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Table of Contents
Year : 2003  |  Volume : 5  |  Issue : 1  |  Page : 10-14

Diagnosis of foreign body aspiration in children

Department of Otolaryngology, King Saud University, Faculty of Medicine, Riyadh, Kingdom of Saudi Arabia

Date of Web Publication11-Jul-2020

Correspondence Address:
MD, FKSU Ahmed Y Al-Ammar
King Abulaziz University Hospital, P.O Box 61419, Riyadh 11565
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-8491.289559

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Objective: To assess the diagnostic value of symptoms, signs, and imaging studies of Iaryngo-tracheo- bronchial foreign bodies (FBS).
Methods: A retrospective analysis of data available from files of 39 consecutive children with presumptive diagnosis of FB aspiration. Based on bronchoscopic findings children were divided into group A (30 children) with FB aspiration, and group B (9 children) no FB aspiration. Comparison between findings in each group was carried out.
Result: History, considering coughing and choking together, had a sensitivity of 67% and specificity of 78% for FB aspiration. The combination of unilateral reduction of air entry with wheezing resulted in a specificity of 100%, however, with a sensitivity of 17% only for FB aspiration. Chest radiograph was found to have a sensitivity of 57% and a specificity of 50% for FB aspiration.
Conclusion: The diagnosis of aspirated FBs should take an advantage of all the available indicators of airway FBS, and above all implement high index of suspicion. This study shows that history seems to have a more diagnostic value than physical examination and chest radiography

Keywords: Airway foreign body; aspiration; tracheobronchial tree; choking

How to cite this article:
Al-Ammar AY. Diagnosis of foreign body aspiration in children. Saudi J Otorhinolaryngol Head Neck Surg 2003;5:10-4

How to cite this URL:
Al-Ammar AY. Diagnosis of foreign body aspiration in children. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2003 [cited 2022 Dec 8];5:10-4. Available from: https://www.sjohns.org/text.asp?2003/5/1/10/289559

  Introduction Top

Foreign Body (FB) aspiration is a very distressing problem to the patient as well as to the doctor. The annual incidence of death from FBs aspiration has been estimated to range between 500-2000 in the United States of America. [1]

Children with airway foreign body, may first present to the pediatrician, pediatric surgeon or the otolaryngologist. History of FB aspiration may be clear, as the child was attended by parents or an attendant who witnesses the incidence. However, the presentation of children with foreign body may not be obvious. Absence of history suggestive of FB aspiration is reported in 50% of patients.[2] The symptoms and/or the signs may not be typical of airway FB or the radiological findings do not support its presence. About 20-24% of children with FB aspiration are treated initially for other respiratory problems before the actual diagnosis is made. [3],[4]

Children with airway FB may be encountered early, late or during complication stage.[5],[14] In the early phase, children may present with choking, difficulty of breathing, stridor or wheeze, coughing, drooling or odynophagia.

This phase may be followed by a period where the presentation is less severe, instead the child may have symptoms and signs mimicking chronic lung diseases, such as bronchial asthma and or recurrent croup. In the complication phase, problems that include lung abscesses, perforation into a nearby structure may be encountered.

For the diagnosis of airway FB, a high index of suspicion has to be implemented.[14] It is reported in the literature [8],[14] that factors including choking, sudden onset coughing, unilateral wheezing, unilateral reduction of air entry, and radiological finding of emphysema and atelectasis are more reliable indicator of FB aspiration.

The question of which is more important for the diagnosis of FB, history, physical examination or radiological findings is very difficult to answer.

The objective of this study is to assess the diagnostic value of symptoms, signs and imaging studies of laryngo-tracheo-bronchial FBs.

  Materials and Methods Top

The files of thirty-nine consecutive children, who underwent laryngo-tracheo-bronchoscopy for possible FB aspiration at King Abdulaziz University Hospital in Riyadh, Saudi Arabia, between January 1991 and December 2000, were reviewed.

All patients underwent bronchoscopy utilizing bronchoscope and Hopkins telescope system, along with different types of FB removal forceps. For the sake of bronchoscopy patients were maintained spontaneous breathing with inhalation anesthesia tell the end of procedure.

The age, sex presenting symptoms, physical examination findings, radiological findings and laryngo- bronchoscopic findings were reviewed. A trial was made to assess the weight of symptoms, signs were reviewed and radiological findings in the diagnostic process of FB aspiration by comparing them to the bronchoscopy findings.

Based on bronchoscopy, FB was documented in the tracheobronchial tree of 30 children (Group A); in nine children no FB was found (Group B).

Excluded from this study children with FB of the nose, pharynx, or esophagus. All patients older than 16 years were excluded.

  Results Top

Thirty-nine children underwent laryngo-tracheo- bronchoscopy; the preliminary diagnosis being laryngotracheo-bronchial FB aspiration. There were 25 males and 14 females. Their age ranged between 9 months and 16 years with a mean age of 28.5 months.

Bronchoscopy confirmed the inhalation of FB in 30 children (Group A), inhalation of FB was excluded by laryngo-tracheo-bronchoscopy in 9 children (Group B)

Most of the children (67%) in group A presented within the first 24 hours after appearance of symptoms; the remaining presented between 2 and 30 days. In group B, the presentation was more delayed and ranged between 2 days and 18 months. FB was located at the larynx in 3 children, at the trachea in 7 children, and the rest were located either in the right (12 children) or left (8 children) bronchus.

Three of the bronchial FBs were localized at the upper lobe bronchus, two in the left and one in the right side.

Seventy-seven percent of FBs were organic in nature. With watermelon seed or seed cover being the most common type, accounting for 53% of the FBS.

The commonest presenting symptom in both Groups was cough. It was found in 87 % and 80 % of the children in each group respectively. Cough had a sensitivity of 87 %; and a very low specificity of 22% for FB aspiration.

Choking on the other hand was the next common presenting symptom in GroupA, affected 77 % of the children. It had a sensitivity of 77 %, however it was more specific than coughing, with a specificity of 67 %. Other presenting symptoms are shown in [Table 1].
Table 1: Freqency of presenting symptoms in Group A and B

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Sixteen of the children in Group A (53%) showed reduction of air entry either in one side or bilateral, however, the reduction of air entry did not match the location of FB by bronchoscopy in 4 cases [Table 2]. Sensitivity of unilateral reduction of air entry as an indicator of presence of FB was found to be 43 %, while it had a specificity of 78 %.
Table 2: The matching between the possible location of FB according to the physical examination and bronchoscopic finding.

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Nineteen children in Group A (63%) presented with wheezing. Seven of them had unilateral wheezing. FB was found in the contra lateral side in one of them.

Twelve children had bilateral wheezing; in four of them the FBs were located in one of the main stem bronchi [Table 2]. Wheezing has specificity of 67 % for FB aspiration.

Stridor was found in 7 children in Group A and 4 children in Group B.

Routine chest radiograph was done for all the patients except two of them; one with laryngeal FB diagnosed by fiberoptic scope and the other patient was distressed and had to be rushed to the operating room. Combination of inspiration and expiration chest radiograph was obtained in 11 patients in group A.

Abnormalities in chest x-ray were demonstrated in 57 % of Group A and 89 % of Group B [Table 3]. X-Ray was done within few hours to 10 days of appearance of symptoms. Emphysema was demonstrated in 28 % of children in Group A. In all of them, it matched the location of FB by bronchoscopy. Emphysema was found in 37 % of children in Group B.
Table 3: Finding on chest X-Ray for the two group of children.

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Atelectasis on the other hand was seen in 11 % of children in Group A. This finding matched the location of FB by bronchoscopy.

Demonstration of FB on chest X-Ray was achieved in 5 children (18 %) of Group A. X-ray demonstrated two laryngeal FB (safety pin and a piece of wood). Another laryngeal FB was missed radio- logically (water melon seed). Two out of seven tracheal FB were demonstrated by chest X-Ray (all water melon seed). Only one (watermelon seed) out of 20 bronchial FB was demonstrated by chest X-Ray.

Considering radiological finding of emphysema, attlectasis, and demonstration of FB, chest x-ray had a sensitivity of 57 % and a specificity of 50 % for FB aspiration.

The more reliable indicatos of FB aspiration like history of chocking, reduction of air entry, wheezing and findings on chest x-ray were all present together in 5 (17%) children in Group A. On the other hand, presentation with at least one of those finings was seen in all the children in Group B.

  Discussion Top

Young children especially between 1 and 3 years of age are particularly at higher risk of FB inhalation[2],[4],[5],[6],[8],[9].

FB may be lodged anywhere along the children’s airway depending on the size and shape of FB and on physical and anatomical factors of the airway.

Bronchial FBs were more common in the right side in our study, which is in agreement with other studies [7],[12],[13],[17]. FBs are often in a dynamic state and can change location,[10],[12] this was confirmed by the miss-match we encountered between the physical examination and bronchoscopic findings [Table 2].

Extraction of FBs utilizing the bronchoscope and Hopkins telescope system along with telescope- guided FB forceps is associated with fewer missed and incomplete removal of FBs.[l] However, the size, shape or the location of FB may require def- firent removal techniques such as tracheostomy or thoracotomy [11],[17],

The type of aspirated FB is based on the life style of the patient, however organic materials were found to be the commonest in this study. This is in agreement with other studies [7],[17], Uncommon iatrogenic FBs may also be encountered e.g. tip of suction catheter and fractured tracheostomy tube [15],[16],

Diagnosis of FB aspiration may be faced with a lot of difficulties. Matching the symptoms with signs and radiological findings does not lead to the diagnosis in so many cases. Oguz et al 2000, found the complete triad of cough, wheezing and unilateral reduction of breath sounds in only 23% of their patients [14].

In our study the reliable findings indicating FB aspiration were found in only 17 % of the children Hence, the diagnosis of FB aspiration based on the entire reliable indicators may result in false negative diagnosis in 83% of patients. This indicates that it is clinically impractical to reach the diagnosis of FB aspiration based on all of the reliable indicators.

On the other hand, making the diagnosis of FB aspiration based on one indicator only has other difficulties. This can be demonstrated clearly from our data.

Cough, either sudden onset or persistent, may be associated with a divergent respiratory problems and is nonspecific indicator of FB aspiration.[8] Despite having high sensitivity in this study and other studies, its specificity was only 22% in our study [12].

We found choking to be more reliable indicator of FB aspiration than coughing, with sensitivity of 77 % and specificity of 67 %. This is in line with the finding of Metrangolo et at. [9] Choking, however, is not specific according to other studies.[8] History alone, considering coughing and choking together, based on our data had a sensitivity of 67 % and specificity of 78 % for FB aspiration.

Unilateral reduction of air entry was the most specific indicator of FB aspiration in this study. This specificity was elevated up to 100 % when it was. combined with wheezing. On the other hand, this combination resulted in a very low sensitivity of 17 % only. This specificity is not on agreement with the reported specificity of the combined signs and symptoms of FB aspiration, (11.7 %) [9].

Chest radiography can be very informative, especially if inspiratory and expiratory films are done. Lateral decubitus and fluoroscopy can add to the diagnostic accuracy in uncooperative chil- dren.[2],[5],[8],[10] Unfortunately, inspiratory and expiratory films were done only for 11 patients (37%) in Group A.

Air-trapping can be demonstrated more commonly in the early period after FB aspiration in 65% of children, while atelectasis develops more slowly and becomes more apparent later on in about 25% of patients.[4],[5],[13] Air-trapping and atelectasis were demonstrated in 37% and 11% successively in group A patients.

Radioopaque FBs can be demonstrated in 5% of the children with FB aspiration,[4] but in our study radioopaque FBs were seen in 18% of children in group A. Laryngeal FBs were more easy to demon strate on x-ray than tracheal or bronchial FBs. This could be related to the size of FB.

In assessing FB, chest radiograph in general had a sensitivity of 57 % and a specificity of 50 %. ‘Sensitivity of about 70 % and specificity of 45-62 % is reported in other studies.[2],[9],[18]

However, normal chest radiograph can be seen in 7- 32% of patient with bronchial FB and in 60-80% of laryngotracheal FBs, depending on the study.[5],[6],[12],[13] We have seen normal chest x-ray in 43% of children in group A. However, normal chest x-ray should not preclude bronchoscopy if there is strong clinical suspicion.

From our data, we consider history, despite having lower specificity compared to physical examination, to have more diagnostic value of FB aspiration. This is because history has more sensitivity compared to both physical examination and chest radiograph.

However, it is very important to take advantage of all the diagnostic indicator of FB aspiration in order to avoid the morbidity and mortality of missing this distressing situation.

In conclusion, the diagnosis of aspirated FBs should take advantage of all the available indicators of airway FB, and above all have a high index of suspicion. From this study, history seems to have a more diagnostic value than physical examination and chest radiography. However, to come with more reliable results and conclusions, larger number of children have to be studied in prospective studies with a clear protocol assessing the children’s symptoms, signs and radiological findings ahead of bronchoscopy.

  References Top

Inglis AF, Wagner DV. Lower complication rates associated with bronchial foreign bodies over the last 20 years. Ann Otol Rhinol Laryngol 1992;101:61-66.  Back to cited text no. 1
Friedman EM. Tracheobronchial foreign bodies. Otolaryngol Clin North Am 2000; 33(1):179-185.  Back to cited text no. 2
Cohen SR., Lewis FH. The emergency management of caustic ingestions. Emerg Med Clin North Am 1984; 2:77-86.  Back to cited text no. 3
Steen KH, Zimmermann T. Tracheobronchial aspiration of foreign bodies in children: A study of 94 cases. Laryngoscope 1990; 100:525-530.  Back to cited text no. 4
Messner AH. Pitfalls in the diagnosis of aerodigestive tract foreign bodies. Clin Ped 1998; 37(6):359-365.  Back to cited text no. 5
Baharloo F, Veyckemans F, Francis C, Biettlot MP, Rodenstein DO. Tracheobronchial foreign bodies: Presentation and management in children and adults. Chest 1999; 115(5): 1357-1362.  Back to cited text no. 6
El-Sayed Y, Ismail S. Foreign bodies in the tracheobronchial tree. Saudi Med J 1996;17(I):73-77.  Back to cited text no. 7
Hoeve LJ, Rombout J, Pot DJ. Foreign body aspiration in children. The diagnostic value of signs, symptoms and pre-operative examination. Clin Otolaryngol 1993; 18:55-57.  Back to cited text no. 8
Metrangolo S, Monetti C, Meneghini L, Zadra N, Giusti F. Eight years’ experience with foreign-body aspiration in children: what is really important for a timely diagnosis?. J Pediatr Surg 1999; 34(8): 1229-1231.  Back to cited text no. 9
Healy GB. Management of tracheobroncial foreign bodies in children: an update. Ann Otol Rhinol Laryngol 1990; 99:889-891.  Back to cited text no. 10
Zeitlin J, Myer CM. Foreign body in the trachea. Ann Otol Rhinol Laryngol 2000; 109:1007-1008.  Back to cited text no. 11
Wolach B, Raz A, Weinberg J, Mikulski Y, Ari JB, Sadan N. Aspirated foreign bodies in the respiratory tract of children: eleven years experience with 127 patients. Int J Pediatr Otorhinolaryngol 1994; 30: 1-10.  Back to cited text no. 12
Liancai Mu, Deqiang Sun, Ping He. Radiological diagnosis of aspirated foreign bodies in children- Review of 343 cases. J Laryngol Otol 1990; 104: 778-782.  Back to cited text no. 13
Oguz F, Citak A, Unuvar E, Sidal M. Airway foreign bodies in childhood. Int J Pediatr Otorhinolarvneol 2000; 52: 11-16.  Back to cited text no. 14
Shapiro NL, Kaselonis GL. Tracheobronchial foreign body management in an acutely ill neonate Int I Pediatr Otorhinolaryngol 2000; 52:75-77.  Back to cited text no. 15
Gana PN, Takwoingi YM. Fractured tracheostomy tubes in the tracheobronchial tree of a child Int J Pediatr Otorhinolaryngol 2000; 53:45-48.  Back to cited text no. 16
Oguzkaya F, Akcali Y, Kahraman C, Bilgin M, Sahin A. Tracheobronchial foreign body aspirations in childhood: a 10-year experience. Eur J Cardiothorac Surg 1998; 14(4):388-392.  Back to cited text no. 17
Silva AB, Muntz HR, Clary R. Utility of conventional radiography in the diagnosis and management of pediatric airway foreign bodies. Ann Otol Rhinol Laryngol 1998; 107 834-838.  Back to cited text no. 18


  [Table 1], [Table 2], [Table 3]


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