mat-low et al.

B Figure 1. Chest films on inspiration and expiration at the time of diagnosis three days after aspiration event. A: Chest film on inspiration shows relative lucency in the left hemithorax and mediastinum shifted to the right. B: Chest film on expiration shows further mediastinal shii to the right. Neither film displays any opacity suggesting a foreign body.

eating, playing, or startling situations, such as traffic accidents (2). FB aspiration usually presents in the ED with acute respiratory distress. Most cases of FB aspiration are diagnosed and treated early. In one-third of cases,the actual aspiration event may not be observed(3). Physical examination may show choking, coughing, wheezing, abnormal breath sounds, respiratory distress, or decreasedair entry. Some children, however, will have no physical signs (4). Chest films are diagnostic for radiopaque objects, but most FBs are organic and radiolucent. In these cases, chest films will display secondaryeffects of aspiration on the lungs, including mediastinal shift, obstructive emphysema, atelectasis, and pneumonia. Mediastinal shift will be toward the FB if significant atelectasis has occurred and away from the FB if the ball-valve effect is causing air-trapping. Inspiratory and expiratory films are ideal for visualizing these secondaryeffects; inspiratory films may show mediastinal shift and hyperlucency of the involved hemithorax, and expiratory films accentuate this air-trapping if the ball-valve mechanismis active. In cases where the young or distressed child is unable to cooperatewith inspiratory and expiratory films, right and left decubitus films may demonstrate the ball-valve effect of the FB by imposing a forced expiration on the lung. In one-third of cases,chest films are normal (5). The diagnosis of FB aspiration can be missed. Late diagnosis is defined as a 3-d spanbetween aspiration and diagnosis (or onset of symptoms) (1). Complications are more frequent in casesin which the diagnosis is delayed. The incidence of complications increaseswith the length of time that the FB is neglected: 64% from 4-7 d, 70% from 1.5-30 d, and 95% over 30 d. Some patients will carry a FB in the airway for decades,especially if it is

DISCUSSION The incidence of FB aspiration changeswith the age of the child, gender, geographic location, and situation. Most casesof FB aspiration involve children betweenthe ages of 1 and 3, which seemsto be due to the innate curiosity and oral fixation of children at this age. Boys are more likely to aspiratethan girls, especially abovethe age of 3. In addition, different objects are more frequently aspiratedin different parts of the world. In Western society, peanuts are the most frequent. However, in Greece,it is the pumpkin seed,and in Turkey and Egypt, the watermelon seed.FB aspiration usually occurs during

Figure 2. Cockroach removed at bronchoscopy. Pictured are the macerated, but identifiable, fragments of a cockroach abdomen.

Endobronchial Cockroach

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nonorganic (i.e. metal or plastic). Most, however, will present with respiratory distress within a week (1). Foreign bodies are usually removed at bronchoscopy. Postoperativecomplications occur in about 5% of cases and are usually secondaryto FB inflammatory reactions. These reactions include atelectasis,pneumonia, retained fragments, vocal cord swelling, bronchospasmor laryngospasm,pneumomediastinum,bleeding from FB perforation, and arrest. Once the FB is removed, the prognosis is excellent in most cases(6). A great variety of aspirated objects have been reported. The most frequent are nuts. Vegetable matter and

bones also are frequently aspirated. Metal and plastic objects are less common. Many unusual aspiratedobjects have been reported, including a doll’s shoe(7). safety pin (8), plastic nose of a toy monkey, plastic spoon, plastic whistle, fishing weight, and straight pin. To our knowledge, there has been no previous report in the literature of an aspiratedcockroach. This underscoresthe need for a thorough searchfor an aspiratedFB when dealing with the noncommunicative child who presentswith respiratory distress. We suggest that an additional clue to the diagnosis is a recent change in environment where new and unusual objects are encountered (9).

REFERENCES 1. Mu L, He P, Sun D. The causesand complications of late diagnosis of foreign body aspiration in children. Arch Otolaryngol Head Neck Surg. 1991;117:876-9. 2. Mu L, Ping H, Sun D. Inhalation of foreign bodies in Chinese children: A review of 400 cases.Laryngoscope. 1991;101:657-60. 3. Cohen SR, Lewis GB Jr, Herbert WI, Geller KA. Foreign bodies in the airway. Five-year retrospective study with special reference to management.Ann Otolaryng. 1980$9:437-42. 4. Hoeve LJ, Rombout J, Pot DJ. Foreign body aspiration in children. The diagnostic value of signs, symptoms and pro-operative examination. Clin Otolaryngol. 1993;18:56-7. 5. Mu L, He P, Sun D. Radiological diagnosis of aspirated foreign

6. 7. 8. 9.

bodies in children: Review of 343 cases. J Laryngol Gtol. 1990; 104:778-82. Black RE, Johnson DG, Matlak ME. Bronchoscopic removal of aspirated foreign bodies in children. J Pediatr Surg. 1994:29: 682-4. Kent SE, Watson MG. Laryngeal foreign bodies. J Laryngol Gtol. 1990;104:131-3. Hussain SSM, Raine CH, Caldicott LD, Wade MJ. An open safetypin in the larynx: A casereport. J Laryngol Otol. 1993;108:254-5. Steen KH, Zimmerman T. Tracheobronchial aspiration of foreign bodies in children: A study of 94 cases.Laryngoscope. 1990;1M): 525-30.