© Borgis - New Medicine 2/2001, s. 20-22
Lidia Zawadzka-Głos1, Anna Jakubowska2, Beata Zając1, Anna Gabryszewska2
Foreign bodies in the airways in children
1 Department of Paediatric Otorhinolaryngology, The Medical University of Warsaw
Head of Department: Prof. Mieczysław Chmielik MD.
2 Institute of Paediatric Radiology, The Medical University of Warsaw
Head of Institute: Prof. Andrzej Marciński MD.
Summary
Foreign bodies (f.b.) in the airways are a constant problem in paediatric laryngological practice. The authors discuss the most frequent types of f.b., the most common locations of f. b. in the air passages, and signs and symptoms of f.b. in physical and radiological examination. The most common location is the main right bronchus, and the inferior lobar bronchus of the right lung. In the larynx, f.b. represent a particularly life-threatening situation. A child suspected of having f.b. in the air passages must be examined radiologically, and needs direct visualisation by bronchoscopy. The authors propose that for children younger than 4 years of age, a radiological examination of the thorax should be performed using a horizontal x – ray with the child lying on its side. Early bronchoscopy (within 48 hours from aspiration) reduces the frequency of subsequent complications.
Acute airway obstruction usually requires immediate diagnosis and therapeutic management. Physical, radiological, and endoscopic examination allows an exact assessment of the location of the airway obstruction, thus initiating the correct treatment. When we suspect a foreign body in the air passages, an exact history is very important. Aspiration of a f.b. occurs more frequently during games or feeding. There is a rapid onset of paroxysmal cough, with cyanosis and psychomotor restlessness. The cough is persistent to the point where the f.b. becomes fixed in the airway. After that, there may be a symptomless interval phase. The cough may recur at night, during sleep, when the child changes position, provoking a dislocation of the f.b. Symptoms may be overlooked by the parents, and a choking episode may be disregarded. Thus, the obstruction leads to pneumonia, usually unilateral. There is no significant improvement after typical treatment for pneumonia, until the f.b. is removed from the bronchus. It is important to remember that a foreign body retained in the bronchus for a long time will facilitate fungal infections and granulation.
Delayed recognition, and consequently delayed proper treatment, increases the complication rate, complications including abscess of the pulmonary tissue and pulmonary fibrosis.
Large round ot oval bodies obstruct bronchi, and cause an obturative atelectasis of the lung or lobe. Foreign bodies decreasing the patency of the bronchus are a cause of obturative emphysema ("check valve" emphysema). An impacted f.b. causes symptoms of spastic bronchitis. Temporary displacement of a f.b. causes paroxysmal dry cough. We can also hear a wheeze or whistle during crying or deep breathing when the f.b. is at the level of the glottis.
A situation in which the air flows through the bronchus behind the f.b. on inspiration, and cannot flow back on expiration, is particularly dangerous. This quickly leads to acute ventilation emphysema.
We find numerous foreign bodies, usually large, at the level of the larynx, which due to their size don´t pass trough the glottis.
Sharp foreign bodies (bones, fish – bones, needles) wedge in the mucous membrane of the laryngeal vestibule. Foreign bodies in the larynx produce rapid inspiratory dyspnoea, and represent a life – threatening condition.
Exogenous f.b. in the trachea are very rare. Sharp – ended f.b. stop at this level. More frequently we see endogenous f.b. – dried secretion forming crusts in the lumen of the trachea (laryngotracheitis crustosa).
The anatomical structure of the respiratory tract facilitates aspiration of most f.b. of the right lung. The most common f.b. we find are pieces of food and nuts, small parts of toys, and needles. Vegetable f.b. retained in the the bronchus for a long time cause an acute inflammatory reaction, leading to the growth of granulation tissue, and markedly stenose the lumen of bronchus.
Diagnosis of an f.b. in the respiratory tract is based on physical and other investigations, such as radiography and endoscopic examination. Physical examination of the thorax shows on percusion an bandbox resonance, dull or non – percussive resonance, and on auscultation there is a decrease in respiratory murmur or bronchial respiratory murmur, due to developing emphysema or obturative atelectasis of the lung.
It is necessary to carry out a radiological examination in every case in which an f.b. in the respiaratory tract is suspected. Due to anatomical structure of the airways, radiological changes are found in the inferior lobe of the right lung. The pathognomonic radiological sign of an f.b. in the bronchus is migration of the mediastinum, known as Holzknechto´s sign. The most common radiological sign is excessively dilated pulmonary tissue, distal to the f.b. Subsequently, pneumonia and atelectasis may occur. Only contrasting f.b. are well – seen on x-ray film (picture 1).
Picture 1. Contrasing foreign body in main right bronchus – the end of a ball – point pen – anteroposterior x – ray.
The aim of a radiological examination of a child suspected of having f.b. is
– to find and localise the f.b.
– to assess the physical properties of the f.b.
– to distinguish single or multiple f.b.
– to confirm or rule out co – existing complications
– to assess indirect signs (emphysema, atelectasis, inflammation) caused by the f.b. – these signs are the basis of diagnosis for non – contrasting f.b.
The x-ray image depends on the type and size of the f.b., and the time since aspiration. It is necessary to make x-rays of the thorax in anteroposterior and lateral projections, including the cervical part, in all children suspected of having f. b. in the trachea or bronchus. Radiological examination should show all parts of the airways. Additionally, we need a lateral projection of the cervix with the patient on one side to show the nasopharynx.
The main problem for the radiologist is to recognise a non-contrasting f.b. In such a case we must base our diagnosis on indirect signs (atelectasis, emphysema or inflammation). When the f.b. obstructs the bronchus and there is no ventilation peripheral to the f.b., the x-ray film shows atelectasis of the segment, lobe or whole lung, with displacement to the side of the f.b. The other situation, when the f.b. only diminishes bronchial patency and air passes to the distal parts through the bronchus only on inspiration, leads to ventilation emphysema.
Signs of ventilation emphysema are found with an x-ray both on inspiration and expiration. The examianation of older children is typically performed in a vertical position. Radiologic examination of younger children in two phases of breathing may be difficult to achieve. Therefore, all children under 4 years of age are examined in a horizontal position, the child lying on one side of the body, with a horizontal x-ray (picture 2). In this position, the lower lung is compressed in a stage similar to the expiration, and the upper lung is in the inspiration phase. This x-ray is done on both sides of the body. The comparison of right and left x-ray images on expiration allows us to recognise ventilation emphysema and the degree of ventilation of the lung.
Picture 2. Non-contrasting body in right side airway – a peanut.
A – anteroposterior x-ray film – the normal ventilation stage of the lungs.
Horizontal x-ray films on both sides of the body;
B – right side;
C – left side.
In both cases (b and c) the right lung is distended – "check valve" emphysema of the right lung..
The conclusive diagnostic and treatment examination is bronchoscopy. This should be performed by an experienced laryngologist with a perfect knowledge of the anatomical structure of the bronchial tree. Bronchoscopy performed up to 48 hours after the aspiration of the f.b. allows reduction of later complictions by the retention of the f.b. in the bronchus. Rigid bronchscopy performed under general anaesthesia is still the most reliable way of removing an f.b. from the air passages in children, and of eventually removing any granulation tissue or secretions which may surround the f.b.
To sum up, we can say that –
1. Foreign bodies in the larynx are life – threatening condition.
2. The most common location for an f.b. is the main right bronchus or the lobular inferior bronchus of the right lung.
3. Early bronchoscopy decreases the risk of later complications.
4. Endoscopic and radiological examinations must be carried out in every case of a suspected f.b. in the respiaratory tract.
5. Horizontal x-rays should be made with the child on its side, in all cases where a child under 4 years of age is suspected of having a non-contrasting f.b.
Piśmiennictwo
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