CASE REPORTS

Case 1

A 2 year old boy presented to the emergency department with wheeze and cough. His symptoms had followed a choking episode while eating a chicken leg two days previously. A chest radiograph was interpreted as normal and he was given inhaled bronchodilator with some improvement and was allowed home. He continued to wheeze and cough and re-presented four weeks later. He was sent home but on review the next day had expiratory wheeze that was louder on the left side of his chest. Inspiratory and expiratory chest radiographs showed left sided hyperinflation (fig 1). Flexible bronchoscopy under general anaesthesia revealed a foreign body in the left main bronchus and a chicken bone was removed with rigid bronchoscopy.

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Figure 1

Expiratory chest radiograph showing left sided hyperlucency.

Case 2

A 2 year old boy developed noisy breathing after a choking episode while playing with a pistachio nut shell. The next day he had increasing difficulty in breathing and his general practitioner referred the child to the emergency department. He was thought to have acute asthma and was given nebulised bronchodilators, oral corticosteroid, and then an aminophylline infusion. After five hours of treatment there was little improvement and he continued to have noisy breathing, recession, and tachynpoea. A chest radiograph showed bilateral hyperinflation. On review he had biphasic stridor more likely to be attributable to upper airway obstruction. He underwent rigid bronchoscopy under general anaesthesia with removal of a pistachio nut shell from just under the vocal cords (fig 2).

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Figure 2

Rigid laryngoscopy showing pistachio nut shell in trachea just below vocal cords.

Case 3

A 10 year old boy had a coughing fit while chewing on a pen top and subsequently realised that the inside of the pen top was missing. He was sent home from the local emergency department after a normal chest radiograph. Two days later he started to wheeze and cough. A chest radiograph was again normal, but he had wheeze that was louder on the right side of the chest and a fever. He was given intravenous antibiotics but he did not improve and the following day was transferred to the regional paediatric centre for assessment. With rigid bronchoscopy under general anaesthesia the pen top was removed from his right main bronchus.

DISCUSSION

Foreign body aspiration by children, especially those below the age of 3 years, is common.¹ If it causes airway occlusion it may lead to asphyxia and it is unfortunately a leading cause of death in childhood.³ However, it more often presents with a history of an initial episode of choking and coughing with subsequent respiratory symptoms.^1,2 These include cough, wheeze, stridor, or pneumonia. The most common physical sign is decreased or abnormal breath sounds.^1,4 Most inhaled foreign bodies in children are food items, with peanuts being the most common.⁴

However, there is often significant delay until the diagnosis is made.^1,4,5 In one series a delay of over three days between aspiration and removal of the foreign body was reported in almost 30% of children.¹ This may be attributable to a high rate of initial alternative diagnoses and this occurred in 24% of cases in a separate series.⁴ Foreign body aspiration can be misdiagnosed as asthma, upper respiratory tract infection, pneumonia, or croup.¹ Delay in diagnosis is associated with increased morbidity, especially respiratory infection.⁵

Most foreign bodies in children are radiolucent, but they may be associated with hyperinflation, atelectasis, or consolidation. In a series of 189 children with proven foreign body aspiration, 90 cases (47.6%) had normal chest radiographs.⁶ Inspiratory and expiratory films, and fluoroscopy can provide extra information, but even these may be normal in children who later are found to have an inhaled foreign body at bronchoscopy.¹ Probably the most important feature of aspirated foreign bodies in children is the initial history of choking. In a series of 87 children who underwent bronchoscopy, a history of a choking episode was present in 67 of 70 with a foreign body and in only 4 of 17 without a foreign body.² The choking history showed a sensitivity of 96% and a specificity of 76%. However, the episode may be unwitnessed, or volunteered only after specific inquiry.⁵

When there is impaction of a foreign body in a major airway with acute respiratory distress and hypoxia the child should be resuscitated according to accepted guidelines.⁷ If urgent operative removal is required it should be carried out by the most experienced surgical and anaesthetic personnel available. However, when an emergency procedure is not indicated then transfer to a centre with regular experience of airway endoscopy in children should occur. In our centre we prefer to have available the option of both flexible and rigid bronchoscopy. If the diagnosis is in doubt flexible bronchoscopy can be used to examine more distal parts of the bronchial tree and more confidently exclude a foreign body than rigid bronchoscopy.⁸ However, flexible bronchoscopy plays little part in the extraction of foreign bodies.

Children who have a sudden onset of choking and coughing should be taken seriously. Most important is a thorough history of the initial episode and if there are persistent symptoms then the child should be referred for bronchoscopic evaluation.

Contributors

Tom Hilliard had the original idea, performed the literature search, and produced the draft manuscript. Richard Sim commented on the draft manuscript. Mike Saunders, Simon Langton Hewer and John Henderson were responsible for the management of the three cases and commented on the draft manuscript. John Henderson is guarantor for the article.