BRIEF REPORT
Expectoration of a Foreign Body at the Late Period A Case Report Tuba Tuncel, MD,* Pinar Uysal, MD,* Fatih Firinci, MD,* Zeynep A. Ayyildiz, MD,* Ozkan Karaman, MD,* Handan Cakmakci, MD,w and Nevin Uzuner, MD*
Summary: Foreign body (FB) aspiration is a relatively
common problem in children, particularly during the first 3 years of life. It is an emergency condition and the removal of the FB by bronchoscopy is the primary treatment. Children with undiagnosed retained foreign bodies may present with respiratory symptoms including recurrent or persistent wheezing, with or without respiratory failure. Spontaneous expectoration of a FB is a rare occurrence. Herein, we present a case that was diagnosed with FB aspiration during investigation for persistent wheezing and who expectorated part of a sunflower seed 2 months after aspiration. Key Words: aspiration, bronchoscopy, foreign body, pediatric airway, wheezing (J Bronchol Intervent Pulmonol 2014;21:93–95)
F
oreign body (FB) aspiration is a common accident in children and a significant cause of morbidity and mortality. FB aspirations account for 5% of deaths among children younger than 4 years of age.1 Spontaneous expectoration of an FB is rare and bronchoscopy must be performed immediately when FB aspiration is suspected. CASE REPORT A 20-month-old girl was admitted to our clinic with recurrent wheezing. Her past medical history was normal until 6 months of age. At 6 months, her wheezing started and she presented thrice to the emergency room with respiratory distress. The patient’s most recent complaint persisted for 2 months before hospital admission. Although her wheezing regressed moderately following albuterol and budesonide treatment, it recurred after discontinuation of the medications. She was referred for further evaluation into causative of the persistent
Received for publication April 16, 2013; accepted December 2, 2013. From the *Department of Pediatrics, Division of Allergy; and wDepartment of Radiology, Dokuz Eylul University Hospital, 35340, Inciralti, Izmir, Turkey. Disclosure: There is no conflict of interest or other disclosure. Reprints: Tuba Tuncel, MD, Department of Pediatrics, Division of Allergy, Dokuz Eylul University Hospital, 35340, Inciralti, Izmir, Turkey (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
J Bronchol Intervent Pulmonol
wheezing. Her personal history was unremarkable for atopy, immune deficiency, FB aspiration, reflux disease, or cystic fibrosis. In her family history, only her grandmother had a history of asthma and allergic rhinitis. On hospitalization, she exhibited wheezing without respiratory failure. Her physical examination findings were as follows: respiratory rate 30/min, heart rate 120/min, 97% oxygen saturation by pulse oximeter on room air, and wheezing. Her weight and height percentile was normal. Breath sounds were diminished in the left lung. The chest x-ray revealed hyperinflation on the left side. Thoracic computed tomography revealed an FB in the left mean bronchus (Fig. 1). The patient’s past history was evaluated again and her mother remembered that she had choked, coughed, and had cyanosis after eating a sunflower seed 2 months previously. She had recovered spontaneously for a short time and her family ignored the event. The patient was hospitalized for bronchoscopy for removal of the FB. The procedure was not thought to be emergent because the patient had no respiratory failure, and the bronchoscopy was scheduled for the next day. Nebulized albuterol was administered to treat the auscultation findings. One day after hospital admission, the patient began to cough suddenly and repeatedly. After 1 minute in to her coughing bout she expectorated a hull of a sunflower seed. Her breath sounds and chest x-ray became normal. Rigid bronchoscopy was performed to rule out any remnant portions of the FB and none were detected. Investigations into the recurrent wheezing including immunoglobulins, specific immunoglobulin E against inhalant, common food allergens, and sweat test were all normal. The patient’s symptoms regressed before she was discharged from the hospital. She had no respiratory complaint throughout 2 years of follow-up period. DISCUSSION
FB aspiration is a common problem in childhood, particularly in the first 3 years of life.1 Foods and small toy parts are the most frequently aspirated substances. The most commonly aspirated foods are peanuts, fruit seeds, and sunflower seeds, although these may change according to the local eating habits.2 In our
Volume 21, Number 1, January 2014
www.bronchology.com |
93
Tuncel et al
J Bronchol Intervent Pulmonol
FIGURE 1. Hyperinflation of the left lung (L) and foreign body in the left mean bronchus (red arrow) at thoracic computed tomography image.
country, the sunflower seed is the most commonly aspirated material.3 The diagnosis of FB aspiration is based on patient history, physical examination, and radiologic images. Patients may present at the hospital with cyanosis, choking, cough, wheezing, or stridor.4 If the aspiration is observed by family, the diagnosis is easy. However, frequently the aspiration is unnoticed or forgotten because of nonspecific symptoms. On such occasions, persistent or recurrent respiratory symptoms may exist without prominent respiratory insufficiency. FB was identified in 4.8% of cases in which flexible bronchoscopy was performed in children with atypical or persistent respiratory symptoms without known history of FB aspiration.5 Indeed, although our patient had an obvious aspiration history, she improved immediately and her parents subsequently forgot the event. The parents assumed that the subsequent symptoms represented a new wheezing episode similar to the previous ones. In patients with FB aspiration, decreased breath sounds on physical examination and air trapping on radiologic examination are the most common findings.4 In our case, because of the location of the TB in the left main bronchus, decreased breath sounds and increased aeration were detected in the left lung. FB aspiration is an emergency condition and once diagnosed, FB must be removed by rigid bronchoscopy. However, bronchoscopy may be postponed in stable conditions, even in the acute stage.6 In a single study, successful removal of the FB with physiotherapy and inhalational
94 | www.bronchology.com
Volume 21, Number 1, January 2014
therapy was reported. Using this method, if a patient is stable after FB aspiration, postural drainage may be performed for 5 to 10 minutes after a bronchodilator is administered via ultrasonic nebulizer. Inhalation-postural drainage is continued for 24 hours until the FB is expectorated. If an FB was not removed within 24 hours, bronchoscopy was performed. It was reported that 25% of FB were expectorated following inhalation-postural drainage. This method was successful in patients who had aspiration for
Expectoration of a Foreign Body at the Late Period A Case Report Tuba Tuncel, MD,* Pinar Uysal, MD,* Fatih Firinci, MD,* Zeynep A. Ayyildiz, MD,* Ozkan Karaman, MD,* Handan Cakmakci, MD,w and Nevin Uzuner, MD*
Summary: Foreign body (FB) aspiration is a relatively
common problem in children, particularly during the first 3 years of life. It is an emergency condition and the removal of the FB by bronchoscopy is the primary treatment. Children with undiagnosed retained foreign bodies may present with respiratory symptoms including recurrent or persistent wheezing, with or without respiratory failure. Spontaneous expectoration of a FB is a rare occurrence. Herein, we present a case that was diagnosed with FB aspiration during investigation for persistent wheezing and who expectorated part of a sunflower seed 2 months after aspiration. Key Words: aspiration, bronchoscopy, foreign body, pediatric airway, wheezing (J Bronchol Intervent Pulmonol 2014;21:93–95)
F
oreign body (FB) aspiration is a common accident in children and a significant cause of morbidity and mortality. FB aspirations account for 5% of deaths among children younger than 4 years of age.1 Spontaneous expectoration of an FB is rare and bronchoscopy must be performed immediately when FB aspiration is suspected. CASE REPORT A 20-month-old girl was admitted to our clinic with recurrent wheezing. Her past medical history was normal until 6 months of age. At 6 months, her wheezing started and she presented thrice to the emergency room with respiratory distress. The patient’s most recent complaint persisted for 2 months before hospital admission. Although her wheezing regressed moderately following albuterol and budesonide treatment, it recurred after discontinuation of the medications. She was referred for further evaluation into causative of the persistent
Received for publication April 16, 2013; accepted December 2, 2013. From the *Department of Pediatrics, Division of Allergy; and wDepartment of Radiology, Dokuz Eylul University Hospital, 35340, Inciralti, Izmir, Turkey. Disclosure: There is no conflict of interest or other disclosure. Reprints: Tuba Tuncel, MD, Department of Pediatrics, Division of Allergy, Dokuz Eylul University Hospital, 35340, Inciralti, Izmir, Turkey (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
J Bronchol Intervent Pulmonol
wheezing. Her personal history was unremarkable for atopy, immune deficiency, FB aspiration, reflux disease, or cystic fibrosis. In her family history, only her grandmother had a history of asthma and allergic rhinitis. On hospitalization, she exhibited wheezing without respiratory failure. Her physical examination findings were as follows: respiratory rate 30/min, heart rate 120/min, 97% oxygen saturation by pulse oximeter on room air, and wheezing. Her weight and height percentile was normal. Breath sounds were diminished in the left lung. The chest x-ray revealed hyperinflation on the left side. Thoracic computed tomography revealed an FB in the left mean bronchus (Fig. 1). The patient’s past history was evaluated again and her mother remembered that she had choked, coughed, and had cyanosis after eating a sunflower seed 2 months previously. She had recovered spontaneously for a short time and her family ignored the event. The patient was hospitalized for bronchoscopy for removal of the FB. The procedure was not thought to be emergent because the patient had no respiratory failure, and the bronchoscopy was scheduled for the next day. Nebulized albuterol was administered to treat the auscultation findings. One day after hospital admission, the patient began to cough suddenly and repeatedly. After 1 minute in to her coughing bout she expectorated a hull of a sunflower seed. Her breath sounds and chest x-ray became normal. Rigid bronchoscopy was performed to rule out any remnant portions of the FB and none were detected. Investigations into the recurrent wheezing including immunoglobulins, specific immunoglobulin E against inhalant, common food allergens, and sweat test were all normal. The patient’s symptoms regressed before she was discharged from the hospital. She had no respiratory complaint throughout 2 years of follow-up period. DISCUSSION
FB aspiration is a common problem in childhood, particularly in the first 3 years of life.1 Foods and small toy parts are the most frequently aspirated substances. The most commonly aspirated foods are peanuts, fruit seeds, and sunflower seeds, although these may change according to the local eating habits.2 In our
Volume 21, Number 1, January 2014
www.bronchology.com |
93
Tuncel et al
J Bronchol Intervent Pulmonol
FIGURE 1. Hyperinflation of the left lung (L) and foreign body in the left mean bronchus (red arrow) at thoracic computed tomography image.
country, the sunflower seed is the most commonly aspirated material.3 The diagnosis of FB aspiration is based on patient history, physical examination, and radiologic images. Patients may present at the hospital with cyanosis, choking, cough, wheezing, or stridor.4 If the aspiration is observed by family, the diagnosis is easy. However, frequently the aspiration is unnoticed or forgotten because of nonspecific symptoms. On such occasions, persistent or recurrent respiratory symptoms may exist without prominent respiratory insufficiency. FB was identified in 4.8% of cases in which flexible bronchoscopy was performed in children with atypical or persistent respiratory symptoms without known history of FB aspiration.5 Indeed, although our patient had an obvious aspiration history, she improved immediately and her parents subsequently forgot the event. The parents assumed that the subsequent symptoms represented a new wheezing episode similar to the previous ones. In patients with FB aspiration, decreased breath sounds on physical examination and air trapping on radiologic examination are the most common findings.4 In our case, because of the location of the TB in the left main bronchus, decreased breath sounds and increased aeration were detected in the left lung. FB aspiration is an emergency condition and once diagnosed, FB must be removed by rigid bronchoscopy. However, bronchoscopy may be postponed in stable conditions, even in the acute stage.6 In a single study, successful removal of the FB with physiotherapy and inhalational
94 | www.bronchology.com
Volume 21, Number 1, January 2014
therapy was reported. Using this method, if a patient is stable after FB aspiration, postural drainage may be performed for 5 to 10 minutes after a bronchodilator is administered via ultrasonic nebulizer. Inhalation-postural drainage is continued for 24 hours until the FB is expectorated. If an FB was not removed within 24 hours, bronchoscopy was performed. It was reported that 25% of FB were expectorated following inhalation-postural drainage. This method was successful in patients who had aspiration for
