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Indian Pediatr 2015;52:
611-612 |
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Unusual Foreign Bodies in the Respiratory
Tract of Children
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Bharat Kansal, *K Mallikarjuna Swamy, Ramesh H and
Basanth Kumar
From Department of Paediatrics, Bapuji Child Health
Institute & Research Center; and *Department of ENT, JJMMC; Davangere,
Karnataka, India.
Correspondence to: Dr Bharat Kansal, Department of
Pediatrics, Bapuji Child Health Institute & Research Center, JJMMC,
Davangere, Karnataka - 577004.
Email: [email protected]
Received: January 27, 2015;
Initial review: March 07, 2015;
Accepted: April 29, 2015.
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Background: Diagnosis of a
foreign body without history of aspiration has always been a challenge
to pediatricians.Case Characteristics: Four cases presented with
non-relieving acute or chronic history of respiratory symptoms.
Observations: All of them had unusual types of foreign bodies –
plastic flower toy, button, sticker or stone in their respiratory tract.
Outcome: All four patients improved after removal of the foreign
body. Message: A differential diagnosis of foreign body should
always be made in an acute or chronic presentation of respiratory cases.
Keywords: Bronchoscopy, Foreign body
aspiration , Respiratory tract.
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Foreign body aspiration (FBA) is frequently
encountered and is a life-threatening condition in children. Its
diagnosis has always been a challenge for the pediatricians, as the
initial choking episodes are not generally witnessed and delayed
residual symptoms tend to mimic other common childhood respiratory
illnesses [1]. The spectrum of airway foreign bodies varies across
different cultures, regions and feeding habits [2]. Food nuts
(especially peanuts) being the most common and toys account for 90% of
foreign bodies found in FBA cases [2,3]. We are presenting 4 FBA cases
that were detected with unusual types of foreign bodies in the
respiratory tract of children.
Case Reports
Case 1: A -10-month-old boy presented
with hoarseness of voice, drooling of saliva and excessive irritability
for 2 days. On examination, the child had respiratory distress along
with inspiratory stridor. The pulse oximeter showed a saturation of 90%.
X-ray neck antero-posterior and lateral view showed a
prevertebral soft tissue swelling of 20 mm at the level of C4-C6
vertebrae with narrowing of the airway. The infant was managed on the
lines of croup for two days. As there were no signs of improvement,
patient was taken up for videolaryngoscopy. The vocal cords were totally
obstructed by a plastic flower toy, and the infant was breathing only
through a hole in the toy (Fig. 1a and 1b).
The infant improved following the removal of foreign body.
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Fig.1 (a) Plastic flower toy (case 1)
after removal, and (b) entrapped between vocal cords seen
through videolaryngoscope; (c) sticker (case 3), and (d) stone
(case 4) after removal.
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Case 2: An 18-month-old boy having cough for
10 days and bilateral rhonchi was not responding to inhalational and
oral medications. Chest X-ray posterioanterior and lateral views
showed a radio-opaque foreign body in the trachea (Fig. 2a).
A button having multiple holes was removed by rigid bronchoscopy, and
the child improved. The child had not developed respiratory distress
probably due to multiple holes in the button through which he was able
to breath.
Case 3: A 29-month-old toddler presented with
cough, irritability and refusal to feed for 6 hours. Child had
respiratory distress with saturation of 86% on pulse oximetry at 6 L/min
of oxygen. Emergency neck radiograph showed the presence of a radio
opaque striker in trachea at the level of C7 vertebrae (Fig.
2b). The foreign body (Fig. 1c) was removed from the
trachea by rigid bronchoscopy following which the toddler improved. In
this case, the sudden emergence of respiratory distress indicated the
diagnosis of FBA.
Case 4: A 34-month-old boy presented with a
history of cough and fever of 1˝ month duration. The child had been
treated with intravenous antibiotics in the referral hospital. On
examination, the child was having bilateral crepitations. The radiograph
showed right upper and middle zone and left middle and lower zone
heterogenous opacities (Fig. 2c). The diagnostic
bronchoscopy showed presence of a stone at the carina (Fig. 1d).
Child improved after removal of the foreign body. The boy had probably
developed secondary pneumonia following FBA.
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Fig. 2 (a) Lateral view chest
radiograph (case 2) shows a button with multiple holes in
trachea, (b) sticker (case 3) in airway in front of C7 vertebrae
on X-ray neck lateral view, (c) multiple bilaterally
heterogeneous opacities (case 4) on chest X-ray (PA view).
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Discussion
FBA is a frequently encountered and life-threatening
condition in young children. Early complications are asphyxia, cardiac
arrest, obstructive dyspnea, laryngeal/glottis edema and loss of
consciousness, which can lead to later complications like secondary
infection and obstructive broncheictasis [4]. In cases of nuts or
vegetables aspiration, the parents may give a history of such
consumption, which increases the suspicion of FBA. However, we have come
across four cases of FBA, wherein objects were flower toy, sticker,
stone and button, respectively. In these cases, the parents are
generally unaware of such an intake by their kids, thus reducing the
chances of being diagnosed as FBA.
Presence of associated conditions like asthma,
pneumonia, reactive airway disease, croup and atelectasis may further
lead to delayed diagnosis [5] of FBA, as seen in three of the cases
presented. In their study, Mahyar, et al. [6] and Rajashekran,
et al. [7] found that a history of aspiration was witnessed in only
57.4% and 62% of the cases, respectively. So a high index of suspicion
is required by the pediatricians for diagnosing FBA in children.
FBA should always be considered as a possibility in
both an acute or chronic respiratory case, even in the absence of any
history of foreign body intake. Bronchoscopic evaluation of bronchial
tree is both diagnostic and therapeutic, and should be done with the
slightest doubt of foreign body aspiration.
Contributors: BK: written the article as well as
assisted other authors in managing the cases; KMS: conducted
Bronchoscopy of all cases; RH: Managed the third and fourth cases ; BK:
Managed the first and second cases.
Funding: None; Competing interests: None
stated.
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