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© Borgis - New Medicine 2/2001, s. 20-22
Lidia Zawadzka-Głos1, Anna Jakubowska2, Beata Zając1, Anna Gabryszewska2
Foreign bodies in the airways in children
1 Department of Paediatric Otorhinolaryngology, The Medical University of Warsaw
Head of Department: Prof. Mieczysław Chmielik MD.
2 Institute of Paediatric Radiology, The Medical University of Warsaw
Head of Institute: Prof. Andrzej Marciński MD.
Foreign bodies (f.b.) in the airways are a constant problem in paediatric laryngological practice. The authors discuss the most frequent types of f.b., the most common locations of f. b. in the air passages, and signs and symptoms of f.b. in physical and radiological examination. The most common location is the main right bronchus, and the inferior lobar bronchus of the right lung. In the larynx, f.b. represent a particularly life-threatening situation. A child suspected of having f.b. in the air passages must be examined radiologically, and needs direct visualisation by bronchoscopy. The authors propose that for children younger than 4 years of age, a radiological examination of the thorax should be performed using a horizontal x – ray with the child lying on its side. Early bronchoscopy (within 48 hours from aspiration) reduces the frequency of subsequent complications.

Acute airway obstruction usually requires immediate diagnosis and therapeutic management. Physical, radiological, and endoscopic examination allows an exact assessment of the location of the airway obstruction, thus initiating the correct treatment. When we suspect a foreign body in the air passages, an exact history is very important. Aspiration of a f.b. occurs more frequently during games or feeding. There is a rapid onset of paroxysmal cough, with cyanosis and psychomotor restlessness. The cough is persistent to the point where the f.b. becomes fixed in the airway. After that, there may be a symptomless interval phase. The cough may recur at night, during sleep, when the child changes position, provoking a dislocation of the f.b. Symptoms may be overlooked by the parents, and a choking episode may be disregarded. Thus, the obstruction leads to pneumonia, usually unilateral. There is no significant improvement after typical treatment for pneumonia, until the f.b. is removed from the bronchus. It is important to remember that a foreign body retained in the bronchus for a long time will facilitate fungal infections and granulation.
Delayed recognition, and consequently delayed proper treatment, increases the complication rate, complications including abscess of the pulmonary tissue and pulmonary fibrosis.
Large round ot oval bodies obstruct bronchi, and cause an obturative atelectasis of the lung or lobe. Foreign bodies decreasing the patency of the bronchus are a cause of obturative emphysema ("check valve" emphysema). An impacted f.b. causes symptoms of spastic bronchitis. Temporary displacement of a f.b. causes paroxysmal dry cough. We can also hear a wheeze or whistle during crying or deep breathing when the f.b. is at the level of the glottis.
A situation in which the air flows through the bronchus behind the f.b. on inspiration, and cannot flow back on expiration, is particularly dangerous. This quickly leads to acute ventilation emphysema.
We find numerous foreign bodies, usually large, at the level of the larynx, which due to their size don´t pass trough the glottis.
Sharp foreign bodies (bones, fish – bones, needles) wedge in the mucous membrane of the laryngeal vestibule. Foreign bodies in the larynx produce rapid inspiratory dyspnoea, and represent a life – threatening condition.
Exogenous f.b. in the trachea are very rare. Sharp – ended f.b. stop at this level. More frequently we see endogenous f.b. – dried secretion forming crusts in the lumen of the trachea (laryngotracheitis crustosa).
The anatomical structure of the respiratory tract facilitates aspiration of most f.b. of the right lung. The most common f.b. we find are pieces of food and nuts, small parts of toys, and needles. Vegetable f.b. retained in the the bronchus for a long time cause an acute inflammatory reaction, leading to the growth of granulation tissue, and markedly stenose the lumen of bronchus.
Diagnosis of an f.b. in the respiratory tract is based on physical and other investigations, such as radiography and endoscopic examination. Physical examination of the thorax shows on percusion an bandbox resonance, dull or non – percussive resonance, and on auscultation there is a decrease in respiratory murmur or bronchial respiratory murmur, due to developing emphysema or obturative atelectasis of the lung.
It is necessary to carry out a radiological examination in every case in which an f.b. in the respiaratory tract is suspected. Due to anatomical structure of the airways, radiological changes are found in the inferior lobe of the right lung. The pathognomonic radiological sign of an f.b. in the bronchus is migration of the mediastinum, known as Holzknechto´s sign. The most common radiological sign is excessively dilated pulmonary tissue, distal to the f.b. Subsequently, pneumonia and atelectasis may occur. Only contrasting f.b. are well – seen on x-ray film (picture 1).
Picture 1. Contrasing foreign body in main right bronchus – the end of a ball – point pen – anteroposterior x – ray.
The aim of a radiological examination of a child suspected of having f.b. is
– to find and localise the f.b.
– to assess the physical properties of the f.b.
– to distinguish single or multiple f.b.
– to confirm or rule out co – existing complications
– to assess indirect signs (emphysema, atelectasis, inflammation) caused by the f.b. – these signs are the basis of diagnosis for non – contrasting f.b.

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New Medicine 2/2001
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