Aspirated tracheobronchial foreign bodies: A Jordanian experience

ASPIRATED TRACHEOBRONCHIAL ORIGINAL FOREIGN ARTICLE BODIES: A JORDANIAN EXPERIENCE Aspirated tracheobronchial foreign bodies: A Jordanian experience Tareq Mahafza, FRCS; Yousef Khader, ScD Abstract We conducted a descriptive study of 524 patients who had been suspected of having aspirated a foreign body and who had been evaluated at one of two major hospitals in Jordan from January 1993 through December 2003. A tracheobronchial foreign body was found in 386 of these patients (73.7%). Most of them (66.8%) were younger than 2 years, and the male-to-female ratio was 3 to 2. The mean duration between aspiration and diagnosis was 48 hours. The most common presenting symptoms were cough (90.4% of foreign-body positive patients), diminished air entry (66.8%), and dyspnea (65.0%). The most frequently aspirated objects were seeds (35.4%), particularly watermelon seeds, nuts (26.8%), and vegetables (25.3%). The most common site of foreign-body impaction was the right bronchus (60.9%). Rigid bronchoscopy was used to remove the foreign body in all cases. The complication rate was 3.4%. Our experience with aspirated tracheobronchial foreign bodies in Jordan was not substantially different from that reported in other countries. The only difference was that the most frequently aspirated foreign body in our study was seeds. Introduction Foreign-body aspiration can be a serious concern, especially in children. It has been estimated that foreign-body aspiration is responsible for 7% of all accidental deaths in children younger than 4 years. 1 Aspirated foreign bodies may remain asymptomatic and undetected for a period of hours to years. 2,3 Most aspirated foreign bodies are organic primarily seeds, nuts, and other foods but plastics and metallic materials are not uncommon. 4-8 Laryngeal foreign bodies are rare because aspirated foreign bodies usually pass the larynx and migrate to the trachea and bronchi. In fact, most respiratory foreign bodies lodge in the right bronchus because it is so anatomically accessible. 4,5,9 The vast majority of patients with a From the ENT Department (Dr. Mahafza) and the Department of Community Medicine, Public Health, and Family Medicine (Dr. Khader), Jordan University of Science and Technology, Irbid, Jordan. Reprint requests: Dr. Tareq Mahafza, ENT Department, Jordan University of Science and Technology, Irbid, Jordan. Phone: 962-7-9555-5598; fax: 962-6-586-1620; e-mail: mahafza@just.edu.jo tracheobronchial foreign body are children, most of whom are younger than 3 years. 2,4,5,10-13 Inhaled foreign bodies should be removed because they pose a risk of serious complications, such as asphyxia, recurrent pneumonia, atelectasis, bronchiectasis, pneumothorax, granulation tissue, lung abscess, strictures, respiratory distress and, as mentioned, death. The usual method of dealing with an aspirated foreign body is rigid bronchoscopy. 4,6-9,12-16 In this article, we report the results of our descriptive study of aspirated tracheobronchial foreign bodies in Jordan, and we compare our findings with those of studies in other countries. Patients and methods We reviewed the records of 524 patients who had been suspected of having aspirated a foreign body from January 1993 through December 2003. All patients had been evaluated at one of two major hospitals in Jordan: Al Bashir Hospital in Amman and Princess Basma Hospital in Irbid. All patients had undergone rigid bronchoscopy for evaluation and, when necessary, foreign-body removal. Patients whose foreign body had been located in the pharynx, larynx, and esophagus were not included in this study. For tracheobronchial-foreign-body positive patients, data were recorded on each patient s age, sex, presenting symptoms, the interval between aspiration and presentation, the site and type of foreign body, the type of treatment provided, and any complications that occurred. Statistical analysis was performed with the Statistical Package for the Social Sciences (SPSS), version 11. Results Of the 524 patients, an aspirated tracheobronchial foreign body was found in 386 patients (73.7%) 230 males (59.6%) and 156 females (40.4%). The mean age of this group was 2.8 years; 258 patients (66.8%) were younger than 2 years, and 39 (10.1%) were older than 5 years. Although 193 patients (50.0%) presented within 2 hours of inhaling the foreign body, the mean duration between aspiration and diagnosis was 48 hours. The most common reason for a delayed diagnosis was that no parent witnessed the foreign body being aspirated. Volume 86, Number 2 107

MAHAFZA, KHADER Table 1. Incidence of symptoms (n = 386) Table 2. Type of foreign body (n = 336*) Symptom n (%) Foreign body n (%) Cough 349 (90.4) Diminished air entry 258 (66.8) Dyspnea 251 (65.0) Choking attack 222 (57.5) Wheezing 200 (51.8) Cyanosis 149 (38.6) Crepitations 75 (19.4) Fever 30 (7.8) Seeds 119 (35.4) Nuts 90 (26.8) Vegetables 85 (25.3) Plastics 17 (5.1) Metals 17 (5.1) Fish bones 8 (2.4) * The type of foreign body was specified in only 336 of the 386 cases. Watermelon, pumpkin, and sunflower seeds. The most common presenting symptoms were cough, diminished air entry and dyspnea (table 1). There was no difference between the sexes in the type or incidence of presenting symptoms. The foreign bodies had settled in the right bronchus in 235 patients (60.9%), in the left bronchus in 112 patients (29.0%), and in the trachea in 39 patients (10.1%). The type of foreign body found in the tracheobronchial tree was specified in only 336 cases. The most common were seeds (watermelon, sunflower, and pumpkin), nuts, and vegetables (table 2). Symptoms were more common in patients who had aspirated an organic foreign body than an inorganic foreign body (table 3). A total of 13 complications occurred (3.4%) 5 cases of pneumonia, 3 cases of atelectasis, 2 cases of pneumothorax, 1 case of bronchiectasis, 1 lung abscess, and 1 death. The Table 3. Distribution of symptoms by type of foreign body (n = 336*) Diminished Choking Foreign Cough air entry Dyspnea attack Wheezing Cyanosis Crepitations Fever body n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Seeds (n = 119) 105 (88.2) 58 (48.7) 77 (64.7) 68 (57.1) 61 (51.3) 47 (39.5) 6 (5.0) 9 (7.6) Nuts (n = 90) 82 (91.1) 72 (80.0) 57 (63.3) 53 (58.9) 73 (81.1) 39 (43.3) 20 (22.2) 8 (8.9) Vegetables (n = 85) 79 (92.9) 68 (80.0) 56 (65.9) 52 (61.2) 18 (21.2) 38 (44.7) 36 (42.4) 7 (8.2) Plastics (n = 17) 14 (82.4) 10 (58.8) 15 (88.2) 7 (41.2) 1 (5.9) 5 (29.4) 0 1 (5.9) Metals (n = 17) 13 (76.5) 10 (58.8) 7 (41.2) 7 (41.2) 0 5 (29.4) 0 0 Fish bones (n = 8) 7 (87.5) 0 5 (62.5) 5 (62.5) 2 ( 25.0) 4 (50.0) 1 (12.5) 0 * The type of foreign body was specified in only 336 of the 386 cases. 108 ENT-Ear, Nose & Throat Journal February 2007

ASPIRATED TRACHEOBRONCHIAL FOREIGN BODIES: A JORDANIAN EXPERIENCE fatality occurred in an 18-month-old with a foreign body in the trachea whose diagnosis had been delayed. Discussion The age distribution in our study 89.9% of our patients were younger than 5 years and 66.8% were younger than 2 years was in concordance with age ranges reported in other studies. 2,4,5,10-13 Several factors can explain the high incidence of aspirated foreign bodies in children: Children are not careful about what substances and objects they put in their mouth. Children often put more food in their mouth than they can properly chew and swallow. The swallowing mechanism is not completely developed in young children. Many children talk, laugh, and run while eating. The clinical presentation of the patients in our study was not different from that found in other studies. 4,5,7,9,12,13 Symptoms were more common in patients with an organic type of foreign body. Our finding that most (60.9%) foreign-body impactions occurred in the right bronchus was similar to results reported by others. 4,5,9,17,18 This finding can be explained by the more vertical position of the right bronchus and the fact that patients generally aspirate foreign bodies while they are in an upright position. The most common types of tracheobronchial foreign body in our study were seeds, nuts, and vegetables, which accounted for 87.5% of all cases in which the type of foreign body was specified. Other studies have shown that nuts and vegetables were the most commonly aspirated foreign bodies. 3,5,7-11,13,19 Our finding that seeds were the most common foreign body was the only finding that differed to any great degree from the findings of other studies. The type of inhaled foreign body seen in a given population is related to the lifestyle and eating habits of that particular society, so on the basis of our findings, seeds appear to be more popular in Jordan than in many other places. Rigid bronchoscopy is the preferred choice of most ENT surgeons for dealing with tracheobronchial foreign bodies, 4-7,12,19,20 and this was the standard practice in our series. The 3-to-2 male-to-female ratio in our study was similar to the ratio reported in many other studies. 2,5,9-11,19 The complication rate of 3.4% in our study was within the range of complication rates reported by others. 6,19,21 With the exception of the popularity of seeds in our population, we conclude that our experience in Jordan was no different from the experience of others who have reported on tracheobronchial foreign-body aspiration. Circle 117 on Reader Service Card Circle 118 on Reader Service Card Volume 86, Number 2 109

MAHAFZA, KHADER CLASSIFIEDS References 1. Mantor PC, Tuggle DW, Tunell WP. An appropriate negative bronchoscopy rate in suspected foreign body aspiration. Am J Surg 1989;158:622-4. 2. Reilly J, Thompson J, MacArthur C, et al. Pediatric aerodigestive foreign body injuries are complications related to timeliness of diagnosis. Laryngoscope 1997;107:17-20. 3. Pyman C. Inhaled foreign bodies in childhood. A review of 230 cases. Med J Aust 1971;1:62-8. 4. Schmidt H, Manegold BC. Foreign body aspiration in children. Surg Endosc 2000;14:644-8. 5. Baharloo F, Veyckemans F, Francis C, et al. Tracheobronchial foreign bodies: Presentation and management in children and adults. Chest 1999;115:1357-62. 6. Dunn GR, Wardrop P, Lo S, Cowan DL. Management of suspected foreign body aspiration in children. Clin Otolaryngol Allied Sci 2002;27:384-6. 7. Fernandez Jiminez I, Gutierrez Segura C, Alvarez Munoz V, Pelaez Mata D. [Foreign body aspiration in childhood. Review of 210 cases]. An Esp Pediatr 2000;53:335-8. 8. Fitzpatrick PC, Guarisco JL. Pediatric airway foreign bodies. J La State Med Soc 1998;150:138-41. 9. Gerbaka B, Azar J, Rassi B. [Foreign bodies of the respiratory tract in children. A retrospective study of 100 cases]. J Med Liban 1997;45:10-18. 10. Harris CS, Baker SP, Smith GA, Harris RM. Childhood asphyxiation by food. A national analysis and overview. JAMA 1984;251: 2231-5. 11. Rothmann BF, Boeckman CR. Foreign bodies in the larynx and tracheobronchial tree in children. A review of 225 cases. Ann Otol Rhinol Laryngol 1980;89:434-6. 12. Oguz F, Citak A, Unuvar E, Sidal M. Airway foreign bodies in childhood. Int J Pediatr Otorhinolaryngol 2000;52:11-16. 13. Yagi HI. Foreign bodies in the tracheobronchial tree in Sudanese patients. J R Coll Surg Edinb 1997;42:235-7. 14. Zaytoun GM, Rouadi PW, Baki DH. Endoscopic management of foreign bodies in the tracheobronchial tree: Predictive factors for complications. Otolaryngol Head Neck Surg 2000;123:311-16. 15. Donato L, Weiss L, Bing J, Schwarz E. [Tracheobronchial foreign bodies]. Arch Pediatr 2000;7(suppl 1):56S-61S. 16. Kruk-Zagajewska A, Szmeja Z, Wojtowicz J, et al. [Foreign bodies in the lower respiratory tract: Experience based on materials gathered in the ENT department of the Poznan Higher School of Medical Sciences between 1945 and 1997]. Otolaryngol Pol 1998;52:683-8. 17. Mu L, He P, Sun D. Inhalation of foreign bodies in Chinese children: A review of 400 cases. Laryngoscope 1991;101:657-60. 18. Wiseman NE. The diagnosis of foreign body aspiration in childhood. J Pediatr Surg 1984;19:531-5. 19. Swanson KL, Prakash UB, Midthun DE, et al. Flexible bronchoscopic management of airway foreign bodies in children. Chest 2002;121:1695-1700. 20. Murty PS, Vijendra SI, Ramakrishna S, et al. Foreign bodies in the upper aero-digestive tract. SQU Journal for Scientific Research 2001;3:117-20. 21. Cohen S, Pine H, Drake A. Use of rigid and flexible bronchoscopy among pediatric otolaryngologists. Arch Otolaryngol Head Neck Surg 2001;127:505-9. Get online Abstracts of all articles, full-color ENT Clinics, past issue archives, more than 300 otolaryngology Web site links, an online convention hall, subscription information, Instructions to Authors, and Editorial Board review. w w w. e ntjournal. com 110 ENT-Ear, Nose & Throat Journal February 2007

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