Foreign Body Aspiration Into the Lower Airways May Not Be Unusual in Older Adults

(SVC) obstruction seconda1y to mediastinal l ymphadenopathy i n a patient with cystic fibro sis. We have previously reported b enign causes of the syndrome. 2 ·3 The most common b enign causes are fibrosing mediastinitis, mediastinal granuloma, or mediastin al l ymphadenopathy from a hos t of i nf ectious eti ologies. Table 1 classifies the various causes of b enign SVC compression synd rome previously reported in the E nglish-language literature. Beni gn SVC syndrome as a oc mplication of reactive mediasti-

Table !-Reported Causes of Benign Superior Vena Cava Compression Syndrome * Mediasti nitis Tu be rculosis Histoplas mosis Actinomycosis Syphilis Pyogenic Postradi ation Idiopathic Filariasis Nocardia asteroides Mediasti nal tumors Cysti c hygroma Substernal thyroid goiter Benign teratoma Dermoid cyst "Benign" mediastinal thymoma Bronchogenic cyst Vascular Amti c anewysm Arteriovenous fistula Vasculitis Congenital superior vena cava aneurys m Bilateral superior vena cava with th rombosis Idiopath ic th rom bophlebitis with th rom bosis Thrombosis accompanyi ng polycythemia Infected supe rior vena cava th rombus Cardi ac Atrial myxoma Intrapericardial b and Pe ricarditis Mitral stenosis Surgical bypass in congenital heart di sease Complication of ventri culoatrial shunt Complication of transvenous cardiac pacemaker Complicati on of Swan-Ganz catheterization Complication ofcentral venous catheterizati on Complication of Hickm an-Broviac catheterization Complication of LeVeen shunting Cardiac surgery/tamponade Pulmonmy Mediastinal emphysema Pneum othorax T rau matic Medi astin al h ematoma Other causes Beh ~et's synd rome Retrope1itoneal fluid Bilateral clavicular osteomyelitis Silicosis Sarcoidosis *Modified with permission from Mahajan et

la. 2

nallymph adenopathy in a patie nt wi th cystic fib rosis can now be added t o the list of known causes. C. Vaughn Strimlan , MD, FCCP University of Pittsbu1·gh Medical Center/South Side

REFERENCES

1 Chow BJ, McKim DA, Shennib H , et al. Supe rior vena cava obstruction secondary to mediastinal l ymph adenopathy in a patient with cystic fibrosis. Chest 1997; 112:1438-41 2 M ahajan V, Strimlan V, Van Ordstrand HS, et a!. Benign superior vena c ava syndrom e. Chest 1975; 68:32-35 3 Strimlan CV. Superior vena cava syndrome. Cleve Clin JMed 1992; 59:356

Foreign Body Aspiration Into the Lower Airways May Not Be Unusual in Older Adults To t he E dito r: We read with great interest the article by C hen and coworkers (J uly 1997) 1 concerning foreign body aspiration i nto the lower m1ways in adults. Although foreign body aspiration into the lower airways is less common in adults th an in children (as stated b ythe authors), silent aspiration is very common and p ays l an important role in pathogenesis o fpne umoni a in elderly patients.2 ·3 Because the meanage of subjects enrolled in the Chen et a! study was 60.5 years and the oldest participant was 80 years old,1 the results from that study might be influenced b y age-related impairment of swallowing reflex 4 ·5 Therefore , th e different results between Asian and Western adults showing th e nature o f foreign body aspiration were not solely d ue to ace r and table c ustoms , but also to th e effect of aging on swallowing refl ex. It has been recognized that swallowing diso rder and a spiration are ve1y com mon in elderly subjects. 4 ·5 We have recently demonstrated that recurrent silent aspiration causes a c hronic inflammation of bronchioles accompanying the re action t o a foreign body. 6 Interestingly, the patients with diffuse aspiration bronchiolitis mostly demonstrated signs o f bronchorrhea, bronchospasm , and dyspnea in cases of food intake. Although the authors concluded that the initial clues to foreign b ody aspiration in adults were usually obscure and indirect, these signs, including bronchospasm and dyspnea during and following a meal, may be important clues to foreign body aspiration into th e lower airways in o ld e r subjects. We doagree with the recom mendation by Chen et a! offl exible fiberoptic bronchoscopy as the first-line approach fo r the detecti on of foreign b odyaspiration i nto th e lower airways. There is no doubt that their data a re important for the understanding of the pathological p rocess of f oreign b odyaspiration. Howeve r, furth er comparative study behveen younger adults (;5;60 years old) and elderly pati ents (> 65 years old ) about features of f oreign body aspiration into the lowe r airways shoul d prove interesting.

Shinji Teramoto, MD, FCCP Takeshi Matsuse, MD Yasuyoshi Ouchi, MD Department of Geriatrics Tokyo UniGe rsity Hospital Tokyo, japan Reprint m quests: Shinji Teram.oto, MD, FCC P, Dept of Geriatrics, Tokyo University Hospital, 7-3- 1 Hongo Bunkyo-Ku, Tokyo 11 3-8055, Japan CHEST I 113 I 6 I JUNE, 1998

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REFERENCES

1 Chen CH, Lai CL, Tsai TT, et al. Foreign body aspiration into the lower airway in chinese adults. Chest 1997; 112:129-33 2 Kikuchi R, Watabe N, Konno T, et al. High incidence of silent aspiration in elderly patients with community-acquired pneumonia. Am J Respir Clit Care Med 1994; 150:251-53 3 Riquelme R, Torres A, EI-Ebimy M, et al. Communityacquired pneumonia in the elderly: a multivariate analysis of

risk and prognostic factors. Am JRespir Crit Care Med 1996; 154: 1450-55 4 Shaker R, Ren J, Zamir Z, et al. Effect of aging, position, and temperature on the threshold volume trigge1ing pha•yngeal swallows. Gastroenterology 1994; 107:396-402 .5 Feinberg MJ, Knebl J, Tully J, et al. Aspiration and the elderly. Dysphagia 1990; 5:1289-93 6 Matsuse T, Oka T, Kida K, et al. Importance of diffuse aspiration bronchiolitis caused by chronic occult aspiration in the elderly. Chest 1996; 110:1289-93

r~~!l~~~~~~ ~~~::es june 20, 1998 Alfred Soffer Educational Center Northbrook, Illinois

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Communications to the Editor