Radiological diagnosis of aspirated foreign bodies in children: review of 343 cases

Foreign Body Accidents in a Pediatric Emergency Department

Introduction  Foreign body accidents (FBAs) are frequent in children and can be severe, being a common cause of morbidity and mortality and a public health problem. As these accidents are multifactorial, their cause can only be determined by analyzing the clinical details and characteristics of the object. Knowing the associated mechanisms and factors is essential to determine a risk profile and have a preventive, therapeutic, and diagnostic purpose. Objective  The present study aimed to describe the incidence of FBAs in otorhinolaryngology according to their anatomical location, focusing on the aerodigestive system. Methods  This is a retrospective study performed by reviewing the medical records of 668 cases seen in the emergency department of a tertiary pediatric hospital in São Paulo, state of São Paulo, Brazil, between 2014 and 2017. Results  Foreign bodies (FBs) were found in the digestive system (238/668), in the nasal cavities (206/668), in the ears (182/668), in the oropharynx (34/668), and in the respiratory system (8/668). A total of 91.77% of the patients were treated in the emergency room. The main age group affected was < 5 years old, with no difference between genders. The most frequent complications affected the digestive system and the most serious occurred in cases involving the respiratory system. Conclusion  Multidisciplinary teams should be ready in the emergency room to provide adequate care in FBAs. Early diagnosis, FB removal in the emergency room or the surgical center and follow-up are essential. Developing prevention campaigns including a risk profile for certain products and/or materials, helping to ensure safety for consumers, is necessary. For this, a national database with compulsory notification containing relevant information on FBAs in the pediatric population should be created.

A Pictorial Review of Radiologic Findings of Foreign Bodies in the Thorax

Thoracic foreign bodies (FBs) are serious and relatively frequent in emergency departments. Thoracic FBs may occur in association with aspiration, ingestion, trauma, or iatrogenic causes. Imaging plays an important role in the identification of FBs and their dimensions, structures, and locations, before the initiation of interventional treatment. To guide proper clinical management, radiologists should be aware of the radiologic presentations and the consequences of thoracic FBs. In this pictorial essay, we reviewed the optimal imaging settings to identify FBs in the thorax, classified thoracic FBs into four types according to their etiology, and reviewed the characteristic imaging features and the possible complications.

Clinico-Radiological Profile and Outcome of Airway Foreign Body Aspiration in Children: A Single-Center Experience From a Tertiary Care Center in Eastern India

Background

Foreign body aspiration is one of the leading causes of childhood morbidity and mortality among older infants and toddler age groups. Missed and delayed diagnosis of foreign body aspiration can lead to increased incidence of complications. Early diagnosis can prevent life-threatening complications and morbidity. In this study, we aimed to evaluate the clinical and radiological details, types, localization of foreign bodies, complications, and outcomes in pediatric patients who presented to our hospital with foreign body aspiration.

Methodology

We conducted a retrospective analysis of hospital case records of children aged one month to 14 years who were admitted to the Department of Pediatrics between June 2018 and May 2020, with clinical suspicion of foreign body aspiration.

Results

A total of 22 children with a diagnosis of airway foreign body were included. The mean age of presentation was three years (SD: ±2.22), with a boy-to-girl ratio of 3.4:1. Cough (81.8%) and tachypnea (72.7%) were the most common clinical symptoms. The median duration between symptom onset and diagnosis was three (interquartile range: 6) days. Unilateral reduced breath sound (81.8%) was the most common clinical examination finding. The common site of impaction was the right main bronchus in 59.1% of cases. The foreign bodies retrieved during bronchoscopy were organic substances in 63.6% of cases, with peanuts being the most common (31.8%). Chest radiographs were normal in 36.3% of cases, and common abnormalities included hyperinflation, collapse, consolidation, and mediastinal shift. Mechanical ventilation was required in 54.5% of cases. The mean duration of hospitalization was five (SD: ±2.84) days. Complications such as pneumothorax were seen in one (4.5%) case. Mortality was seen in 4.54% of cases during the bronchoscopic procedures.

Conclusions

Foreign body aspiration was common in young male children, with cough being the common symptom. Normal X-rays of the chest were seen in one-third of cases. The common site of impaction was the right main bronchus, and organic substances such as peanuts were common foreign bodies retrieved. Strong clinical suspicion of foreign body aspiration should be kept in cases with acute onset of cough in young children. Prompt medical attention is needed to reduce the morbidity and mortality associated with foreign body aspiration.

When is asthma not guilty?

Asthma is a common childhood condition. Its prevalence in Saudi Arabia is high, increasing, and could exceed 20% at the current trajectory. Asthma is a syndrome with different clinical presentations and phenotypes. Many conditions are often misdiagnosed as asthma because they share the same symptoms, particularly coughing and shortness of breath; physical findings, such as wheezing; radiological findings, such as hyperinflation on chest X-ray; or even responses to asthma therapies, as in some patients with bronchiolitis. When treating the younger age group (>5 years old), there should be a high degree of suspicion of alternative causes when evaluating patients presenting with clinical features suggestive of asthma or patients who do not respond well to asthma therapies. This study will highlight common conditions that may mimic asthma and, as a result of incorrect treatment, unnecessarily expose patients to steroids and other therapies for extended periods. Furthermore, we seek to alert healthcare providers to common symptoms and signs that suggest a cause other than asthma and suggest when to refer the patient to subspecialists.

Aspiration of the dental crown in an elderly patient

The aspiration of objects and foreign bodies requires quick and systematic care. During emergent orotracheal intubation, accidental dental crown release can cause a threat to the patient's life. This paper aimed to report a case of foreign body (dental prosthetic crown) aspiration and its management and discuss alternative approaches. An 81-year-old male patient, who was admitted to the hospital's intensive care unit (ICU) for meningitis, presented with altered consciousness, and decreased oxygen saturation. He underwent emergent orotracheal intubation. After intubation, chest radiography was performed to check for proper orotracheal tube positioning and lung expansion. The resultant images revealed the presence of a foreign body within the right lower lobe bronchus in the shape of a dental crown. The foreign body, intubation cannula and basket clamp were successfully removed, followed by reintubation of the patient. The foreign body was a prosthetic upper premolar dental crown (24). While care should be taken to avoid complications, if a foreign body is aspirated during emergent orotracheal intubation, endoscopic removal appears safe and effective. Careful creation, placement, maintenance, and preservation of prosthetic crowns are critically important in elderly patients.

Asymptomatic fixed partial denture aspiration: A case report

Introduction and importance

Foreign body aspiration (FBA) is more frequently presented in children and considered a rare presentation in adults. One of the most common causes of FBA in adults are orthodontic appliances.

Case presentation

We present a case of a 70-year-old male with an accidently discovered fixed partial denture (bridge) in the right mainstem bronchus. The partial denture was removed successfully by flexible bronchoscopy.

Clinical discussion

FBA is an event that most frequently occurs with children, and rarely with adults having various risk factors and complications on patients.

Conclusion

This study aims to spotlight the danger of asymptomatic FBA and how retrieving sharp objects can be managed by flexible bronchoscopy thus leading to better management and increased awareness of such cases.

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Foreign Body Aspiration (FBA) is very uncommon in adults.

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Dental procedures and appliances are considered the second most common leading cause of FBA.

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High level of physicians' susception is needed to identify FBA cases in adults is needed.

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Flexible bronchoscopy has an important role in retrieving aspirated foreign bodies.

Recurrent Respiratory Tract Infection in a 24-Year-Old Female Secondary to a Foreign Body Aspiration

Foreign body aspiration (FBA) is a common problem necessitating prompt recognition and early treatment to minimize the potentially severe and sometimes fatal consequences. We presented a 24-year-old girl who was admitted for chronic cough and recurrent pneumonia associated with constitutional symptoms. She was feverish with a temperature of 39°C and had tachycardia and tachypnoea with an oxygen saturation of 98%. Investigations revealed leukocytosis. CXR showed right lower lobe consolidation, and CT thorax demonstrated collapse consolidation of the right middle and lower lobe, along with associated dilated segmental bronchioles and diffuse patch ground-glass opacity in both lung fields. Bronchoscopy revealed a pen cap at the entrance of the right lower lobe. Patient symptoms improved after removal of the foreign body. In patients with recurrent chest infection, the physician should check for the possibility of FBA and prompt for a referral to a tertiary center for further evaluation.

Risk factors affecting the treatment outcome of pediatric foreign body aspiration: significance of time factors

PURPOSE

The aim of this study was to identify the factors affecting the prognosis of children with foreign body aspiration (FBA) after undergoing rigid bronchoscopy.

METHODS

This was a case series with a chart review of 49 children under 3 years of age who underwent rigid bronchoscopy for suspected FBA at a single tertiary institution.

RESULTS

The time from symptom onset to hospitalization positively correlated with the total hospitalization time (p < 0.001), postoperative hospitalization time (p = 0.006), and operation time (p = 0.013). The time from symptom onset to operation positively correlated with the total hospitalization time (p < 0.001) and operation time (p = 0.046). The time from hospitalization to operation and the operation time positively correlated with the total hospitalization time (p = 0.026, 0.044) and postoperative hospitalization time (p = 0.049, 0.003). The time from symptom onset to hospitalization positively correlated with the incidence of pneumonia (p = 0.028).

CONCLUSION

Rapid hospitalization after symptom onset, rapid surgery after symptom onset, and rapid surgery after hospitalization improve the prognosis of patients with FBA. Further, a short operation time also plays a role in improving patient prognosis.

Foreign Body Aspiration in Infants and Older Children: A Comparative Study

BACKGROUND

Foreign body aspiration (FBA) is a major cause of morbidity and mortality in children. It is a preventable event that predominates in preschool age. The signs and symptoms mimic respiratory diseases common in the same age-group. We compared FBA in infants to FBA in older children.

METHODS

Retrospective analysis of all the cases of suspected FBA of children under the age of 18 years hospitalized at one medical center during 2002 to 2016. We analyzed the data according to age: up to 1 year (infants) and 1 to 18 years.

RESULTS

One hundred seventy-five children with suspected FBA were admitted; of whom, 27 (15%) were infants and 148 (85%) were older children (age 1-18 years). For the 2 age groups, adults witnessed 85% and 73%, respectively, of the incidents (P = .4). In the neonate group, 48% presented with normal X-ray findings compared to only 20% in the older group; 15% of the older group had a positive chest X-ray for a foreign body, while none had such in the infants' group (P = .01). For the 2 age groups, the majority of the FBs found were from organic origin. About half of the patients were diagnosed and managed within 24 hours of the aspiration event. In 10%, repeated bronchoscopy was performed due to a retained FB remnant. In a multivariate analysis, signs and symptoms (P < .05), location of the FB (P < .001), and witnessed aspiration (P < .001) were independent prognostic factors for the length of hospitalization.

CONCLUSION

Foreign body aspiration is not uncommon in young infants; the management is challenging due to small airways, the need to use smaller bronchoscopes, and the lack of working channel forces in pediatric bronchoscopes.

Inhaled Foreign Body Impaction: A Review of Literature in Malaysian Children

Foreign body aspiration in children is a problem that can lead to several complications, including death. In this retrospective publication review from 1970 to 2015, there were altogether 42 Malaysian children below the age of 15 y reported with foreign body (FB) ingestion. There were 31 boys and 11 girls between 2 and 177 mo of age. The incidence of FB ingestion in children varied with dietary practices. Peanut was the most common food-related substance inhaled followed by watermelon seed and coconut kernel. The most common non-food related substances were metal objects (toys, springs, hair clips) and plastic objects (ballpoint tips, pencil caps and whistles). Successful removal of FB by bronchoscopy is achieved in the vast majority of cases except for a case of impacted whistle inhalation and a neglected laryngeal FB which required a tracheostomy. One child required thoracotomy for the removal of a peanut in the right bronchus. The incidence of food-related substance inhalation was more common than non-food related substance (30:7). From this review, the key messages are two: first, prevention can be achieved by educating parents not to allow access to small objects or dangerous foods to children below 3 y age; Second, emergency first aid home measures, in the combination form of back blows in the head down position and chest or abdominal thrusts, should be early performed according to the pediatric age group and can be quite effective.

Death as a Consequence of Foreign Body Aspiration in Children

Aim:

To analyze the rate of mortality in children with foreign body aspiration (FBA).

Methods:

We outlined a retrospective review of hospital data of patients between 1971 and 2013. FBA occurring in children 0 year to 14 years was considered for inclusion (patient ages ranged from 0.6 to 15 years, with a median age of 2.2 years). The gender structure within the investigated cases was 75.8% males and 24.2% females. During the study period, 772 patients undergoing rigid bronchoscopy with the diagnosis of FBA were included. Deaths on arrival were excluded.

Results:

Total rate of mortality (for whole investigated period) was 0.785. For last fifteen years of the investigated period the rate of mortality was zero.

Conclusion:

For prevention of foreign body aspiration in children and its mortality should be taken two strategies: non-medical (alterations in product design and public education campaigns) and medical (education of medical staff and improvement of equipment).

Endobronchial Foreign Body Presenting as Exacerbation of Asthma

Airway foreign bodies are a leading cause of death among children and require urgent recognition by medical personnel. While most cases are diagnosed readily from a clinical history of acute respiratory distress, some cases remain more indolent and present later. We report the case of a 7-year-old boy who aspirated a "LEGO" toy and presented with a week history of increasing respiratory distress compatible with known asthma. Despite a normal chest X-ray, a low-dose computed tomography showed the presence of a foreign body in the left main bronchus, which was subsequently removed by fiberoptic bronchoscopy. Our case serves to reemphasize the importance of considering airway foreign bodies as a cause of respiratory distress, especially in young children.

Tracheobronchial Foreign Bodies in Children: The Role of Emergency Rigid Bronchoscopy

Foreign body aspiration (FBA) is a common and lethal accident in the pediatric age group. It requires early recognition and treatment by rigid bronchoscopy to avoid fatal outcomes. Objective. The aim of this study was to study the pattern of FBA in the tracheobronchial tree as well as the success rate of rigid bronchoscopy in children admitted to a single center and to analyze the relationship of the type of foreign body (FB) with patients' age, presentation, and complications. Methods. A retrospective cross-sectional study of FBA was conducted in children in the Sulaimani/Kurdistan region, Iraq, admitted to the emergency teaching hospital of the University of Sulaimani from January 2014 to March 2016. Result. Data of 83 patients between 6 months and 15 years old were studied. The most affected was the 1- to 5-year-old group. There was a slight female predominance (male to female ratio 0.93:1). The most common FB was sunflower seed (49.4%). History of choking was present in 92.8% of patients; 55.4% had normal air entry, and 37.3% had no added sound on chest auscultation. Normal chest X-ray (CXR) was found in 40% of patients. The most common site was the right bronchial tree (39.8%). Two patients needed mechanical ventilation; both of them died. There was a significant relationship between the type of FB (P = .013, .000, respectively). Conclusion. Medical history is the most important factor for reaching the diagnosis; bronchoscopy is mandatory if choking was witnessed, even if examination and CXR are normal. Organic material causes more local reaction than nonorganic material.

Pediatric Pulmonary Hemorrhage vs. Extrapulmonary Bleeding in the Differential Diagnosis of Hemoptysis

Introduction

Hemoptysis is an important symptom which causes a major concern, and warrants immediate diagnostic attention. The authors compared a group of patients with pediatric pulmonary hemorrhage with pediatric patients diagnosed with extrapulmonary bleeding focusing on differences in etiology, outcome and differential diagnosis of hemoptysis.

Methods

We performed the retrospective analysis of medical charts of 134 pediatric patients admitted to the Emergency Department because of pulmonary and extrapulmonary hemorrhage and were diagnosed with suspected hemoptysis or developed hemoptysis (ICD10-CM code R04.2). The cases with pulmonary hemorrhage (Group 1) were compared with cases of extrapulmonary bleeding (Group 2) using the Fisher Exact test or Pearson's χ² test for categorical variables. The t-test was used to assess differences between continuous variables of the patients in the two groups.

Results

Bloody cough was the presenting symptom in 73.9% of cases. 30 patients had pulmonary hemorrhage (Group 1), while 104 patients had extrapulmonary bleeding (Group 2). The underlying causes of bleeding in Group 2 included epistaxis, inflammatory diseases of nasopharynx and larynx, foreign bodies, gingivitis, and hypertrophy of adenoids. Mortality rate was 10% in Group 1, whereas Group 2 did not have any mortality outcomes during the observation period. Etiologycal factors were significantly different between hemoptysis and extrapulmonary bleeding in children.

Conclusions

Our research suggested that pulmonary and extrapulmonary bleeding are two conditions that differ significantly and cannot be unified under one diagnostic code. It is important to differentiate between focal and diffuse cases, and between pulmonary and extrapulmonary hemorrhage due to the diversity of clinical courses and outcomes.

Foreign Body Aspiration in Northern Ghana: A Review of Pediatric Patients

Background

Foreign body (FB) aspiration requires a high index of suspicion for diagnosis and prompt management to avoid morbidity and mortality. This retrospective study was conducted to review pediatric foreign body aspiration at the Ear, Nose and Throat (ENT) Unit of the Tamale Teaching Hospital (TTH).

Materials and Methods

The theater records of children managed for foreign body aspiration from January 2010 to December 2016 at the ENT Unit of TTH were retrieved and data summarized with respect to age, gender, indications for bronchoscopy, nature of foreign body, location of foreign body, and outcome of the bronchoscopy procedure.

Results

A total of 33 children were managed within the five-year study period and comprised 16 (48.5%) males and 17 (51.5%) females. The commonly aspirated FBs were groundnuts (13, 39.4%) and metallic objects (7, 21.1%). The peak incidence occurred in children aged ≤ 3 years. The foreign bodies (FBs) were commonly localized to the right (24.2%) and left (24.2%) main bronchi, respectively. One patient had emergency tracheostomy for failed bronchoscopy.

Conclusion

Groundnuts were the most commonly aspirated foreign body with most of the FBs localized in the bronchi.

Aspiration of Aluminum Beverage Can Tab: Case Report and Literature Review

We describe the case of a 16-year-old male who aspirated a beverage can tab resulting in significant functional impairment. Since the introduction of beverage can opening tabs (“pop-tops” or “pull-tabs”) nearly 50 years ago, five cases of their aspiration have been reported in the literature and this is the first case to report tracheal lodgment. We describe the clinical course for this patient including the inadequacy of radiographic evaluation and a significant delay in diagnosis. We highlight unique features of small aluminum foreign bodies that require consideration and mention a potential change in epidemiology associated with evolving product design. Our primary objective is increased awareness among otolaryngologists that radiography is unreliable for diagnosis or localization of small aluminum foreign bodies. The patient history must therefore be incorporated with other imaging modalities and/or endoscopic evaluation. Also, given the marked prevalence of aluminum beverage cans, we suspect that the inadvertent aspiration of can tabs is more common than indicated by the paucity of published reports.

Lessons Learned From 35 Cases of Laryngeal Foreign Bodies Undergoing Misdiagnosis in Pediatric Population

OBJECTIVES

To present 35 cases of laryngeal foreign bodies (FBs) in pediatric population undergoing misdiagnosis so as to draw on our lessons to improve early diagnosis.

METHODS

A retrospective analysis over 15 years was conducted of 35 cases of laryngeal FBs undergoing misdiagnosis in children. Meanwhile, a control group, including 42 cases of laryngeal FBs without misdiagnosis in children, was set. These patients' clinical data were collected and analyzed to identify the risk factors for misdiagnosis.

RESULTS

The results of chi-square test and univariate analysis both showed a significant difference in time elapsed between discomforts and admission, witnessed foreign body (FB) aspiration history, biphasic stridor, aphonia, roentgenologic findings, and type and size of FBs between the misdiagnosed group and control group. Multivariate analysis further identified delayed doctor visits, unwitnessed FB aspiration history, nonspecific symptoms, and negative roentgenologic manifestations as independent risk factors for misdiagnosis.

CONCLUSIONS

Diagnosis of laryngeal FBs, especially small, thin, and radiolucent FBs, remains a challenge. We emphasized the importance of timely doctor visits, careful clinical history inquisition, and prompt performance of radiographic or endoscopic examinations for diagnosis.

Review of tracheobronchial foreign body aspiration in the South African paediatric age group

Children, and in particular young children under the age of three, are the most vulnerable for aspiration and ingestion of foreign bodies (FBs). The Red Cross War Memorial Children's Hospital in Cape Town is the only children's hospital in South Africa and is unique in having a dedicated trauma unit for children under the age of 13 as part of its institution. Core activities of Childsafe South Africa (CSA), located at the hospital, are data accumulation and interpretation, development of educational programmes, health inculcation and advising in legislation involving child health. To achieve this task, CSA works in close co-operation with government, industry, non-governmental and community predicated organisations, community groups and individuals. A database of all children treated for trauma at CSA has been maintained since 1991; it currently contains detailed information of over 170,000 injuries in children under the age of 13. This review consists of a literature review combined with data from our database and aims to provide information on our experiences with tracheobronchial aspiration of FBs in children.

Foreign Bodies in Trachea: A 25-years of Experience

OBJECTIVE

Tracheobronchial foreign body aspirations may cause cardiopulmonary arrest and sudden death. The incidence in children is higher than in adults. Rapid diagnosis and treatment is live saving. In this paper, we aimed to present our experience in tracheal foreign body aspirations and rigid bronchoscopy for 25-years.

MATERIALS AND METHODS

From January 1990 to January 2015, 805 patients with suspected tracheobronchial foreign body aspiration were admitted to our department. Hundred and twelve patients with tracheal foreign body were included in this study. We evaluated patients' records, retrospectively. Age, gender, clinical symptoms, physical examination findings, radiological evidences, type of foreign body and intervention types were noted.

RESULTS

Sixty-five of the patients were female (58%) and 47 patients were male (42%), and mean age was 8.1 years (8 month-58 years). Coughing was the main symptom (n=112, 100%). Other symptoms and findings included dyspnoea and bilateral decreased lung sounds (n=73, 65.1%), bilateral rhonchi (n=68, 60.7%) and cyanosis (n=41, 36.6%). Rigid bronchoscopy was performed in all patients. The most common foreign body was nuts (n=75, 67%). The main radiologic finding was radiopaque image of the related foreign body in 27 patients (n=27, 24.1%). Cardio-pulmonary arrest occurred in 11 patients and two of them died.

CONCLUSION

Tracheobronchial aspirations of foreign bodies are life-threatening events. If not diagnosed and treated rapidly, distressful results can be seen. Warning people by skilled persons on this topic will reduce the incidence of foreign body aspirations.

Role of Computed Tomography in Pediatric Chest Conditions

CT is the preferred cross-sectional imaging modality for detailed evaluation of anatomy and pathology of the lung and tracheobronchial tree, and plays a complimentary role in the evaluation of certain chest wall, mediastinal, and cardiac abnormalities. The article provides an overview of indications and different types of CT chest, findings in common clinical conditions, and briefly touches upon the role of each team member in optimizing and thus reducing radiation dose.

A case control study of the factors associated with occurrence of aerodigestive foreign bodies in children in a regional referral hospital in South Western Uganda

Background

Aerodigestive foreign bodies (ADFB) in children are a common emergency in ENT clinics globally. The aim of this study was to determine the prevalence and common types of ADFB’s presenting to a referral hospital in South Western Uganda, and to review clinical presentation and factors that influence their occurrence among children under 12 years of age.

Methods

We conducted a case control study comprising 40 cases and 80 unmatched controls. Consecutive and random sampling were used for the cases and controls respectively. A questionnaire was used to collect data. Clinic records were reviewed to calculate prevalence.

Results

Prevalence was 6.6 % of all paediatric cases seen in the ENT department that year. The most common symptoms included: history of choking [45 %], sudden cough [72.5 %], stridor [60 %] and failure to swallow [35 %]. The most common location for an airway foreign body was the right main bronchus [40 %] and the upper one third of the oesophagus [32.5 %] for digestive tract foreign bodies. Seeds and coins were most frequently removed. Children from upper level SES had a significantly lower risk of foreign body occurrence [OR = 0.29, p = 0.02] compared to those from a low SES. Also significantly, most cases were referrals from other government health centres [p = <0.01]. The male to female ratio among cases was 2:1. Children of older mothers were less likely to have an ADFB.

Conclusion

Prevalence of ADFB’s is relatively high. The most common symptoms are a history of choking, cough and failure to swallow. Age under 5 years, male sex, younger maternal age and low socioeconomic status increased odds of ADFBs.

Importance of back blow maneuvers in a 6 month old patient with sudden upper airway obstruction

Foreign body aspiration in children under four years old is one of the most frequently observed reasons for accident related deaths. It is more common in this age group due to inadequate swallowing functions and exploration of objects with the mouth. The most frequently encountered foreign bodies are food and toy parts. Life threatening complete laryngeal obstruction is rarely observed. Dyspnea, hypersalivation, cough and cyanosis can be seen. The basic and life-saving treatment approach is complete removal of foreign body maneuvers in the sudden onset of total obstruction. Here we report a six-month old male, who ingested a foreign body and was treated with back blow maneuvers successfully. In this case we emphasized the importance of back blow maneuvers.

Subcutaneous emphysema: Unique presentation of a foreign body in the airway

Foreign body airway (FBA) is a common problem among the children. Variable presentation makes it difficult to diagnose a case of FBA, particularly, when no definite history of aspiration is available. Subcutaneous emphysema (SCE) and pneumomediastinum are rare presentations. We report a case of FBA who presented with SCE without any history of aspiration. A 3-year-old female child was admitted with respiratory distress, fever and SCE over the right side of chest, neck and face. Initially, she was diagnosed as a case of pneumonitis with barotrauma. X-ray of the chest revealed SCE with pneumomediastinum without pneumothorax. Diagnostic bronchoscopy with rigid ventilating bronchoscope was done under general anesthesia. A plastic foreign body with sharp projections embedded in the mucosa was detected and retrieved from right main bronchus. Postoperatively SCE regressed gradually.

Review of Ingested and Aspirated Foreign Bodies in Children and Their Clinical Significance for Radiologists

Ingested and aspirated foreign bodies are a common occurrence in children and are important causes of morbidity and mortality in the pediatric population. Imaging plays an important role in the diagnosis of ingested and aspirated foreign bodies in children and can be crucial to guiding the clinical management of these patients. Prompt identification and localization of ingested foreign bodies is essential to determining the appropriate treatment, as several types of commonly ingested foreign bodies require urgent removal and others can be managed conservatively. In particular, disk batteries impacted in the esophagus carry a high risk of esophageal injury or perforation; multiple ingested magnets can become attracted to each other across bowel walls and cause bowel perforation and fistula formation; and sharp objects commonly cause complications as they pass through the gastrointestinal tract. Accordingly, these ingested foreign bodies warrant aggressive clinical management and therefore radiologists must be familiar with their imaging appearances and clinical implications. Prompt recognition of secondary radiographic signs of foreign-body aspiration is also crucial, as clinical symptoms can sometimes be nonspecific and most aspirated foreign bodies are radiolucent. Overall, radiography is the most important modality in the evaluation of ingested or aspirated foreign bodies; however, fluoroscopy and computed tomography play an ancillary role in complicated cases. It is essential that every radiologist who interprets imaging examinations of children be aware of the imaging appearances of commonly ingested and aspirated foreign bodies and their clinical significance.

Reducing the number of rigid bronchoscopies performed in suspected foreign body aspiration cases via the use of chest computed tomography: is it safe? A literature review

BACKGROUND

Foreign body aspiration is common and potentially life threatening. Although rigid bronchoscopy has the potential for serious complications, it is the 'gold standard' of diagnosis. It is used frequently in light of the inaccuracy of clinical examination and chest radiography. Computed tomography is proposed as a non-invasive alternative to rigid bronchoscopy.

OBJECTIVE

This study aimed to evaluate the accuracy and safety of computed tomography used in the diagnosis of suspected foreign body aspiration, and compare this with the current gold standard, in order to examine the possibility of using computed tomography to reduce the number of diagnostic rigid bronchoscopies performed.

METHOD

The study comprised a review of literature published from 1970 to 2013, using the PubMed, Scopus, Web of Knowledge, Embase and Medline electronic databases.

RESULTS

The sensitivity for computed tomography ranged between 90 and 100 per cent, with four studies demonstrating 100 per cent sensitivity. Specificity was between 75 and 100 per cent. Radiation exposure doses averaged 2.16 mSv.

CONCLUSION

Computed tomography is a sensitive and specific modality in the diagnosis of foreign body aspiration, and its future use will reduce the number of unnecessary rigid bronchoscopies.

Role of virtual bronchoscopy in children with a vegetable foreign body in the tracheobronchial tree

OBJECTIVES

Multidetector computed tomography virtual bronchoscopy is a non-invasive diagnostic tool which provides a three-dimensional view of the tracheobronchial airway. This study aimed to evaluate the usefulness of virtual bronchoscopy in cases of vegetable foreign body aspiration in children.

METHODS

The medical records of patients with a history of foreign body aspiration from August 2006 to August 2010 were reviewed. Data were collected regarding their clinical presentation and chest X-ray, virtual bronchoscopy and rigid bronchoscopy findings. Cases of metallic and other non-vegetable foreign bodies were excluded from the analysis. Patients with multidetector computed tomography virtual bronchoscopy showing features of vegetable foreign body were included in the analysis. For each patient, virtual bronchoscopy findings were reviewed and compared with those of rigid bronchoscopy.

RESULTS

A total of 60 patients; all children ranging from 1 month to 8 years of age, were included. The mean age at presentation was 2.01 years. Rigid bronchoscopy confirmed the results of multidetector computed tomography virtual bronchoscopy (i.e. presence of foreign body, site of lodgement, and size and shape) in 59 patients. In the remaining case, a vegetable foreign body identified by virtual bronchoscopy was revealed by rigid bronchoscopy to be a thick mucus plug. Thus, the positive predictive value of virtual bronchoscopy was 98.3 per cent.

CONCLUSION

Multidetector computed tomography virtual bronchoscopy is a sensitive and specific diagnostic tool for identifying radiolucent vegetable foreign bodies in the tracheobronchial tree. It can also provide a useful pre-operative road map for rigid bronchoscopy. Patients suspected of having an airway foreign body or chronic unexplained respiratory symptoms should undergo multidetector computed tomography virtual bronchoscopy to rule out a vegetable foreign body in the tracheobronchial tree and avoid general anaesthesia and invasive rigid bronchoscopy.

A reclusive foreign body in the airway: a case report and a literature review

A foreign body in the larynx is an airway emergency that requires urgent evaluation and treatment. Irregular foreign bodies tend to orient in a sagittal plane and may produce only partial obstruction, allowing adequate air movement, hence making them undetectable for a long period of time. We report a case of a laryngotracheal foreign body that remained reclusive for 9 years.

Tumors and tumorlike conditions of the large airways. AJR Am J Roentgenol. 2013;201:301-313. [PMID: 23883210 DOI: 10.2214/ajr.12.9043]

OBJECTIVE

Large-airway tumors and tumorlike conditions are uncommon, but a systematic approach aids in narrowing the differential diagnosis. In this article, we describe an approach to dealing with large-airway lesions and discuss their imaging characteristics and clinical presentations.

CONCLUSION

We have found it useful to separate these entities into groups on the basis of the distribution pattern (focal vs diffuse) and location (trachea vs bronchi).

Comparison between tracheal foreign body and bronchial foreign body: a review of 1,007 cases

OBJECTIVE

To determine the differences between tracheal foreign body aspiration and bronchial foreign body aspiration.

METHODS

This retrospective study includes 1007 patients with the diagnosis of foreign body aspiration according to rigid bronchoscopy. Patients were divided into two groups: tracheal and bronchial foreign body groups. Age, sex, clinical presentation, pre-operative radiographic findings, rigid bronchoscopy findings, types of foreign body, and the complications of each group were observed and analyzed.

RESULTS

Out of 989 study patients, there were 146 patients (14.5%) in the tracheal foreign body group and 843 patients (83.7%) in the bronchial foreign body group. Eighteen patients with FBs located in the larynx and presenting with multiple FBs located in the tracheal and bronchial regions were excluded from this study. The majority of the patients were under the age of three for both groups. The male to female ratio was significantly higher in the bronchial foreign body group (P<0.001). More patients in the bronchial foreign body group were misdiagnosed upon first clinical visit (P=0.001), referred from another hospital (P<0.05), or had delayed diagnosis (P<0.05). The most prominent symptom in both groups was cough, followed by decreased breath sounds, wheezing, and dyspnea. More patients in the bronchial foreign body group experienced decreased breath sounds (P<0.001), while more patients in the tracheal foreign body group experienced dyspnea (P<0.05). Chest fluoroscopy abnormalities were observed at a higher frequency in the bronchial foreign body group (P<0.001). Lateral neck X-ray results showed higher frequencies of abnormalities in the tracheal foreign body patients. Out of 30 patients in the tracheal foreign body group received a CT scan, 27 had abnormal scan results, while all 253 patients in the bronchial foreign body subgroup had abnormal results. The majority of foreign bodies were organic materials and were removed by rigid bronchoscopy at the first clinical session in 96.6% of tracheal foreign body cases and 96.0% of bronchial foreign body cases (P=0.727). Major complications, including one death, were observed only in the bronchial foreign body group.

CONCLUSIONS

The nature of tracheal foreign body aspiration is different from bronchial aspiration. Clinical presentation and pre-operative radiographic findings are helpful for diagnosis. The clinician should understand the differences between tracheal and bronchial FB cases and provide the appropriate management when either is presented.

[Bronchial foreign bodies]

Coughing, wheezing, dyspnea and recurrent pneumonia can be signs of foreign body aspiration. About 80% of all foreign body aspirations occur in children, especially in infants between 1 and 3 years of age. Although most foreign bodies are found in the bronchi they are especially dangerous in the larynx or trachea. Foreign body aspiration is less common in adults, being confirmed in only about 1-2 of every 1,000 bronchoscopies. The most common foreign bodies are foods particles. Bronchoscopy is the method of choice for foreign body removal.

Foreign bodies in the airways: a meta-analysis of published papers

BACKGROUND

Very recently, some attempts have been made to start a systematic collection of foreign bodies (FB) in view of using them to characterize the risk of chocking in terms of size, shape and consistency of the FB. However, most of the epidemiologic evidence on foreign bodies in children comes from single-center retrospective studies, without any systematic geographical and temporal coverage. This paper is aimed at providing an estimate of the distribution of foreign body's injuries in children according to gender, age, type of FB, site of obstruction, clinical presentation, diagnostic/therapeutic procedures, complications, as emerging from a meta-analytic review of published papers.

METHODS

A free text search on PubMed database ((foreign bodies) OR (foreign body)) AND ((aspiration) OR (airways) OR (tracheobronchial) OR (nasal) OR (inhalation) OR (obstruction) OR (choking) OR (inhaled) OR (aspirations) OR (nose) OR (throat) OR (asphyxiation)) AND ((children) OR (child)) finalized to identify all English written articles referring to foreign body inhalation over a 30 years period (1978-2008) was performed. The target of the analysis has been defined as the proportion of injuries as reported in the studies, stratified according to children demographic characteristics, type of FB, site of obstruction. The pooled proportions of FB were calculated using the DerSimonian and Laird approach.

RESULTS

1699 papers were retrieved and 1063 were judged pertinent; 214 English written case series were identified, among them 174 articles were available and have been included in the analysis. Airway foreign body most commonly occurs in young children, almost 20% of children who have inhaled foreign bodies being between 0 and 3 years of age. Organic FB, particularly nuts, are the most documented objects while, among inorganic FBs, the greatest pooled proportion has been recorded for magnets, which can be particularly destructive in each location. Non specific symptoms or a complete absence of symptoms are not unusual, justifying mistaken or delayed diagnosis. Acute and chronic complications seem to occur in almost 15% of patients.

CONCLUSIONS

Even if an enormous heterogeneity among primary studies seems to exist and even if the absence of variables standardized definitions across case series, including class age definition and symptoms and signs descriptions, seriously impairs studies comparability, our results testify the relevant morbidity associated with foreign body inhalation in children, stressing the importance of preventive measures.

Removal of an Impacted Distal Airway Foreign Body using a Guidewire and a Balloon Angioplasty Catheter

Airway aspiration of foreign bodies is relatively common in young children. Visible objects are commonly removed under direct vision using grabbing forceps inserted through a rigid bronchoscope. We describe a case of aspiration of the hollow tip of a plastic pen which lodged distally in the right main bronchus of an older child. This object was located so distally that it could only be visualised using flexible fibreoptic bronchoscopy. A novel method was required for successful retrieval, which involved the passage of a guidewire through the centre of the foreign body. A balloon angioplasty catheter was then railroaded over the guidewire through the foreign body and the balloon inflated with saline. This allowed the foreign body to be pulled proximally out of the airway.

Foreign body aspiration in children and adolescents: experience of a Brazilian referral center

OBJECTIVE

To describe the clinical, radiological and endoscopic characteristics of foreign body aspiration among individuals under the age of 15 treated at a referral center in the city of São Luís, Brazil.

METHODS

This was a descriptive study using data from the medical charts of patients treated for foreign body aspiration at the Hospital Universitário Materno Infantil between 1995 and 2005. We investigated 72 confirmed cases of foreign body aspiration, evaluating the place of residence, as well as biological, clinical, radiological and endoscopic variables. We used the chi-square test to identify statistically significant differences in frequency among the variables studied.

RESULTS

The majority of the patients were from outlying areas (55.6%). The following variables presented the highest frequencies: 0-3 year age bracket (81.9%); male gender (63.9%); evolution > 24 h (66.7%); hypotransparency on chest X-ray (57.7%); foreign body in the right lung (41.2%) or in the larynx (20.5%); organic nature of the foreign body (83.3%); complication in the form of localized inflammation (59.4%); glottal edema as an endoscopic complication (47.6%); and seeds (46.6%), fishbone (28.3%) or plastics (25.5%) as the type of foreign body. There were no deaths.

CONCLUSIONS

Preventive care should be a priority for male children under the age of 3 living in outlying areas. Such children should not be given access to substances that can be aspirated, including certain foodstuffs. Simple and easily accessible radiological tests have been underused, which jeopardizes the quality of the initial treatment.

[Management of emergency vs. otorhinolaryngology department tracheobronchial foreign-body aspiration]

Foreign-body aspiration (FBA) obstructing the airways may lead to choking and cardiopulmonary arrest without immediate emergency care. We retrospectively reviewed medical records of 17 otorhinolaryngology subjects-8 men and 9 women aged 0 to 84 years-88% of whom were < 3 years old, requiring tracheobronchial FBA between January 1995 and October 2006 and of 62 emergency subjects-43 men and 19 women aged 0 to 91 years--10% of whom were < 3 yeares old 68% of whom > or = 50 years old, admitted between January 2000 and October 2006. Emergency Department personnel saw a mean of 8.9 patients per year versus the mean of 1.4 patients per year seen by Otorhinolaryngology Department personnel. Foreign bodies extracted most frequently from the 17 otorhinolaryngology patients were 9 seen for peanut injestion followed by 1 each seen for bean, screw, and false teeth injestion among other objects. Sixteen of the 17 were discharged without complications. Foreign bodies extracted from the 62 emergency patients most frequently involved food, especially rice cakes. Over half seen had already gone into cardiopulmonary arrest upon arrival and required cardiopulmonary resuscitation. Of the 62, 32 patients died, 13 were sent to another hospital after in-patient care, 9 were sent home without admission, and 7 were discharged without complications.

Tracheobronchial foreign bodies in infants

OBJECTIVE

Tracheobronchial foreign body aspiration (FBA) is a common cause of respiratory distress between 1 and 3 years of age. Literature on airway foreign bodies in this age group is abundant; however no study has addressed this problem in infants exclusively. This study aimed to review the clinical presentation, management and outcome of infants with tracheobronchial foreign bodies at a referral tertiary care hospital over a decade.

METHODS

102 infants who underwent bronchoscopy for suspected FBA from 1997 to 2007 were retrospectively reviewed. Details of demographic data, clinical features, radiologic and bronchoscopic findings, postbronchoscopy events and eventual outcome were analysed.

RESULTS

The mean age was 10.5 months. 8 (7.8%) were 0-6 months of age, the youngest being 2 months. Males outnumbered (72:30) females. 10 (9.8%) presented secondarily after treatment elsewhere, 6 of them were initially misdiagnosed. The onset-presentation interval ranged from 1 day to 3 months, 41 (40.2%) reporting within a day and 19 (18.6%) a week after onset. 20 (19.6%) had no history suggestive of FBA but harboured airway FBs at bronchoscopy. The clinical triad of cough, respiratory distress and stridor was highly predictive of FBA. 8 (7.84%) had no abnormal physical findings while 8 (10.81%) had grossly normal chest radiographs. All the patients underwent emergency/elective rigid bronchoscopy (Karl Storz system) under general anesthesia as in-patients. The physical findings did not always correlate with radiology or bronchoscopic location of the FB. A peanut cotyledon was the commonest FB retrieved across infancy; in 5 (4.9%) no FB was found/identifiable. 2 required postbronchoscopy mechanical ventilation and 1 a repeat bronchoscopy. There were 6 complications but no mortality in the series. The average hospital stay was 1.4 days. At a week's follow-up, all were asymptomatic and well.

CONCLUSIONS

The clinical presentation, diagnosis and management of FBA in 102 infants are presented and certain peculiar features are described. A high index of suspicion coupled with a combination of history, physical signs and radiology is more conclusive than any of them in isolation. Availability of expertise and endoscopic equipment ensures a favourable outcome without significant morbidity and mortality.

Removal of inhaled foreign bodies--middle of the night or the next morning?

OBJECTIVE

Foreign body inhalation is a potentially life-threatening emergency and is the commonest cause of accidental death in children under one year old. There is varying opinion regarding the urgency for removal of inhaled foreign bodies; most centres in the United Kingdom will take the patient to theatre as soon as can be arranged, regardless of the time of day. At Great Ormond Street Hospital for children it has been standard practice to perform rigid bronchoscopy and removal of an inhaled foreign body on the next available daytime operating list, providing the patient is clinically stable, even if this incurs a delay until the following day. We aimed to identify if any additional morbidity resulted from delaying removal of the foreign body.

METHODS

Retrospective case note review of all cases of foreign body inhalation seen at our institution over an 11-year period between July 1996 and July 2007.

RESULTS

165 patients were referred to our institution with a suspected inhaled foreign body in the study period. 14 patients were managed conservatively due to low clinical suspicion and 57 patients underwent a negative bronchoscopy: these groups were excluded from our analysis. Of the remaining 94 patients, only 7 were taken to theatre outside a scheduled daytime operating list. All of these patients had signs of severe respiratory distress and were operated upon within 4h of their arrival. Of the remaining patients, 41 were taken to theatre on the day of presentation and 46 on the day after presentation; all within normal daytime working hours. No additional post-operative morbidity was identified as a result of our policy to delay bronchoscopy until the next available daytime operating list.

CONCLUSIONS

It is our perception that delaying removal of suspected inhaled foreign bodies to allow optimal circumstances for manipulation of the paediatric airway is a safe practice at our institution. We have not identified any adverse outcomes related to delaying bronchoscopy to the next available daytime operating list in the clinically stable patient. This remains our preferred method of practice.

Management strategies in foreign-body aspiration

OBJECTIVE

The aim of this study is to outline a management algorithm to ensure effective teamwork in decreasing morbidity and mortality in pediatric Foreign-Body Aspirations (FBA). Furthermore, the role of flexible bronchoscopy when compared to rigid bronchoscopy in FBA was evaluated.

METHODS

Charts of patients with suspected FBA from October 1999 to September 2006 were reviewed and data with regards to the history, presenting symptoms, diagnostics and therapeutic tactics, was collected.

RESULTS

A total of 77 children with suspicion of FBA were managed in the 7 year period. Bronchoscopies were performed in 63 patients and in 26 foreign-bodies (FB) were found and extracted. At referral, 53 patients did not present acute respiratory symptoms, but had a positive history of FBA, and in 13 FB were found. Despite negative chest x-rays in 55 patients, FB were found in 8. Rigid bronchoscopy was performed in 53 and flexible in 10 patients. In 3 out of 10 patients who had undergone flexible bronchoscopy a FB was identified, the extraction of which was performed using a rigid bronchoscope.

CONCLUSION

Clinical and radiological findings in children with typical history of suspected FBA are not enough to confirm the presence of FB. Successful management with an extremely low rate of morbidity and no mortality was observed using the algorithm used at our center. Flexible bronchoscopy reduces the chances of airway tract injury; however a rigid bronchoscope is necessary for FB removal.