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Tracheobronchial foreign bodies in children: importance of accurate history and plain chest radiography in delayed presentation
Clinical Radiology (2004) 59, 609–615
Tracheobronchial foreign bodies in children: importance of accurate history and plain chest radiography in delayed presentation B. Tokar*, R. Ozkan, H. Ilhan Departments of Paediatric Surgery and Radiology, Osmangazi University Faculty of Medicine, Eskisehir, Turkey Received 17 November 2003; received in revised form 15 January 2004; accepted 19 January 2004
KEYWORDS Foreign bodies; In air and food passages; Trachea; Stenosis or obstruction; Bronchi; Children; Respiratory system; Radiography; Infants and children
AIM: To evaluate the factors associated with delayed diagnosis of foreign body aspiration (FBA) in children and to compare clinical, radiological and bronchoscopic findings in the patients with suspected FBA. MATERIAL AND METHODS: The medical records of 214 children who underwent bronchoscopy for suspected FBA were reviewed. The data were analysed in three groups: the patients with negative bronchoscopy for FBA (group I), early (group II) and delayed diagnosis (group III). RESULTS: The majority of the patients with FBA were between 1 and 3 years of age. Choking episodes, coughing and decreased breath sounds were determined in a significantly higher number of the patients with FBA. The plain chest radiography revealed radio-opaque foreign bodies (FBs) in 19.7% of all patients with FBA. Emphysema was more common in children with FBA. Clinical and radiological findings of pneumonia and atelectasis were significantly more common in the groups with negative bronchoscopy and with delayed diagnosis ðp , 0:01Þ: The FBs were most frequently of vegetable origin, such as seeds and peanuts. A significant tissue reaction with inflammation was more common in the delayed cases. CONCLUSION: To prevent delayed diagnosis, characteristic symptoms, signs and radiological findings of FBA should be checked in all suspected cases. As clinical and radiological findings of FBA in delayed cases may mimic other disorders, the clinician must be aware of the likelihood of FBA. Regardless of radiological findings, bronchoscopy should be considered in patients with an appropriate history. q 2004 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Introduction As children under 3 years of age tend to place and explore most objects in their mouths, there is a significant risk of foreign body aspiration (FBA). Morbidity and mortality increase in the younger age group, presumably because children of a young age have narrow airways and immature protective *Guarantor and correspondent: B. Tokar, Osmangazi Universitesi, Tıp Fakultesi, Cocuk Cerrahisi AD, Meselik, 26480 TR Eskisehir, Turkey. Tel.: þ90-222-239-2979x3255; fax: þ90222-229-0110. E-mail address: [email protected], barantokar@hotmail. com (B. Tokar)
mechanisms.1 In one series, 78% of those who died after FBA were between 2 months and 4 years of age.2 FBA is a life-threatening emergency and requires prompt removal, but sometimes it may remain undetected due to atypical history or misleading clinical and radiological findings.3,4 Delayed diagnosis can occur when parents under-appreciated symptoms or when physicians overlook clinical and radiological findings. Inflammation and granulation tissue develop around the foreign body (FB) in delayed cases, and thus it is not uncommon for patients to be treated for other disorders such as persistent fever, asthma or recurrent pneumonia for a long period of time.5,6 The diagnosis and
0009-9260/$ - see front matter q 2004 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.crad.2004.01.006
45.7 ^ 51.7 (1.5– 192)
13.6% ðn ¼ 17Þ 57.6% ðn ¼ 72Þ 28.8% ðn ¼ 36Þ 57/68 86.4% ðn ¼ 108Þ 94.4% ðn ¼ 118Þ 24.8% ðn ¼ 31Þ 52.8% ðn ¼ 66Þ 6.4% ðn ¼ 8Þ 1.6 ^ 0.9 (1 h–3 days) 35.5% ðn ¼ 22Þ 56.4% ðn ¼ 35Þ 8.1% ðn ¼ 5Þ 24/38 12.9% ðn ¼ 8Þ 67.8% ðn ¼ 42Þ 33.9% ðn ¼ 21Þ 22.6% ðn ¼ 14Þ 25.8% ðn ¼ 16Þ 18 ^ 23.4 (2–120)
Age and sex of the patients, witnessed ingestions, signs and symptoms determined in the history, physical examinations, and duration of symptoms before bronchoscopy are listed in Table 1. The difference was not significant for sex distribution ðp . 0:05Þ: The mean age difference was significant between groups I and II ðp , 0:01Þ: The number of the patients under the age of 1 year was significantly higher in group I than groups II and III ðp , 0:01Þ; and the number of the patients above the age of 3 years in group I was significantly less than group II. The majority of the patients with FBA were between 1 and 3 years of age, 57.6% and 81.5%, respectively, in groups II and III. There was no significant difference between the groups regarding wheezing, but choking episodes and coughing were determined in a significantly higher number of the patients in groups II and III compared with group I ðp , 0:01Þ: The differences
Table 1 Clinical data of the groups
Clinical findings
17.8 ^ 15.1 (1–60)
Results
Age, months: mean ^ SD (min –max) Age distribution , 1 Years old 1–3 Years old . 3 Years old Gender F/M Witnessed choking Cough Wheezing Decreased breath sound Pneumonia Duration of symptoms (days): mean ^ SD (min– max)
Group I ðn ¼ 62Þ
Group II ðn ¼ 125Þ
Group III ðn ¼ 27Þ
From January 1994 to September 2003, the medical records of 214 children who underwent bronchoscopy for suspected FBA were reviewed. Age and sex of the patients, symptoms and signs, duration of symptoms before bronchoscopy, radiological and bronchoscopic findings including the type and the location of the FB were analysed in three groups. In group I ðn ¼ 62Þ; patients had a negative bronchoscopy for FB; in group II ðn ¼ 125Þ; patients received the diagnosis of FBA within 72 h of aspiration, in the group III ðn ¼ 27Þ the diagnosis of FBA was delayed beyond 72 h after aspiration. The diagnosis of FBA was confirmed by bronchoscopic examination. The statistical analysis was performed with an analysis of variance (ANOVA) followed by Tukey’s procedure and post-Hoc tests and chi-square tests. p-Values less than 0.05 were considered as statistically significant.
28.6 ^ 23.1 (9 –120)
Materials and methods
3.7% ðn ¼ 1Þ 81.5% ðn ¼ 22Þ 14.8% ðn ¼ 4Þ 11/16 77.7% ðn ¼ 21Þ 92.6% ðn ¼ 25Þ 40.7% ðn ¼ 11Þ 59.3% ðn ¼ 16Þ 37% ðn ¼ 10Þ 65.8 d ^ 152.2 (4 days–2 years)
Total ðn ¼ 214Þ
removal of the object becomes much more difficult in such cases. The purpose of this study was to assess the factors associated with delayed diagnosis of FBA and to compare clinical, radiological and bronchoscopic findings of delayed cases in patients who had negative bronchoscopy for FBA and patients who received diagnosis of FBA within 72 h of aspiration.
18.7% ðn ¼ 40Þ 60.3% ðn ¼ 129Þ 21% ðn ¼ 45Þ 92/122 64% ðn ¼ 137Þ 86.4% ðn ¼ 185Þ 29.4% ðn ¼ 63Þ 44.9% ðn ¼ 96Þ 15.8% ðn ¼ 34Þ 14.5 ^ 58.5 (1 h–2 years)
B. Tokar et al.
35.5 ^ 42.9 (1–192)
610
Tracheobronchial foreign bodies in children
611
were not significant between groups II and III for witnessed ingestion associated with a choking episode and coughing. Decreased breath sounds were determined in a significantly higher number of patients in groups II and III than group I ðp , 0:01Þ: The number of the patients who had clinical findings of pneumonia was significantly higher in the groups I and III than group II. The duration of symptoms was significantly longer for the patients in group III compared with the other groups ðp , 0:01Þ:
Radiological findings A plain chest radiograph was routinely obtained in all suspected cases, and only one patient underwent emergency bronchoscopic removal of the FB (a bean in the trachea) without undergoing prebronchoscopic radiography. Paired inspiratory and expiratory films were not routinely feasible due to lack of cooperation. The radiographs of 165 patients were available for review, and for the rest of the patients, previous radiographic reports were used. Radiological findings on plain chest radiography are listed in Table 2. The radiographs revealed radio-opaque FBs in 19.7% of all patients with FBA (Tables 2 and 3). The number of the radio-opaque FBs was significantly higher in group II than group III ðp , 0:05Þ: Emphysema was more common in children with FBA (Fig. 1), and the number of radiographs with a diagnosis of emphysema was significantly higher in groups II ðp , 0:01Þ and III ðp , 0:05Þ than group I. Atelectasis and pneumonia were significantly more common in groups I and III compared with group II ðp , 0:01Þ: The number of normal radiographs was significantly higher in group I than the other groups with FBA ðp , 0:05Þ: The majority of the emphysematous changes were unilateral, only three radiographs in group II with a tracheal FB showed a generalized hyperinflation. There was no bilateral atelectasis. Upper lobe atelectasis was determined in eight radiographs of which six were in the group with negative bronchoscopy findings. Ten records of chest fluoroscopy were found, and eight were positive for air trapping Table 2 Radiological findings on plain chest radiography Group I
Group II
Group III
Visible foreign body Emphysema Atelectasis Pneumonia
– 5 (8%) 18 (29%) 16 (25.8%)
29 (23.4%) 55 (44.4%) 11 (8.9%) 8 (6.4%)
1 (3.7%) 8 (29.6%) 8 (29.6%) 10 (37%)
Normal radiograph
23 (37%)
25 (20.2%)
3 (11%)
Figure 1 Plain chest radiograph showing air trapping on the right with shift of the mediastinum to the left caused by a peanut in the right main bronchus.
and mediastinal shift suggesting FBA, which was later confirmed by bronchoscopy. All these patients had some significant clues in their histories and/or physical examinations, but they had negative radiographs, or the patients were too young to cooperate to produce an appropriate film. Although fluoroscopy did not indicate FBA in two patients, we performed bronchoscopy because of an appropriate history and subsequently found FBs. Seven computed tomography (CT) records of the chest were found. CT was performed for the differential diagnosis of suspected cases having atypical histories, clinical and radiological findings. FBA with a delayed presentation was considered as one of the possible aetiologies. Clinical, radiological and bronchoscopic examinations, including bronchoalveolar lavage, revealed the diagnosis in these cases. Of these seven patients, only one case of FB was detected by bronchoscopy with delayed presentation of obstruction of the right bronchus by a swollen bean. The plain chest radiograph and CT of this case showed atelectasis (Figs. 2 and 3). Other patients had pneumococcal pneumonia, recurrent pneumonia due to gastro-oesophageal reflux ðn ¼ 2Þ; trachea-oesophageal fistula, atelectasis caused by intra-bronchial obstruction due to secretion and mucous plugs of acute tracheobronchitis ðn ¼ 2Þ:
Bronchoscopy findings The types of the aspirated FBs are listed in Table 3. The majority were radiolucent (80.3%) and they were most frequently of vegetable origin. Forty-six
612
B. Tokar et al.
Table 3 Foreign body types Group
Non-radio-opaque foreign bodies Seed
Group II (n ¼ 96a) Group III ðn ¼ 26Þ
Group II ðn ¼ 29Þ Group III ðn ¼ 1Þ a
Peanut
Bean
Nut
Other food
Plastic objects
Soil
Coagulum
36 24 12 8 10 6 4 – Radio-opaque foreign bodies
14 1
2 2
– 2
– 1
Pin
Needle
Pebble
Pen parts
Tooth
Bead
Other metal objects
16 –
4 –
3 –
2 –
1 –
– 1
3 –
Emergency bronchoscopic removal of a bean was performed in one patient without a pre-bronchoscopic radiograph taken.
seeds (most commonly sunflower seeds) and 30 peanuts were the most common FB aspirated. The most frequent radio-opaque FB determined by plain chest radiography and bronchoscopy were pins (Fig. 4). The number of the radio-opaque FBA was significantly less in the group with delayed presentation, and the only radio-opaque object removed in this group was a bead lodged for three weeks in the right bronchus (Fig. 5). The locations of FBs are listed in Table 4. The majority of the FBs were located in the bronchus and there was no statistically significant difference for the left and the right sides for both groups. The review of the bronchoscopy reports showed that significant tissue reaction was more common in the group III. While inflammation and granulation tissue around the object with copious mucoid, purulent secretion was determined in 66.7%
Figure 2 Right side atelectasis on plain chest radiography due to delayed presentation of an obstruction of the right bronchus by a swollen bean.
ðn ¼ 18Þ of the patients in the group with delayed presentation, a serious tissue reaction was determined in only 9.6% ðn ¼ 12Þ of the patients in group II. Minor mucosal reactions to FBs, such as oedema and hyperaemia, were not considered significant tissue responses. In group I, FBs were not found, but pathological changes, such as mucosal oedema or hyperaemia, purulent secretion and mucous plugs were determined in 35.5% ðn ¼ 22Þ of the patients. In all but one of the 152 patients, the FB was removed successfully with rigid bronchoscopes under general anaesthesia. In the patient with a history of pica and aspiration of soil, total removal of the particles and cleaning of the whole respiratory tract was not possible during the initial bronchoscopy, so that a second bronchoscopy was needed. While the majority of the patients in group II were treated as outpatients, with the longest hospital stay of 5 days, the duration of hospital stay for the patients in group III ranged from 2–12 days with the mean duration of 5.8 ^ 3 (mean ^ SD) days.
Figure 3 Right side atelectasis on a CT image of the patient mentioned in the Fig. 2.
Tracheobronchial foreign bodies in children
Figure 4 A plain chest radiograph showing a pin lodged in the right main bronchus.
613
Figure 5 A plain chest radiograph showing a radioopaque bead lodged for 3 weeks in the right main bronchus.
Discussion The diagnosis of FBA can be elusive in delayed cases. Children may present with no history of aspiration or atypical history with non-specific symptoms.3,4,7,8 Accurate history and a high index of suspicion are needed to prevent delayed diagnosis and the complications. Age of the patient is one of the significant criteria in diagnosis of the suspected cases. As we observed in our study, whether it is an early or delayed presentation, approximately 50% of FBA occur below the age of 3 years.7,9 We found that the frequency of FBA increases between 1 and 3 years of age. We also determined that the possibility of negative bronchoscopy in suspected cases is significantly high under the age of 1 year. This may be due to mucous plugs, which can mimic FBA, causing obstruction of the bronchioles because the airways of infants of this age are narrower. The most common signs and symptoms of FBA are choking, coughing, wheezing and decreased breath sounds.10,11 Of all these signs and symptoms, the most predictive one is witnessed aspiration associated with a choking episode. Long-standing FBs can cause significant inflammation and tissue reactions;
and with delayed presentation, additional symptoms and signs of unresolved or recurrent pneumonia and persistent cough may occur.7,9 In our study, we also showed that the clinical signs and symptoms of pneumonia were found in a significantly higher number of the patients with delayed diagnosis. Radio-opacity of FBs prevents misinterpretation of the symptoms and provides an early and accurate diagnosis. In the present study, only 19.7% of all FBs were radio-opaque and we also found that the number of the radio-opaque FBs was significantly less in the group with delayed diagnosis. The type of FB is an important factor that determines the progress of the pathology caused by the lodgement. As we determined in our study, most aspirated FBs are radiolucent and most frequently of food origin.12,13 In children younger than 3 years, 80% of airway FBs are found to be food or other radiolucent items.11 If the clinician only trusts the radiological findings and does not consider an early bronchoscopy in patients with strong history, the diagnosis can be delayed if there are no indirect signs indicating the presence of a radiolucent object on the plain chest radiograph. This is
Table 4 Foreign body locations Diffusea
Group
Trachea
Right bronchus
Left bronchus
Group II Group III
25 2
52 9
42 12
6 4
125 27
Total
27
61
54
10
152
a
Diffuse tracheobronchial or bilateral bronchial lodgement of fragmented or multiple foreign bodies.
Total
614
B. Tokar et al.
important, because the longer a FB is left in situ, the greater the inflammatory response and the likelihood of complications. The inflammatory response is much more significant with food particles. Because of their oil content, most frequently inhaled vegetable matters, such as peanuts, seeds and nuts set up intense inflammatory responses, thus narrowing the airway further, causing consolidation to develop distal to the obstruction. Unilateral obstructive emphysema is the typical indirect radiological sign of a radiolucent object. Hyperinflation due to a check valve obstruction by the object and reflex oligemia due to hypoventilation cause unilateral hyperlucent lung.14 In our study, the most significant indirect radiological signs of FBA we found were emphysema, atelectasis and pneumonia. While emphysema was observed in both early and delayed presentation of FBA, atelectasis and pneumonia were determined significantly in higher number of the patients with delayed diagnosis. In persistent bronchial obstruction, pneumonia develops in 9 –26% of cases.15 – 17 In the present study 11.8% of the patients with FBA had pneumonia, but the number increased significantly with delayed presentation in 37%. In the delayed cases, the bronchoscopic evaluation showing intense inflammatory changes with increased granulation and mucoid secretion confirmed our
Figure 6
prebronchoscopic clinical and radiological findings suggesting pneumonia. Plain chest radiography shows atelectasis in approximately 25% of the patients with FBA.16 – 18 In this study, atelectasis was determined in 12.5% of the patients with FBA, and in the delayed cases it increased to 29.6%. With persistent lodgement, the object may progress distally resulting in complete endobronchial obstruction and mucosal inflammation with oedema, granulation and viscous secretion, which aggravates the pathology and may result in atelectasis. A convincing history and plain chest radiography are two main criteria for the diagnosis of FBA. Combining our experience with that in the literature, we would recommend the algorithm for the diagnosis includes the radiological evaluation and management of FBA (Fig. 6). In the presence of normal radiographs and a strong history, the radiologist and clinician, depending on their experiences and facilities, should decide whether the child should undergo fluoroscopy or bronchoscopy. If an expiratory film cannot be obtained due to lack of cooperation, or negative radiological findings are present, then fluoroscopy may help to detect the presence of a FB. If present, air trapping and shift of mediastinal structures to the opposite side can be easily identified at fluoroscopy. An FB in the main bronchus may initiate an inhibitory reflex causing
Suggested algorithm for the diagnosis and the management of FB aspiration.
Tracheobronchial foreign bodies in children
paradoxical diaphragmatic movement and this could be determined at fluoroscopy.5,9 If it is positive, fluoroscopy can be helpful for the differential diagnosis, but as we observed in our cases it may show no signs of an FB and it can be normal 11 – 45% of the time.7 Although CT occasionally demonstrates an opacity not visualized on the plain film, it should not be considered as one of the initial diagnostic methods for FBA. CT may help with the differential diagnosis of suspected cases having atypical histories, clinical and radiological findings with delayed presentation and complications. The differential diagnosis in such cases include tracheobronchial obstructions caused by external compression of airways (e.g., enlarged lymph node, tumours, cardiac enlargement) or intra-luminal obstructions (e.g., tumours, granulomatous tissue, as in tuberculosis, secretions and mucous plugs as in bacterial pneumonia, cystic fibrosis, asthma, pulmonary abscess and acute laryngotracheobronchitis). Children with FBA may present with atypical or misleading history, clinical and radiological findings. Misdiagnosis such as asthma, pneumonia, croup and reactive airway diseases may lead to a delayed diagnosis. To prevent complications caused by delayed diagnosis, the clinician must maintain a high index of suspicion. In suspected cases, a more extensive history and physical examination should be obtained. Regardless of radiological findings, when FBA is the suspected diagnosis in a patient with a history of a witnessed episode of choking, a transient cyanosis and coughing, an early bronchoscopic examination should be considered. Negative radiography and fluoroscopy should not preclude bronchoscopy in patients with a strong history.
615
2. 3. 4.
5.
6.
7. 8. 9.
10.
11. 12.
13.
14. 15. 16.
17.
References 18. 1. Pasaoglu I, Dogan R, Demircin M, Hatipoglu A, Bozer AY.
Bronchoscopic removal of foreign bodies in children: retrospective analysis of 822 cases. Thorac Cardiovasc Surg 1991; 39:95—8. Mittleman RE. Fatal choking in infants and children. Am J Forensic Med Pathol 1984;5:201—10. Banks W, Potsic WP. Elusive unsuspected foreign bodies in the tracheobronchial tree. Clin Pediatr 1977;16:31—5. Franzese CB, Schweinfurth JM. Delayed diagnosis of a pediatric airway foreign body: case report and review of the literature. Ear Nose Throat 2002;81:655—6. Healy GB. Aerodigestive tract foreign bodies. In: Fallis JC, Filler RM, Lemoine G, editors. Pediatric thoracic surgery. New York: Elsevier; 1991. p. 192—200. Reilly J, Thompson J, MacArthur C, et al. Pediatric aerodigestive foreign body injuries are complications related to timeliness of diagnosis. Laryngoscope 1997;107: 17—20. Messner AH. Pitfalls in the diagnosis of aerodigestive tract foreign bodies. Clin Pediatr 1998;37:359—65. Papsin BC, Friedberg J. Aerodigestive tract foreign bodies in children: pitfalls in management. J Otol 1994;23:102—8. Duncan AW. Emergency chest radiology in children. In: Carty H, editor. Emergency pediatric radiology. Berlin, Germany: Springer-Verlag; 1999. p. 98—102. Darrow DH, Holinger LD. Aerodigestive tract foreign bodies in the older child and adolescent. Ann Otol Rhinol Laryngol 1996;105:267—71. Deskin R, Young G, Hoffman R. Management of pediatric aspirated foreign bodies. Laryngoscope 1997;107:540—3. Zerella JT, Dimler M, McGill LC, Pippus KJ. Foreign body aspiration in children: value of radiography and complications of bronchoscopy. J Pediatr Surg 1998;33: 1651—4. Baharloo F, Veyckemans F, Francis C, Biettlot MP, Rodenstein DO. Tracheobronchial foreign bodies: presentation and management in children and adults. Chest 1999;115: 1357—62. Lange S, Walsh G. Radiology of chest disease, 2nd ed. Stuttgart: Thieme; 1998. p. 132—133. Blazer S, Naveh Y, Friedman A. Foreign body in the airway. A review of 200 cases. Am J Dis Child 1980;134:68—71. Steen KH, Zimmermann T. Tracheobronchial aspiration of foreign bodies in children: a study of 94 cases. Laryngoscope 1990;100:525—30. Mu LC, Sun DQ, He P. Radiological diagnosis of aspirated foreign bodies in children: review of 343 cases. J Laryngol Otol 1990;104:778—82. McGuirt WF, Holmes KD, Feehs R, Browne JD. Tracheobronchial foreign bodies. Laryngoscope 1988;98:615—8.
Tracheobronchial foreign bodies in children: importance of accurate history and plain chest radiography in delayed presentation B. Tokar*, R. Ozkan, H. Ilhan Departments of Paediatric Surgery and Radiology, Osmangazi University Faculty of Medicine, Eskisehir, Turkey Received 17 November 2003; received in revised form 15 January 2004; accepted 19 January 2004
KEYWORDS Foreign bodies; In air and food passages; Trachea; Stenosis or obstruction; Bronchi; Children; Respiratory system; Radiography; Infants and children
AIM: To evaluate the factors associated with delayed diagnosis of foreign body aspiration (FBA) in children and to compare clinical, radiological and bronchoscopic findings in the patients with suspected FBA. MATERIAL AND METHODS: The medical records of 214 children who underwent bronchoscopy for suspected FBA were reviewed. The data were analysed in three groups: the patients with negative bronchoscopy for FBA (group I), early (group II) and delayed diagnosis (group III). RESULTS: The majority of the patients with FBA were between 1 and 3 years of age. Choking episodes, coughing and decreased breath sounds were determined in a significantly higher number of the patients with FBA. The plain chest radiography revealed radio-opaque foreign bodies (FBs) in 19.7% of all patients with FBA. Emphysema was more common in children with FBA. Clinical and radiological findings of pneumonia and atelectasis were significantly more common in the groups with negative bronchoscopy and with delayed diagnosis ðp , 0:01Þ: The FBs were most frequently of vegetable origin, such as seeds and peanuts. A significant tissue reaction with inflammation was more common in the delayed cases. CONCLUSION: To prevent delayed diagnosis, characteristic symptoms, signs and radiological findings of FBA should be checked in all suspected cases. As clinical and radiological findings of FBA in delayed cases may mimic other disorders, the clinician must be aware of the likelihood of FBA. Regardless of radiological findings, bronchoscopy should be considered in patients with an appropriate history. q 2004 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Introduction As children under 3 years of age tend to place and explore most objects in their mouths, there is a significant risk of foreign body aspiration (FBA). Morbidity and mortality increase in the younger age group, presumably because children of a young age have narrow airways and immature protective *Guarantor and correspondent: B. Tokar, Osmangazi Universitesi, Tıp Fakultesi, Cocuk Cerrahisi AD, Meselik, 26480 TR Eskisehir, Turkey. Tel.: þ90-222-239-2979x3255; fax: þ90222-229-0110. E-mail address: [email protected], barantokar@hotmail. com (B. Tokar)
mechanisms.1 In one series, 78% of those who died after FBA were between 2 months and 4 years of age.2 FBA is a life-threatening emergency and requires prompt removal, but sometimes it may remain undetected due to atypical history or misleading clinical and radiological findings.3,4 Delayed diagnosis can occur when parents under-appreciated symptoms or when physicians overlook clinical and radiological findings. Inflammation and granulation tissue develop around the foreign body (FB) in delayed cases, and thus it is not uncommon for patients to be treated for other disorders such as persistent fever, asthma or recurrent pneumonia for a long period of time.5,6 The diagnosis and
0009-9260/$ - see front matter q 2004 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.crad.2004.01.006
45.7 ^ 51.7 (1.5– 192)
13.6% ðn ¼ 17Þ 57.6% ðn ¼ 72Þ 28.8% ðn ¼ 36Þ 57/68 86.4% ðn ¼ 108Þ 94.4% ðn ¼ 118Þ 24.8% ðn ¼ 31Þ 52.8% ðn ¼ 66Þ 6.4% ðn ¼ 8Þ 1.6 ^ 0.9 (1 h–3 days) 35.5% ðn ¼ 22Þ 56.4% ðn ¼ 35Þ 8.1% ðn ¼ 5Þ 24/38 12.9% ðn ¼ 8Þ 67.8% ðn ¼ 42Þ 33.9% ðn ¼ 21Þ 22.6% ðn ¼ 14Þ 25.8% ðn ¼ 16Þ 18 ^ 23.4 (2–120)
Age and sex of the patients, witnessed ingestions, signs and symptoms determined in the history, physical examinations, and duration of symptoms before bronchoscopy are listed in Table 1. The difference was not significant for sex distribution ðp . 0:05Þ: The mean age difference was significant between groups I and II ðp , 0:01Þ: The number of the patients under the age of 1 year was significantly higher in group I than groups II and III ðp , 0:01Þ; and the number of the patients above the age of 3 years in group I was significantly less than group II. The majority of the patients with FBA were between 1 and 3 years of age, 57.6% and 81.5%, respectively, in groups II and III. There was no significant difference between the groups regarding wheezing, but choking episodes and coughing were determined in a significantly higher number of the patients in groups II and III compared with group I ðp , 0:01Þ: The differences
Table 1 Clinical data of the groups
Clinical findings
17.8 ^ 15.1 (1–60)
Results
Age, months: mean ^ SD (min –max) Age distribution , 1 Years old 1–3 Years old . 3 Years old Gender F/M Witnessed choking Cough Wheezing Decreased breath sound Pneumonia Duration of symptoms (days): mean ^ SD (min– max)
Group I ðn ¼ 62Þ
Group II ðn ¼ 125Þ
Group III ðn ¼ 27Þ
From January 1994 to September 2003, the medical records of 214 children who underwent bronchoscopy for suspected FBA were reviewed. Age and sex of the patients, symptoms and signs, duration of symptoms before bronchoscopy, radiological and bronchoscopic findings including the type and the location of the FB were analysed in three groups. In group I ðn ¼ 62Þ; patients had a negative bronchoscopy for FB; in group II ðn ¼ 125Þ; patients received the diagnosis of FBA within 72 h of aspiration, in the group III ðn ¼ 27Þ the diagnosis of FBA was delayed beyond 72 h after aspiration. The diagnosis of FBA was confirmed by bronchoscopic examination. The statistical analysis was performed with an analysis of variance (ANOVA) followed by Tukey’s procedure and post-Hoc tests and chi-square tests. p-Values less than 0.05 were considered as statistically significant.
28.6 ^ 23.1 (9 –120)
Materials and methods
3.7% ðn ¼ 1Þ 81.5% ðn ¼ 22Þ 14.8% ðn ¼ 4Þ 11/16 77.7% ðn ¼ 21Þ 92.6% ðn ¼ 25Þ 40.7% ðn ¼ 11Þ 59.3% ðn ¼ 16Þ 37% ðn ¼ 10Þ 65.8 d ^ 152.2 (4 days–2 years)
Total ðn ¼ 214Þ
removal of the object becomes much more difficult in such cases. The purpose of this study was to assess the factors associated with delayed diagnosis of FBA and to compare clinical, radiological and bronchoscopic findings of delayed cases in patients who had negative bronchoscopy for FBA and patients who received diagnosis of FBA within 72 h of aspiration.
18.7% ðn ¼ 40Þ 60.3% ðn ¼ 129Þ 21% ðn ¼ 45Þ 92/122 64% ðn ¼ 137Þ 86.4% ðn ¼ 185Þ 29.4% ðn ¼ 63Þ 44.9% ðn ¼ 96Þ 15.8% ðn ¼ 34Þ 14.5 ^ 58.5 (1 h–2 years)
B. Tokar et al.
35.5 ^ 42.9 (1–192)
610
Tracheobronchial foreign bodies in children
611
were not significant between groups II and III for witnessed ingestion associated with a choking episode and coughing. Decreased breath sounds were determined in a significantly higher number of patients in groups II and III than group I ðp , 0:01Þ: The number of the patients who had clinical findings of pneumonia was significantly higher in the groups I and III than group II. The duration of symptoms was significantly longer for the patients in group III compared with the other groups ðp , 0:01Þ:
Radiological findings A plain chest radiograph was routinely obtained in all suspected cases, and only one patient underwent emergency bronchoscopic removal of the FB (a bean in the trachea) without undergoing prebronchoscopic radiography. Paired inspiratory and expiratory films were not routinely feasible due to lack of cooperation. The radiographs of 165 patients were available for review, and for the rest of the patients, previous radiographic reports were used. Radiological findings on plain chest radiography are listed in Table 2. The radiographs revealed radio-opaque FBs in 19.7% of all patients with FBA (Tables 2 and 3). The number of the radio-opaque FBs was significantly higher in group II than group III ðp , 0:05Þ: Emphysema was more common in children with FBA (Fig. 1), and the number of radiographs with a diagnosis of emphysema was significantly higher in groups II ðp , 0:01Þ and III ðp , 0:05Þ than group I. Atelectasis and pneumonia were significantly more common in groups I and III compared with group II ðp , 0:01Þ: The number of normal radiographs was significantly higher in group I than the other groups with FBA ðp , 0:05Þ: The majority of the emphysematous changes were unilateral, only three radiographs in group II with a tracheal FB showed a generalized hyperinflation. There was no bilateral atelectasis. Upper lobe atelectasis was determined in eight radiographs of which six were in the group with negative bronchoscopy findings. Ten records of chest fluoroscopy were found, and eight were positive for air trapping Table 2 Radiological findings on plain chest radiography Group I
Group II
Group III
Visible foreign body Emphysema Atelectasis Pneumonia
– 5 (8%) 18 (29%) 16 (25.8%)
29 (23.4%) 55 (44.4%) 11 (8.9%) 8 (6.4%)
1 (3.7%) 8 (29.6%) 8 (29.6%) 10 (37%)
Normal radiograph
23 (37%)
25 (20.2%)
3 (11%)
Figure 1 Plain chest radiograph showing air trapping on the right with shift of the mediastinum to the left caused by a peanut in the right main bronchus.
and mediastinal shift suggesting FBA, which was later confirmed by bronchoscopy. All these patients had some significant clues in their histories and/or physical examinations, but they had negative radiographs, or the patients were too young to cooperate to produce an appropriate film. Although fluoroscopy did not indicate FBA in two patients, we performed bronchoscopy because of an appropriate history and subsequently found FBs. Seven computed tomography (CT) records of the chest were found. CT was performed for the differential diagnosis of suspected cases having atypical histories, clinical and radiological findings. FBA with a delayed presentation was considered as one of the possible aetiologies. Clinical, radiological and bronchoscopic examinations, including bronchoalveolar lavage, revealed the diagnosis in these cases. Of these seven patients, only one case of FB was detected by bronchoscopy with delayed presentation of obstruction of the right bronchus by a swollen bean. The plain chest radiograph and CT of this case showed atelectasis (Figs. 2 and 3). Other patients had pneumococcal pneumonia, recurrent pneumonia due to gastro-oesophageal reflux ðn ¼ 2Þ; trachea-oesophageal fistula, atelectasis caused by intra-bronchial obstruction due to secretion and mucous plugs of acute tracheobronchitis ðn ¼ 2Þ:
Bronchoscopy findings The types of the aspirated FBs are listed in Table 3. The majority were radiolucent (80.3%) and they were most frequently of vegetable origin. Forty-six
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B. Tokar et al.
Table 3 Foreign body types Group
Non-radio-opaque foreign bodies Seed
Group II (n ¼ 96a) Group III ðn ¼ 26Þ
Group II ðn ¼ 29Þ Group III ðn ¼ 1Þ a
Peanut
Bean
Nut
Other food
Plastic objects
Soil
Coagulum
36 24 12 8 10 6 4 – Radio-opaque foreign bodies
14 1
2 2
– 2
– 1
Pin
Needle
Pebble
Pen parts
Tooth
Bead
Other metal objects
16 –
4 –
3 –
2 –
1 –
– 1
3 –
Emergency bronchoscopic removal of a bean was performed in one patient without a pre-bronchoscopic radiograph taken.
seeds (most commonly sunflower seeds) and 30 peanuts were the most common FB aspirated. The most frequent radio-opaque FB determined by plain chest radiography and bronchoscopy were pins (Fig. 4). The number of the radio-opaque FBA was significantly less in the group with delayed presentation, and the only radio-opaque object removed in this group was a bead lodged for three weeks in the right bronchus (Fig. 5). The locations of FBs are listed in Table 4. The majority of the FBs were located in the bronchus and there was no statistically significant difference for the left and the right sides for both groups. The review of the bronchoscopy reports showed that significant tissue reaction was more common in the group III. While inflammation and granulation tissue around the object with copious mucoid, purulent secretion was determined in 66.7%
Figure 2 Right side atelectasis on plain chest radiography due to delayed presentation of an obstruction of the right bronchus by a swollen bean.
ðn ¼ 18Þ of the patients in the group with delayed presentation, a serious tissue reaction was determined in only 9.6% ðn ¼ 12Þ of the patients in group II. Minor mucosal reactions to FBs, such as oedema and hyperaemia, were not considered significant tissue responses. In group I, FBs were not found, but pathological changes, such as mucosal oedema or hyperaemia, purulent secretion and mucous plugs were determined in 35.5% ðn ¼ 22Þ of the patients. In all but one of the 152 patients, the FB was removed successfully with rigid bronchoscopes under general anaesthesia. In the patient with a history of pica and aspiration of soil, total removal of the particles and cleaning of the whole respiratory tract was not possible during the initial bronchoscopy, so that a second bronchoscopy was needed. While the majority of the patients in group II were treated as outpatients, with the longest hospital stay of 5 days, the duration of hospital stay for the patients in group III ranged from 2–12 days with the mean duration of 5.8 ^ 3 (mean ^ SD) days.
Figure 3 Right side atelectasis on a CT image of the patient mentioned in the Fig. 2.
Tracheobronchial foreign bodies in children
Figure 4 A plain chest radiograph showing a pin lodged in the right main bronchus.
613
Figure 5 A plain chest radiograph showing a radioopaque bead lodged for 3 weeks in the right main bronchus.
Discussion The diagnosis of FBA can be elusive in delayed cases. Children may present with no history of aspiration or atypical history with non-specific symptoms.3,4,7,8 Accurate history and a high index of suspicion are needed to prevent delayed diagnosis and the complications. Age of the patient is one of the significant criteria in diagnosis of the suspected cases. As we observed in our study, whether it is an early or delayed presentation, approximately 50% of FBA occur below the age of 3 years.7,9 We found that the frequency of FBA increases between 1 and 3 years of age. We also determined that the possibility of negative bronchoscopy in suspected cases is significantly high under the age of 1 year. This may be due to mucous plugs, which can mimic FBA, causing obstruction of the bronchioles because the airways of infants of this age are narrower. The most common signs and symptoms of FBA are choking, coughing, wheezing and decreased breath sounds.10,11 Of all these signs and symptoms, the most predictive one is witnessed aspiration associated with a choking episode. Long-standing FBs can cause significant inflammation and tissue reactions;
and with delayed presentation, additional symptoms and signs of unresolved or recurrent pneumonia and persistent cough may occur.7,9 In our study, we also showed that the clinical signs and symptoms of pneumonia were found in a significantly higher number of the patients with delayed diagnosis. Radio-opacity of FBs prevents misinterpretation of the symptoms and provides an early and accurate diagnosis. In the present study, only 19.7% of all FBs were radio-opaque and we also found that the number of the radio-opaque FBs was significantly less in the group with delayed diagnosis. The type of FB is an important factor that determines the progress of the pathology caused by the lodgement. As we determined in our study, most aspirated FBs are radiolucent and most frequently of food origin.12,13 In children younger than 3 years, 80% of airway FBs are found to be food or other radiolucent items.11 If the clinician only trusts the radiological findings and does not consider an early bronchoscopy in patients with strong history, the diagnosis can be delayed if there are no indirect signs indicating the presence of a radiolucent object on the plain chest radiograph. This is
Table 4 Foreign body locations Diffusea
Group
Trachea
Right bronchus
Left bronchus
Group II Group III
25 2
52 9
42 12
6 4
125 27
Total
27
61
54
10
152
a
Diffuse tracheobronchial or bilateral bronchial lodgement of fragmented or multiple foreign bodies.
Total
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B. Tokar et al.
important, because the longer a FB is left in situ, the greater the inflammatory response and the likelihood of complications. The inflammatory response is much more significant with food particles. Because of their oil content, most frequently inhaled vegetable matters, such as peanuts, seeds and nuts set up intense inflammatory responses, thus narrowing the airway further, causing consolidation to develop distal to the obstruction. Unilateral obstructive emphysema is the typical indirect radiological sign of a radiolucent object. Hyperinflation due to a check valve obstruction by the object and reflex oligemia due to hypoventilation cause unilateral hyperlucent lung.14 In our study, the most significant indirect radiological signs of FBA we found were emphysema, atelectasis and pneumonia. While emphysema was observed in both early and delayed presentation of FBA, atelectasis and pneumonia were determined significantly in higher number of the patients with delayed diagnosis. In persistent bronchial obstruction, pneumonia develops in 9 –26% of cases.15 – 17 In the present study 11.8% of the patients with FBA had pneumonia, but the number increased significantly with delayed presentation in 37%. In the delayed cases, the bronchoscopic evaluation showing intense inflammatory changes with increased granulation and mucoid secretion confirmed our
Figure 6
prebronchoscopic clinical and radiological findings suggesting pneumonia. Plain chest radiography shows atelectasis in approximately 25% of the patients with FBA.16 – 18 In this study, atelectasis was determined in 12.5% of the patients with FBA, and in the delayed cases it increased to 29.6%. With persistent lodgement, the object may progress distally resulting in complete endobronchial obstruction and mucosal inflammation with oedema, granulation and viscous secretion, which aggravates the pathology and may result in atelectasis. A convincing history and plain chest radiography are two main criteria for the diagnosis of FBA. Combining our experience with that in the literature, we would recommend the algorithm for the diagnosis includes the radiological evaluation and management of FBA (Fig. 6). In the presence of normal radiographs and a strong history, the radiologist and clinician, depending on their experiences and facilities, should decide whether the child should undergo fluoroscopy or bronchoscopy. If an expiratory film cannot be obtained due to lack of cooperation, or negative radiological findings are present, then fluoroscopy may help to detect the presence of a FB. If present, air trapping and shift of mediastinal structures to the opposite side can be easily identified at fluoroscopy. An FB in the main bronchus may initiate an inhibitory reflex causing
Suggested algorithm for the diagnosis and the management of FB aspiration.
Tracheobronchial foreign bodies in children
paradoxical diaphragmatic movement and this could be determined at fluoroscopy.5,9 If it is positive, fluoroscopy can be helpful for the differential diagnosis, but as we observed in our cases it may show no signs of an FB and it can be normal 11 – 45% of the time.7 Although CT occasionally demonstrates an opacity not visualized on the plain film, it should not be considered as one of the initial diagnostic methods for FBA. CT may help with the differential diagnosis of suspected cases having atypical histories, clinical and radiological findings with delayed presentation and complications. The differential diagnosis in such cases include tracheobronchial obstructions caused by external compression of airways (e.g., enlarged lymph node, tumours, cardiac enlargement) or intra-luminal obstructions (e.g., tumours, granulomatous tissue, as in tuberculosis, secretions and mucous plugs as in bacterial pneumonia, cystic fibrosis, asthma, pulmonary abscess and acute laryngotracheobronchitis). Children with FBA may present with atypical or misleading history, clinical and radiological findings. Misdiagnosis such as asthma, pneumonia, croup and reactive airway diseases may lead to a delayed diagnosis. To prevent complications caused by delayed diagnosis, the clinician must maintain a high index of suspicion. In suspected cases, a more extensive history and physical examination should be obtained. Regardless of radiological findings, when FBA is the suspected diagnosis in a patient with a history of a witnessed episode of choking, a transient cyanosis and coughing, an early bronchoscopic examination should be considered. Negative radiography and fluoroscopy should not preclude bronchoscopy in patients with a strong history.
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2. 3. 4.
5.
6.
7. 8. 9.
10.
11. 12.
13.
14. 15. 16.
17.
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