© Borgis - New Medicine 4/2009, s. 102-103
Mieczysław Chmielik, *Jolanta Jadczyszyn
FOREIGN BODIES IN LOWER AIRWAYS IN CHILDREN TREATED IN THE PAEDIATRIC OTOLARYNGOLOGY CLINIC OF THE MEDICAL UNIVERSITY OF WARSAW IN 2005-2009
Department of Paediatric Otorhinolaryngology, Medical University of Warsaw, Poland
Head of Department: Prof. Mieczysław Chmielik, MD, PhD
Summary
Introduction: Foreign bodies in lower airways in children are present there mainly by accident. Most frequently when children are from 1 to 3 years old. A foreign body in airways poses a direct threat to life, so each child with such a suspicion should be hospitalised. Bronchoscopy is the method of choice in treatment.
Aim: To analyse case histories of children treated in 2005-2009 in the Paediatric ENT Clinic in Warsaw.
Material and method: The case histories analysed are those of children treated in the last 5 years in the Paediatric ENT Department of the Medical University of Warsaw. The age of the children ranged from 6 months to 16 years.
Results: The majority of hospitalised children with a foreign body in airways were not older than 3.5 years. In 59% of cases a foreign body was detected in males. The most frequent foreign body was peanuts (56.7%).
Conclusions: Bronchoscopy should be administered in each case of a suspicion of presence of a foreign body in airways. If no foreign body is found on one side, bronchoscopy should be administered on the other side.
INTRODUCTION
Foreign bodies in lower airways in children are present there mainly by accident. While children play, they put them into their mouths, and subsequently during abrupt movements, eating, simultaneous laughing, or talking they lose control and aspirate (1). Foreign bodies in airways are present mainly in children who are from 1 to 3 years old. They are rarely present in the larynx, more often in the trachea and bronchi. Any object having a size not exceeding the inside diameter of the larynx may become a foreign body (2). While foreign bodies in the alimentary tract may be naturally excreted, foreign bodies in lower airways have no such possibility. Their spontaneous expectoration rarely happens. Despite progress in treatment, they still pose a direct threat to life, and if they remain in lower airways for a longer time they cause irreversible bronchi and lung reactions (3). In each case of aspiration of a foreign body into lower airways and in the case of a suspicion of aspiration, endoscopic bronchoscopy should be administered.
AIM
The aim was to analyse case histories of children admitted in the Paediatric Otolaryngology Clinic of the Medical University of Warsaw in 2005-2009 with suspicion of aspiration of a foreign body into lower airways. The foreign bodies removed were described and kept for educational purposes.
MATERIAL
The study covered 94 cases with suspicion of aspiration of a foreign body into lower airways - larynx, trachea, or bronchi. 53 boys and 33 girls were hospitalised. The age of the children analysed ranged from 6 months to 16 years. The average age was 4 years.
METHOD
The following aspects were analysed: age, gender, initials of the patients, circumstances of aspiration, occurrence of symptoms, duration of retention of the foreign bodies, performed examinations, endoscopic treatments, location of the foreign bodies, presence of granulation tissue, and complications. Auscultatory symptoms in paediatric examination and duration of the children´s stay in hospital were taken into account.
RESULTS
Presence of a foreign body in airways was detected in 30 children. The age of the children ranged from 14 months to 14 years and 3/12. The majority of children hospitalised were not older than 3.5 years (66.7%). A foreign body was more often detected in males (59%). No foreign body was detected in 64 cases and no spontaneous expectoration of a foreign body was observed.
The most frequently detected foreign bodies in lower airways were as follows: peanuts (56.7%), small plastic objects (16.6%), pieces of food - carrot (6.6%), pins (6.6%). The following objects were detected in single cases: a bone, a pin, a pumpkin seed, a needle (in total 13.6%). Location of a foreign body depended on its shape and size. Among 30 foreign bodies, the majority were removed from the right main bronchus (60%). 4 foreign bodies (a bone, a needle, 2 plastic objects) were removed from the trachea, 18 foreign bodies (13 peanuts, 2 pieces of carrot, 2 small plastic parts, 1 pill) were removed from the right bronchial tree, 8 foreign bodies (2 pins, 4 peanuts, 1 piece of plastic, 1 pumpkin seed) were removed from the left bronchial tree.
The period of retention of foreign bodies in lower airways ranged from 10 hours (needle in the trachea) to 1 month (peanut in the right main bronchus).
In 11 cases bronchoscopy with removal of the foreign body was administered within 12 hours.
DISCUSSION
What was of vast importance in diagnosis was careful questioning of the children´s parents. Symptoms depended on the size, shape, type of the aspirated foreign body, duration of its retention, and its location in lower airways. Aspiration of a foreign body was in almost every case related to eating food with simultaneous talking, laughing, or crying. The main symptom showing that a foreign body passed through was a strong paroxysmal cough reaction, which stopped after a few minutes. Simultaneously with the cough, there was dyspnoea with various intensity, stridor, and livedo of the face. In the case of aspiration of foreign bodies with sharp edges, blood spitting and stabbing pains in chest were observed. No subcutaneous emphysema was observed. Longer retention of foreign bodies caused temperature above normal, shivering, and moist cough. These were symptoms of the outset of pneumonia or bronchitis (4, 10). Paediatric examination – ausculatory and percussion examination of chest did not contribute any material data to the diagnosis as there was no total obstruction of the main bronchus. What was of importance for the diagnosis was radiological examination. However, in the case of non-radiopaque foreign bodies, diagnosis could not be made, only on the basis of existing secondary radiological changes. Ventilation emphysema was diagnosed only in 2 cases among the patients analysed. Bronchoscopy should be administered in each case of a suspicion of presence of a foreign body. This examination is decisive (5, 6, 7).
Endoscopic removal of foreign bodies using a rigid bronchoscopic pipe in general anaesthesia under visual control is the method of choice in treatment in the Otolaryngology Clinic of the Medical University of Warsaw (8, 9). Small foreign bodies were removed by means of a bronchoscope, and larger following directly a bronchoscopic pipe. What caused large difficulties was expanding foreign bodies, which in a few cases were fragmented and removed in parts.
Presence of granulation tissue was observed after removal of a foreign body (16.7%), and in 1 case there was a decubitus ulcer, and in 1 case mucosa of the trachea and left bronchus was cut. No complications in the form of rupture of the bronchus wall, damage to lung tissue, or profuse bleeding were observed. It should be borne in mind that long bronchoscopy in children may lead to oedema of mucous membrane in the subglottic area. In such a case tracheotomy may be necessary. No complication of this type was observed in the clinic covered by the study.
CONCLUSIONS
1. Among 94 hospitalised children with suspicion of presence of a foreign body, a foreign body was detected in 30 cases.
2. Foreign bodies were more often detected in males (59%).
3. The biggest number of foreign bodies was detected in the right bronchial tree.
4. No spontaneous expectoration of a foreign body was observed.
5. Endoscopic bronchoscope examination was administered in each case.
6. If no foreign body is found on one side, bronchoscopy should be administered on the other side.
7. Cough reaction in little children is less intense than in adults and it is frequently neglected by parents.
8. Symptoms that had a dramatic course immediately after aspiration, slowly disappeared in time, and reduced the parents´ vigilance. At the same time, ambiguous information from parents and aspiration unnoticed by parents delayed the treatment.
Piśmiennictwo
1. Szmeja Z: Ciała obce ucha, nosa, gardła, krtani, dolnych dróg oddechowych i przełyku. Przewodnik Lekarza 2002; 9, 94-96. 2. Zakrzewski A, Szmeja Z: Ciała obce tchawicy i oskrzeli. W: otolaryngologia kliniczna. PZWL, Warszawa 1981; 563-570. 3. Kruk-Zagajewska A, Szmeja Z, Wójtowicz J et al.: Problematyka ciał obcych w dolnych drogach oddechowych na podstawie materiału zebranego w Klinice Otolaryngologii AM w Poznaniu (1945-1997), Otolaryng Pol 1998; LII, 6, 683-688. 4. Gregori D, Salerni L, Scarinzi C et al.: Foreign bodies in the upper airways causing compilcations and requiring hospitalization in children aged 0-14 years: results from the ESFBI study. Eur Arch Otorhinolaryngol. 2008 Aug; 265 (8): 971-8. 5. Pinzoni F, Boniotti C, Molinaro SM et al.: Inhaled foreign bodies in pediatric patients: review of personal experience. Int J Pediatr Otorhinolaryngol. 2007 Dec; 71(12): 1897-903. 6. Yadav SP, Singh J, Aggarwal N, Goel A: Airway foreign bodies in children: experience of 132 cases. Singapore Med J 2007 Sep; 48(9): 850-3. 7. Sanchez Echaniz J, Perez Garcia J, Mintegui Raso S et al.: Tracheobronchial aspiration of foreign bodies in children. An Esp Pediatr 1996 Oct; 45(4): 365-8. 8. Divisi D, Di Tommaso S, Garramone M et al.: Foreign bodies aspirated in children: role of bronchoscopy. 9. Brkic F, Umihanic S: Tracheobronchial foreign bodies in children. Experience at ORL Clinic Tuzla, 1954-2004. Int J Pediatr Otorhinolaryngol 2007 Jun; 71(6): 909-15. 10. Chiu CY, Wong KS, Lai SH et al.: Factors predicting early diagnosis of foreign body aspiration in children. Pediatr Emerg Care 2005 Mar; 21(3):161-4.
