Aspirated tracheobronchial foreign bodies: a Jordanian experience.

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 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.

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 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.

References

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(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.

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(10.) Harris CS, Baker SP, Smith GA, Harris RM. Childhood asphyxiation by food. A national analysis and overview. JAMA 1984;251: 2231-5.

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(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.

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Tareq Mahafza, FRCS; Yousef Khader, ScD

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: [phone]; fax: [phone]; e-mail: [e-mail]

Table 1. Incidence of symptoms (n = 386)

Symptom                     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 (78)

Table 2. Type of foreign body (n = 336 *)

Foreign body                n (%)

Seeds ([dagger])         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.

([dagger]) Watermelon, pumpkin, and
sunflower seeds.

Table 3. Distribution of symptoms by type of
foreign body (n = 336 *)

                          Diminished                   Choking
Foreign        Cough      air entry      Dyspnea       attack
body           n (%)         n(%)          n(%)         n (%)

Seeds
(n = 119)    105 (88.2)    58 (48.7)     77 (64.7)     68 (57.1)

Nuts
(n = 90)      82 (91.1)    72 (80.0)     57 (63.3)     53 (58.9)

Vegetables
(n = 85)      79 (92.9)    68 (80.0)     56 (65.9)     52 (61.2)

Plastics
(n = 17)      14 (82.4)    10 (58.8)     15 (88.2)      7 (41.2)

Metals
(n = 17)      13 (76.5)    10 (58.8)      7 (41.2)      7 (41.2)

Fish bones
(n = 8)        7 (87.5)       0           5 (62.5)      5 (62.5)

Foreign       Wheezing     Cyanosis    Crepitations     Fever
body           n (%)        n (%)         n (%)         n (%)

Seeds
(n = 119)    61 (51.3)    47 (39.5)      6 (5.0)       9 (7.6)

Nuts
(n = 90)     73 (81.1)    39 (43.3)     20 (22.2)      8 (8.9)

Vegetables
(n = 85)     18 (21.2)    38 (44.7)     36 (42.4)      7 (8.2)

Plastics
(n = 17)      1 (5.9)      5 (29.4)         0          1 (5.9)

Metals
(n = 17)         0         5 (29.4)         0             0

Fish bones
(n = 8)       2 (25.0)     4 (50.0)      1 (12.5)         0

* The type of foreign body was .specified in only 336
of the 386 cases.