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Indian Pediatr 2015;52: 659-660 |
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Imaging for Diagnosis of Foreign Body
Aspiration in Children
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Lalendra Upreti and *Natasha Gupta
From the Department of Radiology and Imaging,
University College of Medical Sciences and Guru Tegh Bahadur Hospital,
Delhi, India.
Email:
[email protected]
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F oreign body aspiration into the airways is a
significant cause of morbidity and mortality in pediatric patients,
especially in children below 3 years of age. In the absence of clear
history, the correct diagnosis is often missed. The clinical features
may mimic asthma or pneumonia, resulting in delayed diagnosis. Cough or
wheezing of sudden onset, reduced air entry on auscultation, and chronic
or recurrent pulmonary infection are the subtle pointers which prompt an
observant clinician to suspect foreign body aspiration. A foreign body
lodged in the tracheo-bronchial tree warrants prompt removal to prevent
serious respiratory complications as pneumonia, atelectasis,
bronchiectasis and lung abscess [1].
Frontal radiograph of the chest is the initial
investigation for children referred for persistent or severe thoracic
symptoms. In up to 30% of cases of foreign body aspiration, no obvious
abnormality is visible [1]. Positive X-ray findings consist of
increased radiolucency of the lung or lobe, atelectasis, a combination
of emphysema and atelectasis in the same lung, and pulmonary infiltrates
[2]. Increased radiolucency (obstructive emphysema), which develops
secondary to a check-valve mechanism created by the foreign body
obstructing the airway, is the most common finding on chest skiagram
[3]. Demonstration of radio-opaque foreign body on chest X-ray is
seen in less than one-third of cases [3]. Presence of unilateral
radiolucency is however a common finding in young patients due to
imperfect positioning of an irritated child in unfamiliar surroundings.
Also, subtle difference may be difficult to appreciate in a busy
emergency department. A combination of inspiratory and expiratory film
is most often required to demonstrate obstruction caused by the foreign
body. Fluoroscopy and bilateral decubitus views of the chest have also
been traditionally used for the diagnosis [1].
Computed tomography (CT) is an excellent modality for
the diagnosis and may reveal the impacted foreign body directly as a
hyperdensity in the lumen of airway [1]. It is also possible to
differentiate low density foreign bodies from the mucous plug by
determining the Hounsfield value [4]. Ancillary findings such as
post-obstructive emphysema, collapse, consolidation and bronchiectasis
are also well demonstrated. Advent of Multi-detector Computed Tomography
(MDCT) has made it possible to obtain isotropic high resolution images
in any desired plane. Thus it is possible to see and evaluate even a
subtle abnormality. Multiplanar reconstructions, minimal intensity
projection of the airway and virtual bronchoscopy provide an excellent
roadmap to the surgeon for planning the endoscopic removal. With MDCT,
Bai, et al. [5] were able to detect, localize and assess the
crucial parameters of the foreign bodies in all of their cases who
underwent endoscopic removal. Use of MDCT also obviated occurrence of
severe complications in their cases.
Whereas the efficacy of MDCT in the evaluation of
suspected foreign body is extensively backed up by the available
evidence, large radiation exposure to the young patient with its
potential long-term adverse consequences has spawned the need for
exploring alternative low exposure methods which may be equally
effective in the above clinical scenario. The radiation dose to a child
of 1-5 years of age with a standard PA or AP view of the chest is about
0.01 mSv (milliSievert), while that with a CT scan of the chest with
routine pediatric settings is of the order of 4-6 mSv. Low dose CT of
the chest, done at low tube current, exhibit a significant reduction in
radiation dose to the child, and is about 0.2 mSv with scans done at 30
mAs [6].
The retrospective study by Eun, et al. [7],
published in this issue of Indian Pediatrics, is an effort in the
direction of efficacious diagnosis of foreign body aspiration, with low
radiation doses. The authors have objectively measured and compared the
radiodensity of lungs in cases of foreign body aspiration in pediatric
patients. The X-rays were taken using Computed Radiography (CR)
system and the images were processed using the ‘Histogram tool’ of
‘Adobe Photoshop Image Editing Software’ to determine the relative
radiodensity of the two lungs before and after foreign body removal.
They found reduced radiodensity in the affected lung which increased
after the removal of foreign body. The results were found to be
statistically significant, and the authors conclude that measurement of
radiodensity on chest X-ray can be helpful in the diagnosis of
aspirated foreign body in the tracheo-bronchial tree, or alternatively,
may be applied to rule out the possibility of impacted foreign body in
cases where the difference between radiodensity of the two lungs is not
significant. The study essentially adds an objective component to
analysis of the chest skiagram in cases of suspected foreign body
inhalation. However, it is based on the premise that the patient had
normal lungs and airways prior to inhalation of the foreign body. Thus
results may be fallacious in patients having prior co-existing
disorders. It would also require the integration of the CR system and
Picture Archiving and Communication System (PACS) with the software for
image evaluation, apart from delimiting the lung on the images. The
entire procedure is a bit cumbersome and at best provides an indirect
evidence of presence of foreign body in most cases. Further, more
prospective studies would be desirable for validation of the above
application.
The concern about minimizing the radiation exposure
in CT scan has also necessitated introduction of innovations in the
design of the CT equipments and child sizing of imaging protocols. These
include automatic control of the tube current depending upon the body
part being examined and introduction of new image reconstruction
algorithms. It is also possible to exercise manual control by limiting
the field of view, increasing the pitch, and decreasing the tube current
and tube voltage. Conscious use of the above can markedly decrease the
radiation dose in the target population while maintaining the diagnostic
accuracy of the CT scan [8].
We maintain that MDCT is still the most reliable
investigation for the diagnosis of aspirated foreign body, with the
exception of bronchoscopy. Its utility is unlikely to be challenged in
near future, provided all necessary means to reduce the radiation
exposure are implemented scrupulously. Nevertheless, in the scenarios
where the cost and availability of MDCT is a major deterrent to the
acceptance of CT as the preferred modality, if digital radiographs of
chest succeed in correctly suggesting or ruling out the diagnosis of
foreign body lodgment, it would be of great benefit to a large number of
affected patients.
Acknowledgement: Dr Ajai Srivastav, Physicist,
UCMS and GTB Hospital, for information regarding radiation doses.
Funding: None; Competing interests: None
stated.
References
1. Polat K, Ali A, Ismail K, Fazil O, Oguzhan O,
Hasan D, et al. Low-dose MDCT and virtual bronchoscopy in
pediatric patients with foreign body aspirion. AJR. 2004;183:1771-7.
2. Girardi G, Contador AM, Castro-Rodriguez JA. Two
new radiological findings to improve the diagnosis of bronchial foreign
body aspiration in children. Pediatr Pulmonol. 2004;38:261-4.
3. Passali D, Lauriello M, Bellussi L, Passali GC,
Passali FM, Gregori D. Foreign body inhalation in children: an update.
Acta Otorhinolaryngol Ital. 2010;30:27-32.
4. Hong WS, Im SA, Kim HL, Yoon JS. CT evaluation of
airway foreign bodies in children: Emphasis on the delayed diagnosis and
differentiation from airway mucus plug. Jpn J Radiol. 2013;31:31-8.
5. Bai W, Zhou X, Gao X, Shao C. Califano JA, Ha PK.
Value of chest CT in the diagnosis and management of tracheobronchial
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6. American Association of Physicists in Medicine.
The Measurement, Reporting and Management of Radiation Dose in CT. AAPM
Report No 96. 2008, p.13. Available from:
https://www.aapm.org/pubs/reports/RPT_96.pdf. Accessed June 30,
2015.
7. Eun SS, Dong KH, Hwa JC, In SJ, Namsik Y, Jae SM,
et al. Radiodensity on serial chest X-rays for diagnosis
of foreign body aspiration in children. Indian Pediatr. 2015;52:663-7.
8. Frush DP. Overview of CT technologies for children. Pediatr Radiol.
2014;44:422-6.
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