Dr. Terencia, Dr Sajith Kesavan, Dr Greeshma, Dr. C Jayakumar AIMS Kochi
5 years old male child with alleged history of foreign body(front incisor) ingestion during sleep on 26/08/24. Child was evaluated in an outside hospital and foreign body was opined to be in the right lower lobe bronchus. Attempted to extract the foreign body but failed retrieving it and was hence brought here for further evaluation and management.
Perinatal history-Uneventful
No significant past history with no admissions in the past.
Development history- Age appropriate milestones attained
Immunization history- Vaccinated up to age according to NIS
On examination-Child was alert, afebrile
Vitals-HR-88/min, RR-24/min, SPO2-98%RA, CRT <2S
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
No dysmorphic features, No NCM
Systemic examination-
RS-NVBS, AEBE
CVS-S1S2 +
P/a=Soft, NT, BS +
CNS-NFND
Initial labs showed normal counts. LFT, RFT, S.Electrolytes were within normal limits.
Figure-1:- CXR showing foreign body in right lower lobe bronchus.
MDCT chest was done and showed Foreign body(displaced incisor) in right lower lobe bronchus, just below superior segmental bronchus and bridging between the posterior and lateral basal segmental bronchial take off.
After getting consent child was taken up for flexible bronchoscopy in PICU which showed a piece of tooth (missing front incisor) which was wedged in the lateral segment of right lower lobe bronchus which was removed via cryoextraction. Child was intubated for the procedure and was eventually weaned off to room air. Procedure was uneventful and child was stabilized and shifted to ward. Child remained stable and was hence discharged with stable vitals.
Airway foreign bodies in children
●Clinical presentation – Foreign body aspiration (FBA) should be suspected in children who have sudden onset of lower respiratory symptoms or those who do not respond to standard management of other suspected etiologies such as pneumonia, asthma, or croup. The risk is highest in children between one and three years of age.
●History – A history of choking is highly suggestive of FBA, even if it occurred days or weeks before presentation. The episode may be immediately followed respiratory symptoms or there may be a symptom-free period, which must not be misinterpreted as a sign of resolution, since it may delay the diagnosis. The absence of choking history does not rule out FBA, since choking events may be unwitnessed or unrecalled.
●Evaluation – The sequence of evaluation and management depends on the clinical characteristics of the patient at presentation and during the initial workup. Patients with complete or impending airway obstruction move immediately to intervention, whereas stable patients with suspected FBA undergo further evaluation.
•Life-threatening airway obstruction – Children with complete airway obstruction (ie, unable to speak or cough) require immediate resuscitation and examination of the airway
•Suspected FBA – For patients with suspected FBA who are asymptomatic or symptomatic but stable, the first step in the evaluation is to perform plain radiography of the chest with posteroanterior and lateral (or decubitus) views. Ideally, both inspiratory and expiratory (decubitus) radiographs should be obtained because this may increase the sensitivity for detecting a radiolucent FB, but this may be challenging to obtain in young children.
Subsequent steps depend on the degree of clinical suspicion for FBA. Normal radiographic studies do not exclude the presence of an aspirated FB.
–Moderate-high suspicion – A moderate or high suspicion of FBA is appropriate for all children with a witnessed FBA (regardless of symptoms), as well as for young children with suspicious respiratory symptoms or characteristics on imaging, especially if there is a history of choking. Suspicious symptoms include cyanotic spells, dyspnea, stridor, sudden onset of cough or wheezing (often focal and monophonic), and/or unilaterally diminished breath sounds.
Stable patients with a high clinical suspicion of FBA usually should proceed to bronchoscopy, even if the plain radiographs are normal or inconclusive. For patients with moderate clinical suspicion for FBA, a reasonable alternative is a nonsedated airway CT, if a low-dose, high-speed, unsedated protocol is available. Flexible rather than rigid bronchoscopy may be used for diagnostic purposes in cases in which the diagnosis is unclear or if the FBA is known but the location of the object is unclear.
–Low suspicion – A low suspicion of FBA is appropriate if none of the above features are present. In this case, normal results of plain radiographs are sufficient to exclude radiopaque FBA and lessen (but not completely eliminate) the concern for a radiolucent FBA. However, such patients should be observed, with follow-up in two to three days and further evaluation (eg, CT or bronchoscopy) if symptoms persist or progress.
●FB removal – We suggest rigid rather than flexible bronchoscopy for removal of most aspirated FBs in children ; this procedure should be performed an experienced operator. Flexible bronchoscopy is also used to remove the FB in some centers with high levels of experience in this technique
●Prevention – Prevention of pediatric FBA is possible through legislation, caregiver education, and continued product safety vigilance.
Take over message:- Tracheobronchial foreign body aspiration (FBA) is a potentially life-threatening event because it can block respiration obstructing the airway, there impairing oxygenation and ventilation. FBA in children may be suspected on the basis of a choking episode if such an episode is witnessed an adult or remembered the child. In contrast, the clinical presentation of unwitnessed FBA may be subtle, and diagnosis requires careful review of the history, clinical assessment, and the judicious use of radiography and bronchoscopy.