Airway Stenosis Related to Foreign Body Aspiration: An Under-recognized Long term Complication

Removal of airway foreign body using flexible bronchoscopy in children

BACKGROUND

Flexible bronchoscopy is mainly used to diagnose airway foreign bodies (AFBs). Due to advances in pediatric anesthesia, many teams have considered the extraction of AFBs by flexible bronchoscopy. We aimed to assess the success of flexible bronchoscopy in AFB removal in children.

PATIENTS AND METHODS

We analyzed retrospectively the data of children admitted for AFB aspiration in the Pediatric Respiratory Diseases Department B of Abderrahmane Mami Hospital in Tunisia between January 2012 and December 2022. AFB removal was performed by flexible bronchoscopy through the use of a laryngeal mask airway (LMA) or intubation.

RESULTS

Of the 105 children included, AFB was removed by flexible bronchoscopy in 99 children (94.3 %). The mean age of the children was 32 months (9-150 months) with a sex ratio of 2:3. The foreign body was organic in 67 % of cases. Overall, 37 children underwent rigid bronchoscopy first (35.2 %). Flexible bronchoscopy was performed through the LMA in 77 cases (73 %) and after intubation in the other cases. Thoracic surgery was needed in two cases (1.9 %). Four infants expectorated the AFB after the procedure (3.8 %). Only two children developed laryngeal edema with transient oxygen desaturation.

CONCLUSION

AFB removal using a flexible bronchoscope is an efficient and safe procedure when performed by an experienced team. The recent use of LMA has facilitated the use of a larger bronchofiberscope and the insertion of multiple tools that can reach distal airways.

Role of Flexible Bronchoscopy using Biopsy Forceps as the Initial Attempt for Headscarf Pin Aspiration Extraction

Introduction

Flexible bronchoscopy is a less invasive procedure for extracting foreign bodies from the airways. However, studies on the extraction of headscarf pins are still very limited to determine the efficacy and safety of headscarf pin extraction using flexible bronchoscopy with biopsy forceps.

Methods

This retrospective study was conducted at Persahabatan Hospital, Jakarta, Indonesia, on patients who had been treated in this hospital for headscarf pin extraction between January 2013 and February 2023. Fibreoptic bronchoscopy was performed under general anaesthesia. The pin was removed using Radial Jaw 4 mm single-use pulmonary biopsy forceps. The impacted sharp tip of the pin was freed first, and the proximal part of the pin body was gripped using biopsy forceps. Once a firm hold of the sharp end or the proximal part of the pin was secured, the bronchoscope and forceps were both slowly withdrawn under direct vision.

Results

Thirty-two cases with headscarf pin aspiration were managed by fibreoptic bronchoscopy. A total of 12 patients (37.5%) came without any respiratory complaints; however, an equal number complained of cough and 6 cases (18.7%) of haemoptysis. All the cases in which the pins were visible in the airway were found with the round head down and the sharp tip oriented superiorly in the airway and impacted in the mucosa. Fibreoptic bronchoscopy extraction succeeded in 31 cases (96.8%). Only one case was converted to surgery. There were no major complications.

Conclusion

Fibreoptic bronchoscopy with biopsy forceps under general anaesthesia is safe and effective for the removal of headscarf pin aspiration.

Delayed diagnosis of foreign body aspiration in children

AIMS

To assess the diagnostic and therapeutic difficulties as well as the long-term complications of prolonged endobronchial foreign body retention.

METHOD

Between January 2000 and May 2021, 794 patients with suspected foreign body aspiration (FBA) were hospitalized in our department. A total of 12 patients with a delayed diagnosis of over 1 month were included. FBAs were confirmed by flexible or rigid endoscopy. A retrospective analysis of medical records was performed.

RESULTS

Six male patients and six female patients were hospitalized due to prolonged FBA. The average age was 6.90 years (range: 1-13 years). The average duration of the foreign body retention was 2.60 years (2 months to 9 years). A choking event was found in eight cases. Coughing and wheezing were the main symptoms and signs. A misdiagnosis of asthma was made for five patients. Two atypical clinical presentations led to diagnosis of endobronchial foreign body, unilateral pleurisy, and hemoptysis. We report one case of an occult foreign body externalized spontaneously through a pneumo-pleuro-cutaneous fistula. The most common clinical and radiological findings were of pneumonia and atelectasis. Computed tomography showed localized bronchiectasis in three patients. FBAs were removed with a rigid bronchoscope in eight cases. Other extractions were carried out with a flexible endoscope. The foreign bodies were most frequently of vegetable origin, such as seeds and peanuts. A granulation tissue was observed in seven cases. Bronchial stenosis and bronchiectasis are the most common late complications. Only one patient needed a surgical intervention.

CONCLUSIONS

FBA should always be considered in the differential diagnosis of chronic or recurrent respiratory diseases, even in the absence of a previous choking event. Clinical and radiological findings should be carefully evaluated for a possible FBA. Delay in diagnosis and treatment of FBA should be avoided in order to prevent complications. Open surgery may be required when lung abscess has occurred.

Unilateral methotrexate-induced lung injury with foreign bodies in the airway: A case report

A 75-year-old woman who had been taking methotrexate presented to our hospital for fever and dry cough. Chest computed tomography showed ground-glass opacity in the upper lobe of the right lung and foreign bodies in the lower lobe of the right bronchus. During bronchoscopy, foreign bodies were removed from the airway. We found increased levels of lymphocytes and a high CD4/CD8 ratio in the bronchoalveolar lavage fluid. Transbronchial lung biopsy revealed lymphocytic infiltration. Methotrexate was discontinued, and the imaging findings improved. Methotrexate-induced lung injury does occur unilaterally. Foreign bodies in the airway might also trigger unilateral methotrexate-induced lung injury.

Foreign body aspirations in dental clinics: a narrative review

Foreign body aspiration can produce a medical emergency. Obstruction of the airways can be life-threatening, and complications may develop in less-severe cases if it is left untreated. Although it is more prevalent in children by approximately three times, adults can still experience it, and it is more frequently related to healthcare in adults. Objects used in dental treatment are usually placed in the oral cavity and can be ingested or inhaled by accident. Dental treatment has been identified as an important cause of the misplacement of foreign bodies in the airway. However, few reports have been published on dentistry-related foreign body aspiration. This paper discusses the disease course, management, and clinical outcomes of foreign body aspiration, especially those associated with dentistry. The patient must be examined for respiratory distress. If the patient is unstable, urgent airway management and the maneuvers for removal should be performed. Radiographs and computed tomography can help identify and locate the object. The treatment of choice is often bronchoscopy, and both flexible and rigid endoscopes can be used depending on the situation. Preventive measures need to be implemented to avoid inhalation accidents given the potential consequences. Though the incidence is rare, healthcare levels need to be enhanced to avert morbidity and mortality. Radiological evaluation and bronchoscopy are vital for management.

May the first-line treatment for foreign body aspiration in childhood be flexible bronchoscopy?

INTRODUCTION:

Rigid bronchoscopy (RB) is the traditional treatment in foreign body (FB) aspiration in childhood but is a traumatic and invasive procedure. However, flexible optic bronchoscopy (FoB) is a noninvasive and nontraumatic respiratory intervention. The aim of this study was to evaluate FoB as a first-line treatment modality in pediatric cases presenting with a preliminary diagnosis of FB aspiration.

METHODS:

Subjects who underwent FoB under general anesthesia with the preliminary diagnosis of FB aspiration were enrolled in this cross-sectional study. Two cases were inherited from pediatric surgery because they were not removed with FoB. The demographic, clinical, and radiological findings at the presentation were recorded. Results of success rate and complications were recorded.

RESULTS:

Among the FB aspiration cases age range of 7 months to 16 years. FoB demonstrated a FB in the airways of 31 (62.2%) subjects. The duration of the symptoms in the subjects was 9.1 ± 8.8 days. Three of the cases were taken over from pediatric surgery because they were not removed with RB. Most commonly encountered FB's were organic materials (n = 20, 64%). FoB was successful in removing the FB from the proximal and also distal airways in 93% of the subjects. No significant complications and side effects were observed except post-FoB cough.

CONCLUSION:

This result has shown that FoB for the treatment of FB aspiration is successful in removing FB aspiration from both the proximal and distal airway that the RB cannot remove. Furthermore, FoB did not have any significant airway complication. FoB may be used as the first-line treatment modality for FB aspiration instead of RB in childhood the fact that noninvasive and nontraumatic respiratory intervention.

A rare case of foreign body aspiration presenting as subglottic stenosis: A case report

In rare cases, foreign body aspiration may present with similar clinical features and CT findings to subglottic stenosis. A high index of suspicion and additional diagnostic techniques may be required to distinguish them.

Interventional therapy via flexible bronchoscopy in the management of foreign body-related occlusive endobronchial granulation tissue formation in children

BACKGROUND

Occlusive granulation tissue formation, as one of the most common sequelae of chronic foreign body aspiration, can cause tracheobronchial obstruction and delayed fixed airway stenosis necessitating interventions. The aim of this study was to explore the clinical efficacy and safety of interventional therapy via flexible bronchoscopy for treatment of granulation tissue related airway obstruction secondary to foreign body aspiration in children.

METHOD

Patients with long-term foreign body related granulation tissue were treated with flexible bronchoscopy therapeutic modalities, including forceps, cryotherapy, holmium laser, and balloon dilatation. Clinical efficacy was evaluated by clinical symptoms and endoscopic manifestations.

RESULTS

A total of eight patients with granulation tissue hyperplasia caused by foreign body in bronchus, with a median age of 29.5 (range, 18-54) months, underwent interventional therapy between January 2016 and December 2019. Four patients received forceps and CO₂ cryotherapy and one patient required forceps only. The remaining three patients received holmium laser combined with CO₂ cryotherapy, and one of them required additional balloon dilatation. Four cases required a second cryotherapy procedure, and one case received three cryotherapy procedures for extensive granulation tissue. The treatment efficacy was 100% without complications.

CONCLUSION

Interventional procedure via flexible bronchoscopy is a safe, reliable, and effective method in the management of tracheobronchial obstruction and stenosis caused by foreign body-related granulation tissue hyperplasia. It is worthy of clinical application.

A Case of Pediatric Aspiration of a Metallic Spring

Prolonged retention of a foreign body after aspiration can lead to numerous respiratory complications. We present a case in which an unwitnessed aspiration of a metal spring by a child led to several months of unilateral wheezing and subsequent physical changes in his left mainstem bronchus. The prompt removal of an airway foreign body requires a high index of suspicion by the physician in order to facilitate proper workup to confirm the diagnosis, allow for prompt management, and minimize damage to the airway.

How Can We Do Better? Learning From 617 Pediatric Patients With Airway Foreign Bodies Over a 2-Year Period in an Asian Population

Background: Foreign body (FB) in the pediatric airway is a prevailing and crucial emergency with presenting symptoms often overlapping with other common pediatric conditions. There are limited number of large cohort studies in an Asian population which demonstrate the diversity of symptoms, investigations which will aid in obtaining the diagnosis, and management. Using this large cohort, we aim to evaluate the type and location, clinical presentations and outcomes of medical management related to pediatric airway FB in an Asian society. Methods: This is a retrospective study of all airway FB treated in Kunming Children's Hospital, China from February 2016 to June 2019. Six hundred and thirty-two clinical and operative records of all airway FB were retrieved and reviewed from the hospital's central electronic medical records. A total of 617 patients were included in our study. Results: The age ranged from 4 months to 12 years (mean = 1.74 years). The duration of symptoms ranged from 1 h to 605 days, with the diagnosis established at an average 9.16 days. Almost all had multiple symptoms, most commonly cough (98.5%) followed by noisy breathing (98.2%). Majority of the FBs (95.5%) were organic and the rest inorganic. Of the organic FBs, peanut was the most common (31.6%), followed by walnut (13.3%) and sunflower seeds (9.2%). Comparatively, 80.8% of the organic FBs were retrieved incomplete while 85.7% of the inorganic FBs were completely intact. Multiple FBs were noted in 43.3% of the patients, with 2.4% of them in different locations. Conclusions: Airway FB can be easily missed with resultant delay in diagnosis. In an Asian population, walnut and sunflower/pumpkin seeds feature more prominently compared to Western populations. Sunflower seed FBs tend to present earlier and are found intact in the trachea. Rigid bronchoscopy is the most common technique used to remove such FBs and pulmonary-related complications post-operatively, though rare, are the most common adverse outcomes. Preventive strategies targeting the appropriate age group and this type of FB may be useful in an Asian population.