Foreign bodies in the bronchi (a 10 year review of 132 cases).
Foreign bodies in the air passages is a challenging clinical problem. In spite of recent advances in anaesthesia and instrumentation, removal of a foreign body is not an easy procedure and demands skill and expertise on the part of the surgeon. Grave complications like cardiorespiratory arrest may ensue unless prompt treatment is given. We would like to present our experience of such cases with a variety of foreign bodies.
A review of 132 cases of foreign bowie; in the bronchi, admitted to the K.E.M. Hospital, Bombay, during the last 10 years from January 1972 to December 1981 was undertaken. Cases of foreign bodies in the larynx and trachea were excluded as also those in whom thorough investigations including bronchoscopy failed to reveal a foreign body. The analysis of clinical material included age and sex incidence, site, clinical presentation, radiological investigations and management.
The overall incidence of foreign bodies in the bronchi was 0.53% of all the E.N.T. admissions (132/24695). It was 1.6% in children (126/7874), 1.85% in male children (77/4155) and 1.48% in female children (49/3719). The foreign body incidence was 0.036% in adults (6/16821), 0.04% in male adults (4/9367) and 0.03% in female adults (2/7454).
Since 1976, the incidence of cases of foreign bodies referred to our hospital showed a significant decline; e.g., in 1976, there were 18 admissions whereas in 1981, there were only 8 cases.
Age and sex
The ages ranged from 3 months to 35 years, 91 cases (68.9%) being between 3 months and 3 years [Table - 1]. There were 81 males and 51 females in our series.
Types of foreign bodies
Organic foreign bodies were seen in 108 cases (81.8%) as compared to inorganic ones in only 24 cases (18.2%) [Table - 2]. Foodstuffs accounted for 105 cases. In the age group of l to 12 months, organic (8 cases) and inorganic (6 cases) foreign bodies occurred with roughly the same frequency. As opposed to this, between 1 and 2 years, there were 51 cases of organic foreign bodies and only 3 inorganic.
Sixty-eight foreign bodies were found lodged in the right bronchus and 61 in the left. In 2 cases (both inhalation of pea nuts), there were foreign bodies in both the bronchi. In another case (tamarind seed), one cotyledon. lay in the carina and another in the right bronchus.
The duration of enlodgement of the foreign bodies before presentation ranged from 1 hour to 6 months [Table - 3]. A history of an episode of foreign body inhalation (101 cases) and cough (96 cases) were the commonest symptoms followed by breathlessness (79 cases), fever (41 cases), vomiting (12 cases), cyanotic spells (11 cases), hoarseness of voice (4 cases), unconciousness (4 cases), hemoptysis (3 cases) and chest pain (one case).
On clinical examination, diminished breath sounds on one side of the chest (106 cases) was the commonest finding.
In the remaining 26 cases, breath sounds were equal in intensity on both sides. The respiratory system examination revealed no abnormality in 5 cases. A significant number (29 cases) had rales and 22 cases had rhonchi. Intercostal/suprasternal retraction was noted in 26 cases and stridor in 8 cases.
A plain X-ray of the chest revealed obstructive emphysema in 77 cases. Pneumonitis was noted in 20 cases and collapse in 14 cases. Foreign bodies were visualized in 16 cases. Radiology was normal in 25 cases.
In 127 cases, the foreign body was removed successfully by bronchoscopy using a rigid bronchoscope with fibreoptic lighting. General anaesthesia (using muscle relaxants wherever possible and no premeditation except atropine) was used in 125 cases. Removal of the foreign body under local anaesthesia (along with an emergency tracheostomy) was needed in 2 cases. In 2 other cases, the foreign body was lodged beyond the reach of the bronchoscope, necessitating removal by thoracotomy. Tracheostomy was required in 7 cases. One patient coughed out the foreign body. Non-endoscopic methods such as bronchodilators and postural drainage were not utilized. Bronchoscopy was done on one occasion in 108 cases, on 2 occasions in 17 cases, on 3 occasions in 3 cases and on 4 occasions in only one case.
There were 5 deaths in the series. Two patients presented to the hospital in extreme respiratory distress and expired in the emergency room before any treatment could be given. Both had organic foreign bodies (tamarind seed and peanut) enlodged for 12 and 15 days respectively. Autopsy revealed a massive pneumothorax on the side of the foreign body in the latter case. Three other patients expired as a result of cardio-respiratory arrest developed during bronchoscopy.
Twenty patients were discharged within 24 hours, 39 patients on the second day and 37 patients between the 3rd and 5th day. The rest were hospitalized for a longer period between 6 and 20 days.
Foreign bodies in the bronchi is a common problem seen by E.N.T. surgeons. In our institution, the number of cases has declined since 1976 probably as a result of development of a number of suburban hospitals in the city of Bombay.
The high frequency of this problem in children in our series concurs with the observations of other authors.,,,, The child has difficulty in swallowing hard foodstuffs such as nuts and seeds, and has inadequately developed protective respiratory reflexes. This makes it more vulnerable than adults to the inhalation of foreign bodies into the respiratory passage.
The male predominance in this series is in agreement with the published reports.,,,, A possible explanation for this is offered by Gupta et a1, who state that "boys by nature are more curious and inquisitive than girls."
The high predominance of organic foreign bodies in this series is in keeping with published reports.,,, This, coupled with the high frequency in children under the age of 3 years makes it advisable not to offer nuts and seeds to small children, who are liable to aspirate them into the respiratory passage.
We encountered 4 patients with foreign bodies made up of plastics. Mody reported that he came across 6 cases of a plastic whistle in the bronchus within a period of two months, when the plastic, whistle had been introduced into the market as a new toy.
The age of the child seems to determine the relative frequencies of organic and inorganic foreign bodies: they appear to be roughly equal in infants under the age of one year, probably because infants of this age tend to put anything that they can grasp into their mouth. However, older infants and children have a higher frequency of organic foreign bodies, many of which are edible. These older infants and children can discriminate between edible and non-edible material.
Contrary to what is commonly believed, the frequency of foreign bodies in the right and left bronchus was very similar in this series. This has also been reported by other workers.,, We encountered two cases where bits of peanuts were found in both the bronchi and one case where one cotyledon of a tamarind seed was found at the carina and the other in the right bronchus. It is, therefore, necessary to look into both the bronchi when bronchoscoping a patient for a foreign body.
Only one third of our patients presented within 24 hours of aspiration of the foreign body. About 20% came between the 6th and the 10th day; this might be due to the pact that it takes 7-14 days after the aspiration to develop serious complication; such as consolidation or collapse.
Only 76% of the patients admitted of a history of inhalation of a foreign body, many of them after close questioning. The remaining 24% denied history of such an episode. The paediatrician must, therefore, always keep the foreign body in mind when dealing with a respiratory case.,, Of the 41 patients who had fever, 35 had organic foreign bodies; this confirms the observation of Jackson and Jackson that organic foreign bodies are liable to evoke violent laryngo-tracheal bronchitis and to predispose to lung infection.
Contrary to expectation, 20% of patients had equal breath sounds on both sides of the chest and 4% had no auscultatory abnormalities, while only 22% of the patients showed crepitations probably due to lung infection. Thus one must be willing to consider a foreign body as a differential diagnosis even when there are no abnormal physical signs in the chest.
The commonest radiological finding was obstructive emphysema (58% cases). This is in confirmity with other reports.,, Further, X-rays of the chest were completely normal in 19% cases. This would indicate that even a normal X-ray of the chest does not negate the diagnosis of a foreign body in the respiratory passage.
There were 3 deaths due to cardiorespiratory arrest during bronchoscopy.
Many patients underwent repeated bronchoscopies, which increases the hazards of this procedure.
In general, the results of treatment of foreign bodies in the respiratory tract appear to be poorer with delay in diagnosis, presence of lung infection, attempted digital removal by parents and incompetent handling of the bronchoscope by the surgeon. Chevalier Jackson's advice (1950) about the need for educating the parents and doctors about foreign bodies in the respiratory tract is as valid today as it was when it was pronounced.
We are grateful to the Dean, K.E.M. Hospital and Seth G.S. Medical College, Parel, Bombay, for permission to use the hospital data and records.