Foreign body aspiration in children: The value of diagnostic criteria

Objective

Foreign body aspiration (FBA) is a serious problem in children. While bronchoscopy should be performed in all patients with aspiration; patients without aspiration should be carefully excluded to avoid an unnecessary bronchoscopy. In this study we analyzed the details of our series, complication rates and compared the diagnostic findings between patients with an aspirated FB and those without. We also calculated the sensitivities, specificities, positive predictive values and negative predictive values of clinical history, symptoms, physical examination findings and radiological findings in patients with suspected FBA (sFBA). Finally, we evaluated the validity of our bronchoscopy indications in these patients.

Methods

We reviewed the data of 207 patients who underwent rigid bronchoscopy for sFBA. We used clinical history, symptoms, physical examination and radiological findings as diagnostic findings. Complication rates in addition to these four diagnostic criteria constitute our indications for performing a rigid bronchoscopy.

Results

After excluding 15 patients with radiopaque FB or previous fiberoptic bronchoscopy, 138 of 192 patients had an aspirated foreign body. The sensitivity and specificity of clinical history, symptoms, physical examination findings and radiological findings were 90.5% and 24.1%, 97.8% and 7.4%, 96.4% and 46.3, and 71.7% and 74.1% respectively. There was only one major complication which caused moderate neurological sequelae. There was no mortality and no thoracotomy or tracheotomy requirement in this group.

Conclusions

While symptoms, physical examination findings and clinical history had high sensitivities, radiological findings had the highest specificity. Low specificities of clinical history, symptoms and physical examination findings were due to our expanded bronchoscopy indication, which aimed to include all patients with foreign body aspiration. Our low complication rate facilitated the expansion of bronchoscopy indications, even for patients with slight clinical suspicion.     

The complimentary role of diagnostic and therapeutic endoscopy in foreign body aspiration in children

Objective

To review the importance and benefits of flexible bronchoscopy and rigid bronchoscopy in airway foreign body inhalation in children. Prompt diagnosis will lead to safer outcomes when both types of endoscopy are employed within the operating room setting.

Methods

Retrospective review of all cases of foreign body inhalation seen and treated in our Department between July 1986 and December 2010.

Results

Three-hundred and ten children were admitted to our Department from Pediatric Emergency Room for a suspected foreign body inhalation. All patients with suspected FB inhalation underwent bronchoscopy. Of 310 evaluations of tracheobronchial tree performed at our Department, 104 were negative, while an airway FB were observed and removed in 206 cases.

Conclusions

Rigid bronchoscopy under general anesthesia is an extremely accurate surgical technique to identify, localize and remove airway foreign body. In our experience, flexible bronchoscopy under total intravenous sedation and topical anesthesia is very useful in doubtful cases to absolutely exclude the presence of foreign body in upper airway tracheobronchial tree.     

The occurrence of adenoidal signs and symptoms in normal children*

A characteristic clinical picture has been attributed to enlarged adenoids. In order to investigate this concept the occurrence of certain signs and symptoms was compared in a series of children selected for adenoidectomy and in a series of normal children. Nasal obstruction, snoring and speech defect occurred more frequently in children having adenoidectomy. The symptoms of rhinorrhoea, cough and headache and the signs of mouth breathing and abnormality on anterior rhinoscopy occurred as frequently in normal children as in children having adenoidectomy.     

Management of suspected foreign body aspiration in children1

We aimed to establish prevailing consultant opinion on the management of children with a history suggestive of foreign body (FB) aspiration but no clinical or radiological findings. FB aspiration is a common problem in children. Most agree that bronchoscopy should be performed if a child has clinical or radiological signs. With suggestive history but no such signs, the decision is more difficult; both bronchoscopy and neglected FBs have the potential for serious consequences. A postal questionnaire was sent to all British Association of Otolaryngologists and Head and Neck Surgeon (BAO‐HNS) consultants. The 563 questionnaires sent elicited a 63% reply rate. With suspected organic FBs, 52% would bronchoscope immediately, 38% would observe, and 10% would discharge. With suspected inorganic FBs, 35% would bronchoscope, 42% would observe, and 23% would discharge. Thus, the majority suggest admission, showing a preference for bronchoscopy with a history of organic FB, and observation if inorganic. Unless justified, it may be unacceptable to discharge these patients.     

儿童气管支气管异物诊治中应关注的问题

气管支气管异物是儿童耳鼻咽喉头颈外科常见病,具有起病急,病情进展快的特点,严重时可危及生命。本文结合湖南省儿童医院35年气管支气管异物的救治经验,对该病的发展概况、诊断、手术、术后处理、并发症处理及健康教育等方面进行阐述,希望对儿童气管支气管异物的防治工作具有借鉴和参考作用。     

Foreign body aspiration in children: Experience from 2624 patients

Objectives

The objective of this study is to analyze the epidemiological, clinical, radiological and endoscopic characteristics of pediatric foreign body aspiration in Algeria.

Methods

In this retrospective study, the results of 2624 children younger than 18 years admitted in our department for respiratory foreign body removal between 1989 and 2012, were presented. Most of them had an ambulatory rigid bronchoscopy.

Results

The children (62.34% males and 37.65% females) were aged 4 months to 18 years with 66% between 1 and 3 years. Choking was related in 65% of cases. The delay between aspiration and removal was 2–8 days in 65.8% and within 24 h in 9.2%. In the most cases, the children arrived with cough, laryngeal or bronchial signs and unilateral reduction of vesicular murmur. The examination was normal in 13%. The most common radiologic finding was pulmonary air trapping (40.7%). The aspirated bodies were organic in 66.7%, dominated by peanuts, while sunflower seeds, beans and ears of wheat were the most dangerous. In the other cases, they were metallic or plastic as pen caps and recently scarf pins. The endoscopic removal by rigid bronchoscopy was successful and complete in 97%. Cases with extraction failure (3%) limited to certain FBs, all of them inorganic were assigned to surgery. The complications related to the endoscopic procedure were 0.29% with a mortality of 0.26%.

Conclusion

Foreign body aspiration is a real public health problem in Algeria. The best way to manage it is an early diagnosis and a rigid bronchoscopy removal under general anesthesia used by fully trained staff. The prevention of this domestic accident should consider the population lifestyle and cultural habits to be more effective.     

Foreign body aspiration in children: A nationwide survey in Japan

Background

Foreign body aspiration (FBA) is a common cause for a respiratory emergency in young children and can be a life-threatening event. We, therefore, conducted the first nationwide survey in Japan.

Methods

We asked doctors of 261 tertiary hospitals across the nation to fill out a case card of FBA-diagnosed cases they had experienced for the past 2 years. In the case card, age and gender of the patients, elapsed time until being referred to the hospital, presenting symptoms, previous diagnosis, suspected aspiration episode, type and location of aspirated foreign body, and consequences were inquired. This retrospective survey was carried out during 21 months, since January 2005 through September 2006.

Results

Replies from 169 hospitals (64.8%) revealed that 163 cases of FBA had been treated in 114 hospitals during the past 2 years. Median age of cases was 1 year (2 months to 15 years), and 66.5% were male. Only 50.9% of the cases were referred to hospitals within 24 h. Comparing these early-diagnosed cases, children with delayed diagnosis had similar age and sex distribution. In respect of presenting symptoms, characteristic ones such as choking or dyspnea were observed significantly more often in the early-diagnosed cases, whereas significantly predominant symptoms in children with delayed diagnosis were non-specific ones like coughing and wheezing (both, p < 0.05). Although significantly more cases with early diagnosis reported suspected aspiration episodes (p < 0.05), even in the delayed diagnosis group more than half cases (65%) had suspected episodes as well. Severe consequences occurred in seven cases (4.3%): four cases of irreversible hypoxic brain damage and one death due to multiorgan failure in the early diagnosis group; one bronchiectasis and one recurrent pneumonia in the delayed diagnosis group.

Conclusions

Characteristics of FBA among children in Japan were not substantially different from the reports from other countries. Suspected episodes were important, and there were some differences in presenting symptoms between early and delayed diagnosis cases. However, there are still no key sings to make a prompt diagnosis. In order to prevent FBA and make a timely diagnosis, continuous and extensive educational programs should be provided.     

Foreign body in bronchus: An unusual presentation

Exogenous foreign bodies in the trachea bronchial tree are not uncomion particularly in children. Children who are not given proper individual attention at an early age are more hable to ingest or inhale foreign body.     

Foreign body aspiration, a continuously growing challenge: Tanta University experience in Egypt

Objective

To evaluate the different factors that affect the spectrum and frequency of foreign body (FB) aspiration as a growing problem in different ages, and express the experience of our department in managing the problem in the recent two decades.

Methods

The charts of 3600 patients who underwent bronchoscopic evaluation over a period of 20 years for a suspicion of FB inhalation were reviewed. The patients were divided according to the age into group A; up to 10 years, and group B; more than 10 years. Each group was investigated and compared with the other with respect to sex, history of FB aspiration, time elapsed between aspiration and hospital admission, clinical and radiographic findings, and FB location, type, retrieval, and complications. Seasonal, geographic, and socio-cultural factors and frequency of FB aspiration in relation to the study period were also recorded.

Results

In group A, boys were affected more than girls (1.3:1), while in group B, females were affected more than males (40.5:1). Among history positive patients in group A (72.8%) and B (96.8%), FB was detected in 88% and 97% respectively, while among history negative patients, FB was found higher in group A (49%) than group B (25%). The time elapsed before admission was longer in group A than group B. Cough was the most prominent symptom, while decreased breath sounds was the commonest sign in both groups. Pneumatic infiltration was the most frequent radiographic finding in group A (33.6%), while radio-opaque FB was higher in group B (94.1%). Peanut (67.3%) and seeds (21.2%) were the commonest FBs detected in group A, whereas, headscarf pins (91.3%) were predominant in group B. Foreign bodies were almost equally distributed in the laryngotracheobronchial tree in group A, while the left bronchial tree was much more affected in group B. Rigid bronchoscopy was used in groups A and B with a success rate of 99.8% and 99.7% respectively, while flexible bronchoscopy was only used in 0.2% in group B. Complications such as laryngotracheal edema (16.6%) and pneumothorax (2.3%) were encountered in group A more than group B (3.1%, 1.2%) and there was no mortality. Most of the aspirated FBs were recorded during summer months and commonly detected in patients of low socio-cultural status in both groups.

Conclusion

Foreign body aspiration is a continuously growing problem in Lower Egypt affecting all ages with two peaks at 3 and 14 years old. The rate of FB aspiration was affected by age; sex; traditions and believes; and seasonal, geographic, and socio-cultural factors. A high index of suspicion, rapid hospital admission, and bronchoscopic evaluation by experienced specialists were crucial for successful retrieval of the FB with low rate of morbidity. Public awareness through mass media needs attention to decrease the growing rate of this problem.     

Foreign bodies in the tracheobronchial tree: A prospective study of fifty cases

Aspirated foreign bodies continue to present challenges to the otorhinolaryngologists—the major issues being accurate diagnosis and speedy and safe removal of the foreign bodies. Tracheobronchial foreign bodies are most common in the 1–3 year age group and are usually of vegetative origin. The most common signs and symptoms of tracheobronchial foreign bodies are cough, wheeze and decreased air entry on the affected side. Diagnostic bronchoscopy is recommended in all children presenting with a history of sudden onset of cough, choking spell, an unexplained acute wheeze, or a chronic pulmonary infection. The present study was undertaken to study the varied clinical presentations of tracheobronchial foreign bodies.     

利用听力学指标进行耳鸣客观辨证的临床研究

目的 探讨听力学指标进行耳鸣客观辨证的临床应用价值。方法 以主观性耳鸣为主要症状且除耳鸣的主症外别无兼症可辨致使中医辨证分型困难的患者作为人选对象，根据病程长短不同按分层随机化的原则，以2：1的比例随机分为实验组与对照组，实验组进行系统的听力学检测取得相关指标，利用前期工作中建立的以听力学指标为基础的多元判别函数进行客观辨证，根据辨证结果进行诊断性治疗用药；对照组统一视为肾精亏损进行治疗用药，4周后评定近期疗效。结果 实验组64例，有效率71．9％；对照组37例，有效率48．6％。两组疗效差异具有统计学意义（P〈0．05）。结论 依据多项听力学指标建立的判别函数对无典型中医证候的耳鸣进行客观辨证具有一定的应用前景。     

Treatment of 38 cases of foreign body aspiration in children causing life-threatening complications

Objectives

The objectives of this study were to discuss the clinical magnifications and therapies of tracheobronchial foreign body aspiration (FBA) in children causing life-threatening complications.

Method

We retrospectively reviewed 38 cases of FBA with serious complications in children out of 749 cases of FBA in children that had been admitted to and treated in the Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China, from June 1990 to December 2007. The complications included pneumothorax (14 cases); pneumomediastinum (6 cases); pulmonary abscess (7 cases); massive hemorrhage, tracheoesophageal fistula and exudative pleurisy, in 3 cases, respectively; and heart failure (2 cases). Each child's symptoms, including duration, physical findings, chest radiographs, including CT, and the nature of the foreign body causing the complications due to FBA were recorded.

Results

Among the 38 cases of FBA, the FBs in 36 cases were removed by bronchoscopy, and in 2 cases the FBs were removed via thoracotomy. Except for 1 case that resulted in death, the other 37 children were completely cured and discharged to home from the hospital.

Conclusions

For children with FBA who experience severe and life-threatening complications from FBA, our recommendation is that emergency measures should be available during FBs removal. With correct judgment and management of the complications of FBA, the mortality rate can be reduced.     

Efficacy of manual jet ventilation using Manujet III for bronchoscopic airway foreign body removal in children

Objectives

To evaluate the efficacy of a manual jet ventilation device for bronchoscopic removal of foreign bodies in children.

Methods

360 children aged from 10 months to 12 years old undergoing rigid bronchoscopy for airway foreign body (FB) removal from February 2005 to June 2009 were included in the study. Patients were randomly divided into three groups of 120 patients per group (S, P and J). In group S, anesthesia was induced with propofol and γ-hydroxybutyrate sodium and maintained by intermittent bolus administration of propofol; the patients were breathing spontaneously throughout the procedure. In group P, anesthesia was induced with propofol (4-5 mg/kg), fentanyl (1-2 μg/kg) and succinylcholine (2 mg/kg). Mechanical ventilation was performed through the side arm of the rigid bronchoscope. In group J, the patient received propofol, fentanyl and succinylcholine as the same doses administered in group P, and manual jet ventilation was performed by using the Manujet III device. Condition for insertion of bronchoscope, occurrence of hypoxemia, successful rate of FB removal, the duration of the operation, the time of emergence and recovery from anesthesia, and perioperative complications (adverse events) were recorded.

Results

Groups P and J had significantly higher rates of successful bronchoscope insertion (P < 0.05), significantly higher success rates for FB removal (P < 0.05), and lower incidences of hypoxemia during intra- and post-operative periods when compared with group S. Perioperative complications were lower (P < 0.05), duration of operation was shorter, and emergence from anesthesia was faster (P < 0.05) in groups P and J when compared with group S. Incidences of hypoxemia were lower in Group J when compared with Group P (P < 0.05).

Conclusion

This study confirmed the safety and efficacy of performing manual jet ventilation with Manujet III in foreign body removal by rigid bronchoscopy in children.     

Prevalence of broncopulmonary and otorhinolaryngologic symptoms in children under investigation for gastroesophageal reflux disease: retrospective analysis

Gastroesophageal reflux disease (GERD) is a common ailment in children, adding up to the evidence that gastroesophageal reflux is an important cofactor in upper airway disorders, especially in the pediatric population. It is very common for it to impact the upper and lower airways. Our goal was to assess the presence of otorhinolaryngological symptoms in children aged between one and twelve years in whom gastroesophageal reflux is suspected.Materials and methodsWe assessed data from the charts of patients up to 12 years of age submitted to 24 hour pH measuring of one of two channels, placed at 2 and 5 cm from the LEE in order to confirm the diagnosis of Gastroesophageal Reflux Disease.ResultsWe studied 143 charts from children who underwent 24 hour pH measuring to investigate GERD; however, only 65 were included. The most prevalent symptoms in the children were bronchopulmonary, found in 89.2%, of sinonasal symptoms (72.3%), otologic (46.1%) and repetition UAW infections (44.6%). When we compared the presence of each group of symptoms of the results from the pH measuring, no significant differences were found between the symptoms and the pH measuring results.ConclusionGERD can manifest in different ways and otorhinolaryngological symptoms are frequent in children.     

Late diagnosis of foreign body aspiration in children with chronic respiratory symptoms

BACKGROUND: Children with undiagnosed and retained foreign bodies (FBs) may present with persistent respiratory symptoms. Delayed diagnosis is an important problem in developing countries and several factors affect the delay. OBJECTIVES: To investigate, the incidence of clinically unsuspected foreign body aspiration (FBA) in our flexible bronchoscopy procedures, the causes resulting in late diagnosis of FBA, and the incidence of the complications of FBA according to elapsed time between aspiration and diagnosis. METHODS: We reviewed the records of all the patients who underwent flexible bronchoscopy between 1997 and 2004 in our clinic. Patients with FBA were identified and their medical records were reviewed. RESULTS: During the study period, 654 children underwent flexible bronchoscopy; 32 cases (4.8%) of FBA were identified. Median age of patients was 29.5 months at presentation with a median symptomatic period of 3 months. None of the patients had a history of FBA. The most common misdiagnosis was bronchitis. Flexible bronchoscopy was performed to these patients within 1 week following presentation. In 87% of the patients (n=28), FBs were in organic nature. Patients were followed up for 21.0 months after removal of the FBs. Fifty-three percent (n=17) of the patients had a complete remission after bronchoscopic removal of the FBs. However, nine (28.8%) patients had chronic respiratory problems and six patients (18.8%) developed bronchiectasis. CONCLUSIONS: Atypical or prolonged respiratory symptoms should alert the physician and clinical and radiological findings should be carefully evaluated for a possible FBA. Delay in diagnosis and treatment of FBA should be avoided to prevent complications.     

Glottic foreign body in a child with pre-existing vocal cord paralysis and reflux laryngitis: A challenging diagnostic paradigm

Purpose: To illustrate the challenge and approach to diagnosing a laryngeal foreign body (FB) in a child with pre-existing laryngeal pathology. Methods: Case report. The diagnosis of laryngeal FB was initially missed in a 21-month old-infant. Two weeks later, the child experienced worsening in symptoms. Results: Flexible laryngoscopy revealed the presence of a plastic object in the subglottis, which was then removed under general anesthesia. Conclusions: For children with pre-existing laryngeal pathology, a sudden unexplained worsening of laryngeal symptoms, particularly dysphonia and biphasic stridor, should prompt the clinician to consider the possibility of a thin, sharp laryngeal FB.     

Foreign body inhalation in children: Decisive factors for carrying out bronchoscopy

Inhalation of Foreign Body is one of the most common causes of accidental death at home in the paediatric age group. There may not be a clear history of foreign body inhalation and the patient may be asymptomatic at initial presentation. This coupled with the failure of radiological investigations on most occasions makes this a vexing clinical situation. These apparently normal children almost invariably have a bad prognosis if the foreign body is ignored. This study aims to define the most important factors influencing the decision to carry out the definitive surgery, i.e., bronchoscopy, which can be diagnostic as well as therapeutic, based on our experience with 50 cases of suspected FB in the tracheobronchial tree from January 2001 to July 2003. Results from the study suggest that radiological investigations have only limited value in deciding the management of a patient with suspected Foreign Body inhalation. This should not influence the decision to carry out a bronchoscopy, which should rather be based on history and clinical examination.