Delayed diagnosis of a pediatric airway foreign body: case report and review of the literature. (Original Article).

Abstract

Foreign body aspiration is a common pediatric problem that affects children of all ages, including those who are well into their adolescence. We describe the case of a 9-year old boy with an airway foreign body that had gone unrecognized for 3 months. We also review the literature on pediatric airway foreign bodies, with a focus on delayed diagnosis. A diagnosis of foreign body aspiration should be considered whenever a previously healthy child suddenly exhibits unexplained symptoms that are refractory to medical treatment and are consistent with airway obstruction.

Introduction

Foreign body aspiration is a common problem in the pediatric age group. Numerous authors continue to view it as an important cause of mortality in children--especially in smaller children, whose airways are narrow and whose protective mechanisms are immature. (1) Any delay in diagnosis has the potential to make a hazardous situation even more serious. In this article, we describe a case of delayed diagnosis of a pediatric airway foreign body.

Case report

A 9-year-old Hispanic boy had been evaluated at another institution for a 3-month history of shortness of breath, chronic cough, and wheezing. At that time, he was diagnosed with asthma and treated with albuterol and ipratropium inhalers; he was also prescribed the antihistamine cetirizine. No imaging studies were performed. The bronchodilators provided some symptomatic relief, but over the ensuing several months, the patient continued to experience exacerbations of his symptoms, which resulted in multiple hospital visits. His coughing varied in intensity but never resolved for any length of time.

During his most recent episode, the patient was referred to our facility for evaluation. It was during this visit that he first revealed that he had earlier choked on a piece of plastic that had broken off the lid of a laundry hamper. He had not previously disclosed this information because he had been afraid of punishment. His medical history was otherwise unremarkable, and there was no family history of asthma or environmental allergies. He was still taking albuterol, ipratropium, and cetirizine.

On physical examination, the patient was in moderate respiratory distress. Auscultation revealed rhonchi in both lung fields (greater in the right) and a loud transmitted upper airway noise. The patient was mildly hoarse but without stridor. Findings on the remainder of the examination were within normal limits. Chest radiography revealed no abnormality.

The patient was taken to the operating room for diagnostic laryngoscopy and bronchoscopy. As this examination began, the presence of a triangular subglottic piece of macerated white plastic became immediately obvious (figure). After the plastic was removed, the remainder of the respiratory tract and esophagus was examined and no other foreign bodies were discovered. The patient recovered normal voice and swallowing functions within 24 hours and was discharged.

Discussion

Nationwide, pediatric airway foreign bodies are more common in boys than girls (ratio: -2:1) (1) and in nonwhites than whites (1.7:1 ). (2) Most cases occur in children younger than 3 years of age because they tend to explore most objects, including food, with their mouths. (3) Darrow and Holinger reported that 64% of airway foreign bodies in younger children were food items, often nuts and seeds. (4) Among older children, foreign body ingestion is more likely the result of carelessness than curiosity. Darrow and Holinger reported that 17% of the patients in their series were older than 5 years of age, and that 88% of the airway foreign bodies in these children were inorganic; the most common items were pen parts, pins, tacks, and paper clips. (4)

Making a diagnosis of foreign body aspiration can be most challenging, particularly in delayed cases. A thorough history and physical examination and a high index of suspicion are crucial. At the initial evaluation, the most common symptoms are coughing and wheezing; overall, coughing, wheezing, and/or choking are present in 95% of cases. (4,5) Other common signs and symptoms are decreased breath sounds, respiratory distress, fever, pneumonia, and stridor. Of all signs and symptoms, the most predictive is a recent history of an aspiration event, which has been elicited in 73 to 80% of cases. (6) Because many victims are too young to report such an event, a sudden and unexplained onset of symptoms is another important indicator.

The usefulness of radiographic studies in foreign body aspiration is debatable inasmuch as intervention is primarily based on information gleaned from the history and physical examination. In children younger than 3 years, 80% of airway foreign bodies are found to be food or other radiolucent items. (5) In a study of 93 cases, Silva et al reported that plain chest films had a sensitivity of 73% and a specificity of 45% in identifying suspected foreign body aspirations. (6) Esclamado and Richardson found that soft-tissue cervical films were superior to chest films in identifying laryngotracheal foreign bodies; in their study, 12 of 13 cervical films were positive (92.3%), compared with only 8 of 19 chest films (42.1 %). (7) Regardless of these findings, when foreign body aspiration is the suspected diagnosis, radiologic considerations will not change the nature of management and they should certainly not delay intervention. (6) Undue delay can result in foreign body migration and lead to acute and complete air way obstruction.

Direct laryngoscopy and bronchoscopy can be both diagnostic and therapeutic. (1) Removal, especially of distal foreign bodies, can be most difficult. Numerous authors have reported using a wide range of specialized instruments--including Fogerty catheters, ureteral stone baskets, flexible forceps, and even fluoroscopy--to assist them in removal. (5) If conventional methods should fail, thoracostomy is an option; however, thoracostomy is required in less than 1% of cases. (5) Once a foreign body has been removed, the respiratory tract must be re-examined to look for additional foreign bodies.

Avoiding a delay in diagnosis is essential to reducing associated morbidity and mortality. Long-standing foreign bodies can cause significant tissue reactions and severe airway distress or infection, which could result in even worse outcomes and prolonged and complicated hospital courses. (3,4) Delays can be the result of misdiagnosis or a failure by the patient to seek medical care. A diagnosis of an airway foreign body is rarely facilitated by the classic signs of paroxysmal coughing, wheezing, and decreased breath sounds on the affected side, especially in delayed cases. Reilly et al reported that 18% of children with aspirated foreign bodies had been under treatment for another diagnosis, most often pneumonia, asthma, and persistent fever. (3) Other common misdiagnoses include reactive airway disease and croup. Delays attributable to patients' behavior or circumstances are most common in young children whose aspiration of a foreign body went unwitnessed. (6) Older patients tend to seek treatment earlier, but even they postpone evaluation for an average of 2.6 days following ingestion. (4)

References

(1.) Pasaoglu I. Dogan R, Demircin M, et al. Bronchoscopic removal of foreign bodies in children: Retrospective analysis of 822 cases. Thorac Cardiovasc Surg 1991;39:95-8.

(2.) Rimell FL, Thome A, Jr., Stool S, et al. Characteristics of objects that cause choking in children. JAMA 1995;274:1763-6.

(3.) 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.

(4.) Darrow DH, Holinger LD. Aerodigestive tract foreign bodies in the older child and adolescent. Ann Otol Rhinol Laryngol 1996;105:267-71.

(5.) Deskin R, Young G, Hoffman R. Management of pediatric airway foreign bodies. Laryngoscope 1997;107:540-3.

(6.) 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;107:834-8.

(7.) Esclamado RM, Richardson MA. Laryngotracheal foreign bodies in children. A comparison with bronchial foreign bodies. Am J Dis Child 1987;141:259-62.

From the Division of Otolaryngology, Milton S. Hershey Medical Center, Pennsylvania State University, Hershey.

Reprint requests: Christine Franzese, MD, Department of Otolaryngology, University Medical Center, University of Mississippi School of Medicine, 2500 N. State St., Jackson, MS 39216. Phone:[phone]; fax: [phone]; e-mail: [e-mail]

Originally presented at the annual meeting of the Pennsylvania Association of Otolaryngology-Head and Neck Surgeons; Philadelphia; June 30, 2001. No funding was provided for this study.