An esophagobronchial fistula caused by an unusual foreign body in the esophagus leading to mediastinitis with fatal outcome

An 8(10)/(12) year old girl with infantile cerebral paresis (ICP), severe mental retardation and seizure disorder was admitted to the intensive care unit (ICU) with clinical signs of aspiration and died ten days later. Final diagnosis was esophagobronchial fistula caused by a foreign body in the esophagus provoking aspiration pneumonia, mediastinitis and respiratory distress syndrome (ARDS). The foreign body was found to be part of a plastic toy. The clinical relevance of aspiration in mentally retarded children and the peculiar nature of the foreign body impacted in the esophagus in this case are discussed. We conclude that in cases of aspiration pneumonia in mentally retarded children the presence of unusual foreign bodies should be suspected.     

Tracheobronchial aspiration of foreign bodies and rigid bronchoscopy in children

Background: A significant proportion of cases of tracheobronchial foreign body aspiration due to life‐threatening condition is observed during childhood. The aim of the present study was to describe our experience with the diagnosis and treatment of foreign body aspirations during childhood and review published literature. Methods: One hundred and eighty‐four patients under 16 years of age with a tentative diagnosis of foreign body aspiration were retrospectively evaluated according to age, sex, patient delay symptoms at presentation, foreign body type, localization and the diagnostic and therapeutic methods used. Results: The most frequently aspirated objects were shelled nuts and seeds such as sunflower seeds, pistachio and hazelnuts. The chief symptom was cough. On physical examination, the most frequent findings were unilateral decrease of respiratory sound on the affected side with coarsening and bronchi. While 51% of cases presented a radiological finding, chest X‐ray was normal in the other. All patients underwent rigid bronchoscopy under general anesthesia and a foreign body was identified in 137 (74.3%). The rigid bronchoscopy intervention was used in some cases, especially in the presence of tracheal foreign bodies of organic origin. Conclusions: Tracheobronchial foreign body aspiration is a significant cause of childhood morbidity and mortality. Early diagnosis and treatment is of utmost importance. Rigid bronchoscopy under general anesthesia should be performed in all patients suspected of foreign body aspiration, which could minimize mortality and morbidity if performed by experienced personnel with safe methods.     

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??Objective To evaluate the clinical characteristics of children with trachea or bronchus foreign body. Methods The data of 84 children with confirmed diagnosis of trachea or bronchus foreign body was retrospectively analyzed in this study form Jun 2011 to Jun 2016 in Tianjin Children Hospital??including general situation??history of foreign body aspiration??medical history??course of disease??foreign body property??clinical and imaging characteristics. Results The rate for tracheobronchial foreign body occurring in boys and girls were 2.23??1 with the main incidence age of 6 months to 3 years old. The incidence rate in countryside was higher than that in city??69.05% vs. 30.95%????especially boys in countryside. Children who are able to provide an accurate history of foreign body aspiration may be helpful in early diagnosis and treatment of trachea or bronchus foreign body??P??0.05??. The main type of foreign body was food??especially nuts. The proportion of bronchial foreign body which remained in the left or right main bronchial tubes was not different??but the number of cases in right lobe was higher than that in the left. The clinical symptom was different according to the different lesions with block of foreign bodies. The main symptom was cough??98.81%?? and breezing??58.33%????with the imaging characteristics of emphysema ??55.95%??. Conclusion In prevention and control of tracheobronchial foreign bodies??boys under the age of 3 should be paid most attention to in rural areas. The children should be reduced contact with nuts food. The guardian must attach more importance to tracheobronchial foreign body. For children with symptom of cough and wheezing weakening breathing sounds on single side by physical examination??emphysema and pulmonary atelectasis on imaging??health providers should pay attention to the history of foreign body aspiration or cough history??and should actively perform bronchoscopy for early diagnosis and treatment.     

Mucus plugging as a cause of acute lobar overdistension

Acute lobar overdistension in children is usually indicative of foreign body aspiration, especially when a history of a choking episode is recalled. An unusual presentation of asthma as recurrent overdistension of the left lung in a toddler is described. The child had undergone two consecutive negative bronchoscopies with a presumptive diagnosis of foreign body aspiration; however, it was only the antiasthmatic treatment that resulted in an excellent outcome.     

肺CT在诊断和治疗小儿气管、支气管异物中的价值

目的 探讨肺CT在诊断和治疗小儿气管、支气管异物中的价值.方法 对怀疑气管、支气管异物的45例患儿进行肺CT检查,应用的是16层超薄CT扫描,条件为:100～150 kV,30～50 mA,层厚1 mm,CT扫描后进行多层CT影像重建.结果 45例患儿中有42例CT检查发现了异物,另外没发现异物的3例经抗生素对症治疗1周痊愈,避免了支气管镜检术.根据CT影像及异物特点,我们设计了手术方案并选择合适的异物钳,42例患儿均一次即将异物取出,肺CT所显示的异物位置、形状及体积与支气管镜检时所见基本一致.结论 应用肺CT可以准确地诊断出气管、支气管异物,CT所提示的异物位置、形状、体积对于设计手术方案和安全取出异物具有重要价值.     

Tracheobronchial foreign bodies

Ojective : Foreign body inhalation is an extremely serious problem in children and sometimes result in sudden death. The current mortality rate from foreign body inhalation is between 0% and 1.8% according to various studies. In spite of this, undiagnosed and unsuspected foreign bodies still occur in the airway.dMethods : Pediatric patients with documented foreign body inhalation, treated in the Department of Pediatrics, Bapuji Hospital, JJM Medical College during 1997-2000 are included in the analysis. Children with or without positive history of aspiration were examined and the diagnosis was made on the basis of history, clinical findings, radilogic evaluation and strong index of suspicion in those children where reasonable appropriate treatment failed to resolve the respiratory symptoms. Bronchoscopy was performed for a suspected foreign body on 165 children.Result : A review of 165 pediatric cases of suspected foreign body aspiration revealed, children between 1 and 3 years were found to be very vulnerable for aspiration. Majority of children were boys. Over 70% of the patients had positive history of inhalation. Only 60% of the patients presented immediately, that is within 24 hours after aspiration. Common symptoms were cough and respiratory distress. Physical examination showed abnormal finding in 91% of cases. Decreased air entry was the significant clinical sign. Obstructive emphysema was found in majority of the cases (49.5%). Rigid bronchoscopy under general anaesthesia was the preferred method for removal of aspirated foreign body. In 65 (61.9%) cases foreign body was lodged in the right main bronchus and majority of these were organic in nature, that is 96(91.43%).Conclusion : Tracheobronchial foreign bodies should be strongly suspected in pediatric age group who present with a suggestive history, even when physical and radiographie evidence is absent. The modalities of diagnosis, management and outcome are discussed.     

Complicated and dislodged airway foreign body in an intubated child: case report

OBJECTIVE: We report a case of missed foreign body aspiration in a child presenting with status epilepticus. On admission, the patient was found to have pneumonia, which progressed to respiratory failure and acute respiratory distress syndrome. While the patient was intubated and mechanically ventilated, the patient experienced acute respiratory deterioration. Subsequently, it was determined that a previously undetected foreign body had dislodged from the right main to the left main bronchus and was the underlying cause for the child's illness. CONCLUSIONS: A combination of sudden change of physical and radiographic findings with unilateral lung hyperinflation is highly suspicious for an obstructing airway foreign body. This case demonstrates that foreign body aspiration can lead to significant morbidity. It should be in the differential diagnosis for any acute pulmonary process in an otherwise well child because there is no specific clinical or radiographic finding to rule it out.     

Foreign body aspiration

OBJECTIVE:To analyze the clinical and radiological profile of foreign body aspiration in children reaching a tertiary care center and identify areas of possible interventions for proper management of such cases. SETTING: Tertiary level teaching hospital. SUBJECTS: Case records of patients suspected to have foreign body aspiration over the past four years were analyzed. Clinico-radiological features, types and location of foreign bodies were studied. RESULTS: Of 75 children who underwent rigid bronchoscopy, 70 had tracheo-bronchial foreign bodies. History of choking was elicited in 90 percent cases. In 30 percent cases chest radiographs were non-contributory, while the commonest finding (63 percent) was distal emphysema. Over three-fourth of the cases were below the age of 2 years. Vegetative foreign bodies, mainly peanuts, were commonly present. In many cases, referral was delayed as the diagnosis was missed initially. CONCLUSION: Foreign body aspiration remains a common unintentional childhood injury due to improper exposure of young children to otherwise innocuous looking nuts and other small objects.     

Value of chest CT in the diagnosis and management of tracheobronchial foreign bodies

Background: The aim of the present study was to investigate the value of chest multidetector computed tomography (CT) in the evaluation of children with suspected foreign body aspiration. Methods: Chest CT was performed in 45 consecutive children with suspected foreign body aspiration, and plain chest X‐ray was conducted at the same time. Multiplanar reformatted imaging was carried out after multidetector CT. Rigid bronchoscopy and removal of the foreign body was performed under general anesthesia. Results: All 42 patients (100%) with tracheobronchial foreign bodies were identified on chest CT. Three patients avoided unnecessary operations due to negative CT scans. For the patients with tracheobronchial foreign bodies, the occurrence of unilateral hyperlucent lung and post‐obstructive lobar or segmental infiltrates on plain chest X‐ray was 42.9% (18/42) and 4.8% (2/42), respectively. Twenty‐two of the 42 patients (52.4%) had no abnormalities on plain X‐ray. The difference between multidetector CT and plain X‐ray results was statistically significant (P < 0.001). Surgical plans were designed and appropriate foreign body forceps were selected based on the CT scans. All foreign bodies were removed successfully, and no severe complications were observed. The location, shape, and volume of the foreign bodies found at surgery were consistent with the CT images. Conclusions: The diagnosis of foreign body aspiration of the airway in children can be accomplished by using chest multidetector CT. It is often useful in delineating the exact shape, location, volume and form of a bronchial foreign body and can help the surgeon plan for operative bronchoscopy and safe removal of the foreign body.     

Foreign body aspiration in children: diagnosis and treatment

A total of 235 children, aged between 7 months and 15 years had bronchoscopy on suspicion of foreign body aspiration. The histories of these patients were studied to examine the diagnostic value of symptoms, signs, and chest x-rays, and rate of negative bronchoscopy. The sensitivity of choking and coughing was high (82% and 80%), but the specificity was poor (37% and 34%). The sensitivity of a chest radiograph was 66%, the specificity was 51%. The sensitivity of asymmetric auscultation was 80% and specificity was 72%. The sensitivity and specificity of combination of symptoms, signs and abnormal chest radiograph was 61% and 83%, respectively. In 206 (87.7%) children a foreign body was identified and extracted. The remaining 29 patients (12.3%) had negative bronchoscopy. A wide variety of objects was recovered, the most common being seeds and peanuts. Foreign bodies were in the right and left main bronchus in 72 (35%), 50 (24.3%) cases, respectively, while in the remaining 84 cases, the foreign bodies were in other parts of the respiratory tree. In 204 (99%) patients with foreign body aspiration, the foreign bodies were removed successfully using a rigid bronchoscopy. Minor complications like subglottic edema and bronchospasm occurred in 4 children. In conclusion, rigid bronchoscopy is a safe procedure and the only tool that will give certainty about the correct diagnosis of foreign body aspiration in children. Asymmetric auscultation is more specific than history and chest radiograph. The combination of history, clinical signs and radiological signs are more specific than each one separately.     

Three-dimensional computed tomography for detection of tracheobronchial foreign body aspiration in children

Foreign body aspiration (FBA) into the tracheobronchial tree is a frequent and serious cause of respiratory problems in children. Chest X-ray (CXR) is often inaccurate in diagnosing FBA when the object is radiolucent. Three-dimensional computed tomography (CT) is a noninvasive technique that can detect the narrowing of the airway resulting from the presence of a foreign body. We conducted a retrospective study comparing the performance of CT scan and CXR in the diagnosis of FBA. Eleven patients (mean age 2.1 years) with a history suggestive of foreign body aspiration were examined by three-dimensional chest CT and CXR during the study. The presence of foreign bodies was confirmed and they were removed by rigid or flexible bronchoscopy under general anesthesia. Foreign body aspiration (FBA) was detected in all the 11 patients by CT scan (sensitivity, 100%), but CXR of three of the patients showed no evidence of FBA (sensitivity, 72.7%). The foreign bodies were located in the right main bronchus (n = 4), the left main bronchus (n = 5), and the trachea (n = 2). The mean length of hospital stay was 3.8 days. In our study, three-dimensional chest CT scan was more sensitive than CXR in detecting the presence of aspirated foreign bodies in children. The superior sensitivity and short time required for CT should help to reduce delays in diagnosis. These benefits may prompt further studies to determine whether CT could be used to reduce the number of unnecessary bronchoscopies performed in children being evaluated for FBA.     

Normal radiographic findings after foreign body aspiration. When the history counts

Foreign body aspiration in children is frequently associated with unilateral emphysema or atelectasis on chest x-ray. Two cases are reported of tracheal or bilateral foreign bodies in which the original chest x-rays were read as normal, but the history was suggestive of the foreign body aspiration. Early bronchoscopy can prevent the long-term morbidity that results from unrecognized tracheobronchial foreign bodies.     

Tracheobronchomalacia presenting as infantile wheeze

We report six months old infant with a history of recurrent wheeze, admitted for foreign body aspiration like presentation, where fibreoptic bronchoscopy revealed the diagnosis of tracheobronchomalacia.     

数字X线成像与多排螺旋CT对小儿呼吸道透X线异物检出效果的比较

目的 探讨小儿呼吸道透X线异物的临床特点,比较数字X线成像(DR)与16排螺旋CT对其的检出效果.方法 收集本院2007年1月-2011年1月收治的50例经纤维支气管镜检查证实为呼吸道异物患儿的临床资料.男28例,女22例;年龄10个月～11岁.有明确异物吸入史31例,可疑异物吸入史并伴相应症状3例.患儿均经DR行胸部正侧位检查,以及16排螺旋CT检查和CT呼吸道三维重建.结果 31例患儿首诊有异物吸入史,均有不同程度刺激性呛咳、发热、喘鸣等.体格检查发现呼吸音减弱32例,发绀21例,三凹征19例.50例患儿胸部DR均不能直接发现透X线异物;16排螺旋CT三维重建模拟支气管镜可直接发现呼吸道透X线异物.异物附着在管壁上或嵌顿于管腔内.胸壁双边影15例;节段性肺不张12例;纵隔双边影或纵隔移位8例;支气管扩张18例;肺部感染8例;肺野静止征16例.CT的诊断阳性符合率为96％,DR为62％.结论 16排螺旋CT对小儿呼吸道透X线异物的诊断及手术定位具有重要价值,与DR相比具有明显的优势.     

Foreign body aspiration. An atypical clinical case

The case of a 3-year-old female with an atypical presentation of foreign body aspiration is described. Resistance to the therapy, mild radiological signs and a high index of suspicion of the clinician could lead to the right diagnosis.     

Foreign body aspiration in children: diagnostic and therapeutic role of bronchoscopy

Purpose  

Assessment of bronchoscopy usefulness for diagnosis and treatment in children suspected of foreign body aspiration.     

How accurate is chest radiography in the diagnosis of tracheobronchial foreign bodies in children?

The radiographic and endoscopic findings of 83 consecutive patients with suspected foreign body (FB) inhalation into the tracheobronchial tree were compared and the accuracy of chest radiography was estimated. Typical radiologic signs of FB aspiration, such as localized air trapping, atelectasis and infection occurred on radiographs of patients with and without FB. Twenty-four percent of patients with endoscopically verified FB had no abnormalities on chest radiography. In an analysis of radiographs of 83 consecutive patients, in which the prevalence of FB aspiration was 41%, the diagnostic accuracy was 67%, sensitivity 68% and specificity 67%. Plain film radiology alone is not a sufficiently sensitive nor specific method for the diagnosis of FB aspiration.     

Esophageal and tracheobronchial foreign bodies in infants and children

In an effort to improve the diagnosis and management of children with aspiration or ingestion of foreign bodies we reviewed 100 consecutive cases of esophageal (49) or tracheobronchial (51) foreign bodies occurring over a 6-year period. While the incidence of positive physical findings in the esophageal group was low, the combination of plain and contrast radiography was positive in 96% (47/49). Of the patients with tracheobronchial foreign body, 78% (40/51) had lateralizing signs on physical examination and 80% (41/51) had abnormal inspiratory/expiratory radiographs. Disimpaction of esophageal foreign bodies was carried out using a combination of techniques with 100% success and no complications. All cases of tracheobronchial foreign bodies were managed with the rigid bronchoscope with 98% success (50/51) using a variety of instruments. Complications secondary to the foreign body itself rather than its management were seen in 9 patients, and were often due to a delay in diagnosis. A careful history and physical examination along with appropriate radiographic studies will result in a correct diagnosis in virtually all cases of esophageal and tracheobronchial foreign bodies. A liberal indication for endoscopy using an approach tailored to the particular case will almost always be successful. Offprint requests to: J. R. Wesley     

Acute foreign body aspiration as a respiratory emergency in childhood

From 1957 to 1987 altogether 206 cases of tracheobronchial foreign body aspiration were diagnosed. Two third of the patients were one or two years old. Boys prevailed with 57 per cent. 55 per cent of all foreign bodies were nuts. Only 10 per cent were radiopaque (screws, nails, needles or pieces of bones). The attempt to eliminate the foreign body via the bronchoscope was successful in 96 per cent and failed in seven cases. Six children had to undergo a thoracotomy. In one third of the cases the foreign body remained two weeks or longer in the bronchial tree. 66 children with such a "chronic" foreign body were later on examined by bronchography, which showed in 29 per cent severe deformations of the bronchial wall and in 14 per cent even bronchiectasis. An acute foreign body aspiration should always be considered and handled as an emergency.     

Foreign bodies in the tracheobronchial tree: a review of 102 cases in Benghazi, Libya

A total of 102 children in whom foreign body aspiration was suspected were admitted to hospital and their records reviewed. Bronchoscopy was performed on all except two who coughed out the foreign body. In 76 cases (group A), foreign bodies were identified in the tracheobronchial tree. In the remaining 26 (group B), no foreign body was found. Boys predominated over girls. Most of the foreign bodies were lodged on the right side. The commonest foreign body was the peanut. Clinical and radiological features in group A were not diagnostic; in many instances, therefore, the threshold of suspicion of aspiration should be low. Hence, medical personnel and the public should be made more aware of this problem.