A 30-month-old girl was brought by her parents to our hospital with complaints of sudden onset of noisy and difficult breathing for two days that started soon after accidentally falling over a sand pile while playing. There was no history of cough, fever, rhinorrhea, nasal congestion, or history of similar illness in past. Examination revealed inspiratory stridor and wheeze. Breath sounds were heard equally on both sides. Systemic examination was normal. Suspecting sand deposits as possible foreign body in airway, the child was taken up for emergency bronchoscopy. Sand particles were seen during bronchoscopy, and were suctioned out from trachea. Post-bronchoscopy, stridor and wheeze decreased; and the child was discharged after 24 hours. Four days later, child reported back with complaints of progressively increasing noisy breathing following initial improvement. There was no associated history of cough, fever and cold. Examination revealed stridor and wheeze with equal breath sounds. Patient was treated with steroids and antibiotics considering the possibility of post-bronchoscopy edema. Frontal radiograph of the chest showed a well-defined, elongated pointed radio-opaque shadow in the airway at the level of C6-7 vertebrae, suggestive of impacted foreign body in the airway (Fig. 1). A Contract-enhanced Computed tomography (CECT) of neck and thorax was planned in view of persistent symptoms and radio-opaque shadow on X-ray, which revealed an elongated structure isodense to bone, of an unusual shape with inferior sharp margin and superior rounded margin, appearing fixed to the anterior and posterior walls of airway straddling across its lumen, causing significant luminal narrowing, and lodged just below the expected location of true cords (Fig. 2a and 2b).

Fig.1. X-Ray Chest- Frontal view shows elongated pointed foreign body of metallic density (arrow) in the airway at C6-C7 level.

(a)	(b)
Fig. 2 Conrast enhanced computed tomogram of the cervical Sagittal (a), and Coronal (b) multiplanar reconstruction of images reveal high density elongated structure with sharp inferior tip lodged in airway (thick arrow) straddling across its lumen, causing luminal narrowing (arrowheads).

Repeat bronchoscopy revealed greenish deposits of paint just below the glottis and in right main bronchus. Those 1-5 mm paint scrapings were removed using forceps. The aspirated material could not be sent for chemical analysis. Post-bronchoscopy, stridor and wheeze settled. Antibiotics and supportive care were continued for 48 hours. Child improved and on follow-up after one week, child was stable and free of symptoms.

Airway aspiration of sand presenting as respiratory distress is rare. Most of the accidental aspirations, notably those of children being buried under sand masses, improve after successful bronchoscopy treatment [6]. Majority do not require repeat bronchoscopy.

Sand is ubiquitously present and usually contains large or small sedimentary particles known as gravel and silt, respectively. It is usually composed of aluminium silicate, silicon dioxide and calcium carbonate as major components. The percentage of calcium carbonate present directly increases the ‘radio opaque’ property of the aspirated material [7]. At times it may mixed with other things like paint scrapings, small paper pieces and plastic material. Sand with thick bronchial secretions may get adhered to the mucosa, and can form casts in the airway due to its own nature and the mixed substances. Some particles can be larger than the diameter of suction catheter, and may cause continuous plugging. Also, the sand particles can be too heavy to be lavaged easily and may require tedious, repeated manual extraction [8].

In this child, we assume that the paint material present in the sand adhered to the wall of the glottis, and could not be suctioned out during first bronchoscopy. The persistence of stridor and wheeze following emergency bronchoscopy was initially attributed to post-broncho-scopy edema as it is a well-known complication of bronchoscopy [9]. However, persistence of symptoms and radio-opaque sharp shadow on X-ray prompted us to evaluate the child for any retained foreign body, which in this case turned out to be solidified paint material.

The oil-based paint is composed of base, vehicle, pigment, thinner and dryer. Except for the vehicle and thinner, other three components are metallic. Commonly used bases are zinc oxide, iron oxide and metallic powder (Aluminium, Copper, and Bromium), which make the film harder. Calcium carbonate, mica, silicas, and talcs are used as pigment that gives the paint its colour. Organic salts of iron, zinc, lead, manganese and calcium helps in drying [10]. These radiopaque metallic components of paint made the findings evident on radiograph and CT scan in our case. Also being metallic in composition, these paint scrapings were capable of initiating an inflammatory response, which probably led to previous worsening of symptoms compared to the size of foreign material.

Irregular foreign bodies or orientation in sagittal plane may produce only partial obstruction allowing adequate air movement around the obstruction. Later worsening of symptoms in this child can be explained by the fact that air passage realigned the paint scrapings to anterior and posterior walls causing worsening of obstruction and stridor. We could not trace any other report of paint material being aspirated by the children and presenting with obstructive symptoms.

We suggest the need of follow-up and re-evaluation in case of persistence of symptoms and radio-imaging before and after bronchoscopy in cases of sand aspiration. Cases of sand aspiration should be viewed with caution as there could be other material mixed in it.

Contributors: Neha Garg, DS, PG: were involved in management of the patient; Natasha Gupta: was involved in the diagnostic work-up of the patient; The first draft of manuscript was prepared by Neha Garg, and was revised after critical outputs from DS, PG and Natasha Gupta. All authors approved the final version of the manuscript.

Funding: None; Competing Interests: None stated

1. Bittencourt PF, Camargos PA, Scheinmann P, De Blic J. Foreign body aspiration: clinical, radiological findings and factors associated with its late removal. Int J Pediatr Otorhinolaryngol. 2006;70:879-84.

2. Cohen S, Avital A, Godfrey S, Gross M, Kerem E, Springer C. Suspected foreign body inhalation in children: what are the indications for bronchoscopy? J Pediatr. 2009;155:276-80.

3. Metrangolo S, Monetti C, Meneghini L, Zadra N, Giusti F. Eight years’ experience with foreign-body aspiration in children: what is really important for a timely diagnosis? J Pediatr Surg. 1999;34:1229-31

4. Tan HK, Brown K, McGill T, Kenna MA, Lund DP, Healy GB. Airway foreign bodies [FB]: a 10-year review. Int J Pediatr Otorhinolaryngol. 2000;56:91-9.

5. Yetim TD, Bayarogullary H, Arýca V, Akcora B, Aryca SG, Tutanc M. Foreign body aspiration in children; Analysis of 42 cases. J Pulmon Resp Med. 2012;2:121

6. Kettner M, Ramsthaler F, Horlebein B, Schmidt PH. Fatal outcome of a sand aspiration. Int J Legal Med. 2008;122:499-502.

7. Arun Babu T, Ananthakrishnan S. Unusual presentation of sand aspiration in a 14-mo-old child. Indian J Pediatr. 2013;80:786-8.

8. Choy IO, Idowu O.Sand aspiration: a case report. J Pediatr Surg. 1996;31:1448-50.

9. Ciftci AO, Bingöl-Koloðlu M, Senocak ME, Tanyel FC, Büyükpamukçu N. Bronchoscopy for evaluation of foreign body aspiration in children. J Pediatr Surg. 2003;38:1170-6.