A 14-month-old boy presents to the GP with a three-month history of recurrent croup and chest infection for which he had received antibiotics. On this occasion, there is a history of having choked while eating raisins a week earlier.
He is referred to the paediatric ENT department where he is noted to have laboured breathing and pyrexia. There is decreased air entry, bronchial breathing and wheeze in his right mid-zone. A chest radiograph shows right midlobe consolidation.
A probable diagnosis of inhaled foreign body – with chest infection secondary to delayed presentation – is made and rigid bronchoscopy finds a peanut is in his right main bronchus – the recent episode with raisins had prompted the GP to consider an inhaled foreign body, but the key peanut incident must have happened previously.
It is removed using optical forceps and antibiotic therapy is continued. He recovers well and the infection settles but he continues to have an intermittent cough, sometimes with associated pyrexia. A subsequent CT scan shows no evidence of bronchiectasis.
The problem
Foreign body inhalation in children causing obstruction to the respiratory tract is an uncommon but serious condition. In England, during 2010–2011, there were around 450 hospital episodes relating to foreign body inhalation in children under 15 years old1 and in the US, foreign body inhalation is responsible for 7% of accidental deaths in children under four years old.2
The diagnosis can be easily missed as there is not always a clear history of choking and the physical examination and chest radiograph can be normal.
Features
GPs should have a high index of suspicion in any child with respiratory signs and symptoms, particularly with a history of choking.
- Foreign body inhalation mainly affects children between one and three years old.3
- The classic symptoms and signs are coughing or choking, wheezing and unilateral reduced breath sounds.3
- Foreign bodies are most often found in the right bronchial tree (60%) but can also lodge in the left bronchial tree (23%), larynx (3%) or trachea (13%).4
- Untreated inhaled foreign body can lead to complications such as pneumonia, pneumothorax, lung abscess and even death.
- Delayed treatment of inhaled foreign body can lead to persistent cough and bronchiectasis.
- In general, small, round, crunchy foods pose a risk of choking and so educating parents is an important aspect of prevention. Peanuts are the most common foreign body in the airways.5
Bronchoscopic view of right main bronchus showing peanut occluding it
Examination
- General signs include increased respiratory rate, decreased oxygen saturation, pyrexia if there is infection, while chest signs include tracheal shift, decreased breath sounds, wheeze and bronchial breath sounds.
- Chest radiographs may show a radio-opaque foreign body, air trapping, atelectasis, pneumothorax or pneumonia. The chest radiograph is normal in about a third of cases.6
- Definitive diagnosis is only with direct bronchoscopy.
Management
A child presenting with respiratory signs and symptoms after an episode of choking should be referred immediately to a paediatric ENT service to be seen the same day.6 Even in the absence of clinical signs, in cases with a clear history of choking, GPs should have a low threshold for referral.
Also consider this diagnosis in children with persistent or recurrent unilateral chest symptoms or signs who are non-responsive to medical treatment, even in the absence of a clear history of choking. Always refer if in doubt.
Rigid bronchoscopy should be performed at the earliest opportunity. Foreign bodies are removed from the airway under direct vision with optical forceps, dormia baskets or bronchial lavage. If removal of the foreign body is delayed, the ensuing airway damage and infection often results in the child having to take long-term antibiotics. Such cases are best managed in conjunction with paediatricians.
Bronchoscopic view of right main bronchus after removal of the foreign body showing oedema
Miss Sujata De is a consultant paediatric ENT surgeon and Mr Anand Kasbekar is an ENT specialist paediatric registrar at Alder Hey Children’s Hospital, Liverpool
Alder Hey is one of Europe’s busiest children’s hospitals providing care for over 275,000 children and young people each year. Alder Hey has a broad range of hospital and community services for direct referral from primary care. The trust also offers more complex tertiary services – it is the designated national centre for head and face surgery and a centre of excellence for children with cancer, spinal and brain disease. Alder Hey has been chosen to be a national centre for heart surgery, a respiratory ECMO surgery centre and one of just four specialist centres to provide surgery for drug-resistant epilepsy. More information can be found at alderhey.nhs.uk
References
1 Hospital Episode Statistics. Accessed 26/10/12
2 Mantor PC, Tuggle DW and Tunell WP. An appropriate negative bronchoscopy rate in suspected foreign body aspiration. Am J Surg 1989; 158: 622-4
3 Wang K, Harnden A and Thomson A. Foreign body inhalation in children. BMJ 2010; 341: c3924
4 Mani N, Soma M, Massey S et al. Removal of inhaled foreign bodies -middle of the night or the next morning? Int J Pediatr Otorhinolaryngol 2009; 73: 1085-9
5 Gregori D, Salerni L, Scarinzi C et al. Foreign bodies in the upper airways causing complications and requiring hospitalisation in children aged 0-14 years: results from the ESFBI study. Eur Arch Otorhinolaryngol 2008; 265: 971-8
6 Passali D, Lauriello M, Bellussi L et al. Foreign body inhalation in children: an update. Acta Otorhinolaryngol Ital 2010; 30: 27-32
