Abstract             This retrospective study of series of 50 cases of inhaled foreign bodies in pediatric patients in one year, deals with which the cases presented and the types of foreign body removed. Diagnostic flexible bronchoscopy aid in the diagnosis of unsuspected foreign body aspiration, or with doubtful history of foreign body aspiration without physical or X-ray signs and can proceed with definitive treatment in the same preparation without delay. Tracheotomy is indicated for foreign body that cannot be removed through glottis. A team work of anesthetist, endoscopist, and assistants are essential to ensure the safety of procedure with no compromise on availability of instruments.  Key words Tracheo Bronchial · Foreign Bodies · Children · Management

Anbalagan, Subramanian

BalaChandran, Krishnamoorthy

Rajasekaran, Srinivasan

Satish Kumar, Paramasivan

vikram, venkata jagannathan

English

Otolaryngology online journal

 
ISSN:2250-0359                                                          VOLUME 3 ISSUE 3 2013 
 
Management of Tracheo Bronchial Foreign Bodies in Children 
– A Retrospective Study of series of 50 cases 
Srinivasan Rajasekaran, Krishnamoorthy, BalaChandran, Subramanian Anbalagan, Paramasivan 
Satish Kumar, Venkata jagannathan vikram 
Institute of Pediatrics Madras Medical College 
 
Introduction 
  Foreign body aspiration in the airway of children is a life threatening clinical situation responsible 
for many deaths each year, with children less than two years of age being most commonly affected
 [1]. 
The peak incidence of inhaled foreign bodies in early childhood is because of two reasons: 
1)  The exploring nature of the young child who is often edentulous and has a tendency to place any 
object in the mouth, the solid objects entering the pharynx elicits a startle response permitting the 
foreign body to enter the open larynx during forced inspiration
 [2]. 
2)  High incidence of upper respiratory tract infection makes the young children mouth breathers. Also 
due to the presence of coughing, the inhalation of food particles may easily occur with sharp intake of 
breath following a bout of cough
 [3]. 
               The  course  of  illness  after  a  foreign  body  lodges  in  the  air  passage  depends  on  the 
characteristics of the foreign body and its length of stay. The unsuspected longstanding foreign bodies 
may lead to complications such as pneumonia, bronchiectasis, atelectasis, and even death.                         Many advances have been made since Chevalior Jackson described the technique of the 
removal of foreign bodies from the airway and with the advent of ventilating bronchoscope has greatly 
improved the illumination and thus facilitates the endoscopist to remove foreign bodies easily
 [4].   
 
Materials and Methods: 
  In this retrospective study of 50 pediatric cases of foreign body removal done between May 2010 
to May 2011, the record’s of each patient was examined for the age, sex, nature, site of the foreign body, 
interval between inhalation or the symptoms to admission in the hospital, presenting symptoms and signs, 
appearance of chest roentgenograms at the time of admission and results of bronchoscopy were noted. 
  Patients presenting with definitive history of foreign body aspiration, or recent onset of cough, or 
breathlessness, with suspicion of foreign body aspiration, rigid bronchoscopy was performed.  In some 
patients  with  chronic  or  subtle  symptoms  with  no  history  of  foreign  body  aspiration,  or  patients  with 
symptoms unresponsive to bronchodilator therapy, or history consistent with aspiration but no physical or 
x-ray signs, flexible bronchoscopy was performed to rule out any other lung pathology. On diagnosis of 
foreign body the child was shifted immediately to operation theatre for foreign body removal using rigid 
bronchoscope under general anesthesia, with induction by propofol, relaxation and apnoea with scoline, 
oxygenation  with  jet  ventilation.  On  visualization  of  the  foreign  body  it  is  grasped  with  forceps  and 
removed.  Foreign  bodies  in  sub  glottis  and  trachea  had  to  be  removed  at  earliest  as  they  caused 
respiratory emergency. Central foreign bodies were pushed down to either bronchi before removal. We 
routinely give intravenous steroids along with antibiotics to decrease post operative sub glottis edema. 
In  one  case  tracheotomy  was  done  to  remove  tamarind  seed  as  it  has  swelled  due  to  its 
hygroscopic action and successful decannulation was done on fifth post operative day. We repeat chest X 
– ray after forty eight hours. Most of our patients were discharged on third post operative day.     
 
Observations 
  Our study is based on removal of foreign bodies in 50 pediatric patients. The period of study was 
one year. The most common age group was 9 months to 2 years, boys were 30 and girls were 20. Table 
1 shows the comparative study of age group of patients with that of J. Srppnath et al.  
 
 
Table 1: Age Group 
 
 
 
 
 
 
 
Time taken to report at hospital: 
  Most of our children came immediately after aspiration probably due to the positive history of 
aspiration. The time taken between aspiration and removal of foreign body has been compared with that 
of J. Srppnath et al as shown in Table II.  
In one patient prolene suture was removed after 6 months operated from tracheo- oesophageal 
fistula. History of aspiration was present in 31 cases.   
 
Table II: Time taken between aspiration and removal of foreign body: 
Days  J. Srppnath et al  Our Study 
0 – 1  14%  12% 
1 – 7  28%  46% 
7 – 15  32%  16% 
15 – 30  25%  14% 
Over 30  1%  12% 
 
Age in years  J. Srppnath et al  Our Study 
0 – 2  64%  54% 
2 - 4  20%  32% 
4 – 5  6%  6% 
5 - 15  8%  8% 
Above 15  2%  0% Symptoms with which presented: 
  Fever was present in long standing cases. This has been compared with that of J. Srppnath et al 
as shown in Table III. 
 
 
 
 
 
Table III: Symptoms with which presented: 
   Symptoms  J. Srppnath et al  Our Study 
History of aspiration  60%  62% 
Cough  50%  72% 
Respiratory distress  42%  68% 
Wheezing  56%  54% 
Fever  24%  44% 
 
Common Signs: 
  Diminished air entry and wheeze were the most common signs. In 3 cases there was stridor. The 
signs we observed has been compared with that of J. Srppnath et al and shown in Table IV. 
 
Table IV: Signs 
 
 
 
 
 
 
Signs  J. Srppnath et al  Our Study 
Diminished air entry  72%  72% 
Wheeze  45%  54% 
Stridor  4%  6%  
 
 
Radiological Findings: 
  Obstructive emphysema (fig I) was the most common radiological finding. Collapse (fig II), Radio 
opaque foreign bodies was seen in 2 cases (fig  III, IV) Normal X – Ray chest does not rule out the 
possibilities of foreign body. 
  The radiological findings has been compared with J. Srppnath et al and shown in Table V. 
 
 
Table V: Radiology 
 
                
       
 
   
Radiology  J. Srppnath et al  Our Study 
Obstructive emphysema  54%  58% 
Collapse  12%  8% 
Consolidation  20%  6% 
Radio opaque FB  2%  4% 
Bronchopneumonia  -  14% 
Lung abscess  2%  - 
Lower lobe collapse  6%  - 
Normal  4%  10%  
 
 
        Fig I                                           Fig II                                Fig III                                    Fig IV 
 Site of foreign body: 
  There was equal distribution of lodgement in both right and left main bronchus. In 1 case there 
was a subglotic lodgement of foreign body and 3 cases in trachea. These findings were compared with 
that of J. Srppnath et al and shown in Table VI.   
 
Table VI: Site of foreign body 
Site of foreign body  J. Srppnath et al  Our Study 
Right Bronchus  56%  46% 
Left Bronchus  30%  46% 
Lower lobe of lung  4%  - 
Sub glottis  4%  2% 
Trachea  6%  6% 
 
Types of foreign bodies: 
The  majority  of  foreign  bodies  in  our  series  were  groundnut  seed,  but  we  also  encountered 
different types of foreign bodies as shown in Table VII.  
 
 
 
 
 
  
Table VII: 
Types of Foreign Bodies   Number of cases 
Groundnut  34 
Betelnut  4 
Plastic pen cap  1 
Custard apple seed  1 
Prolene Suture  1 
Tamarind seed  1 
Ginger piece  1 
Garlic  1 
Black Gram  1 
Meat piece  1 
Steel nail  1 
Lemon seed  1 
Water melon seed  1 
Hair pin  1 
 
The vegetative foreign bodies and non vegetative foreign bodies are shown below.   
 
 
 
 
 Vegetative Foreign Bodies 
 
 
        Betelnut                                 Peanut                         Watermelon seed           Custard apple seed 
 
Non Vegetative Foreign Bodies 
 
 
 
        
                       Hair pin                                                  Screw                                 Pen cap           
 
   Complications: 
  In our series of 50 cases we have not encountered any complications due to bronchoscopy.  
 
Review of Literature: 
Foreign  bodies  in  the  bronchi  are  a  common  problem  seen  by  E.N.T.  surgeons.  The  high 
frequency of this problem in children in our series concurs with the observations of other authors 
[7, 8, 9]. 
The  child  has  difficulty  in  swallowing  hard  foodstuffs  such  as  nuts  and  seeds,  and  has  inadequately 
developed protective respiratory reflexes 
[10], making it more vulnerable than adults to the inhalation of 
foreign bodies into the respiratory passage.   
The male predominance in this series is in agreement with the published reports 
[2, 7, 8]. A possible 
explanation for this is offered by Gupta et a1 
[8] who state that "boys by nature are more curious and 
inquisitive than girls."  
The  high  predominance  of  organic  foreign  bodies  in  this  series  is  in  keeping  with  published 
reports
  [2,  7,  8].  This,  coupled  with  the  high  frequency  in  children  under  the  age  of  3  years  makes  it 
advisable not to offer nuts and seeds to small children, who are liable to aspirate them into the respiratory 
passage.  
We encountered 2 patients with metallic foreign bodies and 1 plastic pen cap. Merchant et al
 [11] 
reported 4 cases of plastic foreign bodies in the bronchus.  
The age of the child seems to determine the relative frequencies of organic and inorganic foreign 
bodies, probably because infants of this age tend to put anything that they can grasp into their mouth. 
However, older infants and children have a higher frequency of organic foreign bodies, many of which are 
edible. These older infants and children can discriminate between edible and non-edible material. There 
are incidents of elder sibling thrusting foreign bodies in the younger sibling’s oral cavity. Contrary to what 
is commonly believed 
[9] the frequency of foreign bodies in the right and left bronchus was very similar in 
this series. This has also been reported by other workers 
[2, 8, 11, 12].Only 12% of patients presented within 
24 hours and about 46% came between the 2
nd and the 7
th day, while 14% of patients and 28% of them 
presented within 24 hours and between 2
nd day and 7
th day in the study by J. Srppnath et al.  Only 62% of the patients had history of inhalation of a foreign body,  while in the study of J. 
Srppnath et al 60% and 76% in the study of Merchant et al.  Thus pediatrician must therefore, always 
keep the foreign body in mind when dealing with a respiratory case 
[9, 13]. 
Fever was present in 44% of cases of organic foreign bodies; this confirms the observation of 
Jackson and Jackson 
[9] that organic foreign bodies are liable to evoke violent laryngo-tracheal bronchitis 
and to predispose to lung infection. 
 
                    The  commonest  radiological  finding  was  obstructive  emphysema  (58%  cases).  This  is  in 
confirmity with other reports 
[9, 11] Further, X-rays of the chest were completely normal in 10% cases while 
it was 19% in the study of Merchant et al 
[11]. This would indicate that even a normal X-ray of the chest 
does  not  negate  the  diagnosis  of  a  foreign  body  in  the  respiratory  passage.  In  21  cases  flexible 
bronchoscopy  was  performed  to  find  out  the  cause  of  breathlessness  not  responding  to  medical 
management and foreign  body  was diagnosed  and  the  patient underwent rigid bronchoscopy  without 
further delay for foreign body removal. Just localization of the foreign body during fibreoptic bronchoscopy 
allows subsequent rigid bronchoscopy to be shorter in duration with fewer complications. Foreign body 
aspiration  should  always  be  considered  in  the  aetiology  of  recurrent  pulmonary  infections,  fibrotic 
changes  such  scar  formation  and  bronchiectasis  all  of  which  may  necessitate  a  surgical  resection. 
Removal of the foreign body in such cases can achieve the resolution of the parenchymal or bronchial 
pathology and prevent unnecessary surgery 
[15]. A good thumb rule used in the assessment of airway 
foreign body is that diagnostic bronchoscopy should be performed if any of the three diagnostic tools 
(history, physical examination, or radiography) is considered positive 
[14]. 
       Tracheotomy was performed in 1 case of tamarind seed in our series while in 4 cases of 342 cases in 
study by Singh J K et al 
[1], indications being long standing subglottic foreign bodies, sharp subglottic 
foreign bodies and foreign bodies that were larger than glottis chink. There were no complications during 
bronchoscopy, similar to lower complication of bronchoscopy studied by Gursu Kiyan et al 
[16]. 
      Chevalier Jackson's 
[9] advice (1950) about the need for educating the parents and doctors about 
foreign bodies in the respiratory tract is as valid today as it was when it was pronounced. 
 Conclusion: 
  Otolaryngologist must proceed for bronchoscopy even if there is mere suspicion of foreign body. 
Flexible bronchoscopy if available will aid in diagnosis of long standing foreign body and its removal can 
be done immediately without delay. There should not be any compromise on the availability of various 
types  of  instruments  for  bronchoscopy.  Tracheotomy  is  indicated  if  foreign  body  cannot  be  removed 
through glottis. A team work of anesthetist, endoscopist, and assistants is essential to ensure safety of 
procedure which prevents most of intra-operative and post-operative complications. 
 
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Management of Tracheo Bronchial Foreign Bodies in Children – A Retrospective Study of series of 50 cases

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Management of Tracheo Bronchial Foreign Bodies in Children – A Retrospective Study of series of 50 cases

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