Ear, Nose & Throat Journal2023, Vol. 102(10) 661 –666© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/01455613211023019journals.sagepub.com/home/ear
Objective: To analyze the factors influencing the diagnosis and treatment of tracheobronchial foreign bodies (TFBs) in children. Methods: The clinical data of 300 consecutive children with suspected TFBs who were admitted to our department between January 2016 and December 2019 were retrospectively collected, including demographics, diagnosis, history of foreign body inhalation, preoperative chest computed tomography (CT) findings, duration of foreign body retention, time from admission to operation, operation duration, duration of hospitalization, and complications. Results: Among the 300 cases, the male:female ratio was 193:107, and the age range was 6 months to 12 years (median age: 19 months). A total of 291 cases (97.0%) involved TFBs confirmed by rigid bronchoscopy, while the other 9 cases (3.0%) involved bronchopneumonia. The diagnostic accuracy, sensitivity, and specificity of a history of foreign body inhalation and chest CT were 96.0%, 98.6%, and 11.1% and 97.7%, 97.6%, and 100%, respectively. The duration of hospitalization, time from admission to operation, and operation duration were all related to bronchopneumonia (P < .05). Conclusions: A detailed history, adequate physical examination, and preoperative imaging examination help improve the diagnostic accuracy. Preoperative bronchopneumonia in children with TFBs will increase the surgical risks and treatment costs, prolonging the duration of hospitalization.
Keywordsbronchopneumonia, chest computerized tomography, history of foreign body inhalation, tracheobronchial foreign body
Tracheobronchial foreign bodies (TFBs) are a common clinical emergency in children, with common symptoms of cough, fever, and dyspnea,1,2 which may be life-threatening. A previous study reported that the mortality of TFB in patients is about 2.5%.3 An early accurate diagnosis and surgical treatment are important for reducing mortality.4 The right main bronchus, which has a relatively straight anatomical structure and is thicker in diameter, is more likely to involve the incarceration of foreign bodies.5
Foreign bodies are commonly of plant, animal, metallic, mineral, or chemical origin; among them, plant foreign bodies are the most common. The free fatty acids of plants can substantially irritate the airway, leading to mucosal congestion, swelling, and secretions, making bronchoscopy more difficult.6 The tracheobronchial obstruction caused by foreign bodies may lead to emphysema, atelectasis, bronchitis, or bronchopneumonia. If foreign bodies are not removed as soon as possible, they may cause an inflammatory response and granulation formation, edema of the mucosa, bronchoconstriction, and so on. Pneumonia and bronchitis are the most common lower respiratory tract infections (LRTIs) associated with TFBs.7 The complaint of foreign body inhalation is the basis for diagnosing TFBs; however, a small proportion of parents or caregivers cannot confirm whether the foreign bodies are inhaled by mistake when the children present with an irritating cough, wheezing, or fever. Chest X-ray and chest fluoroscopy are the common important auxiliary examinations for diagnosing TFBs, while bronchoscopy is the gold standard for diagnosis. This study aimed to analyze the factors influencing the diagnosis and treatment of TFBs in children.
Demographic factors. This study was approved by our hospital’s ethics committee. The clinical data of 300 patients with suspected TFBs on preoperative chest computed tomography (CT) who were admitted to our department between January 2016 and December 2019 were retrospectively collected. We included all patients who underwent preoperative chest CT. All CT examinations performed at other hospitals were reviewed by radiologists at our hospital, and the patients underwent rigid bronchoscopy. We excluded cases involving foreign bodies that were ejected by the patient’s cough and in whom the second chest CT examination revealed no foreign bodies, children who died when they arrived at the outpatient clinic, and those with a clear history of foreign body because of dyspnea requiring urgent rigid bronchoscopy. The medical data collected included demographics, diagnosis, foreign body history, duration of foreign body retention, time from admission to operation, operation duration, duration of hospitalization, species of the foreign body, location of the foreign body, and preoperative complications.
Classification setting. Age was divided into 2 categories: <3 years and 3 to 12 years. The foreign body retention duration started at the time of the foreign body inhalation or at the onset of the irritant cough, wheezing, or other symptoms. Durations within 24 hours were considered 1 day, those between 24 and 48 hours were considered 2 days, and so on. A similar classification scheme was used for the time of surgery after hospitalization: surgery within 24 hours was considered the first day, surgery between 24 and 48 hours was the second day, and so on. The duration of the operation was defined as the period from the beginning to end of the operation. Hospitalization for less than 24 hours was considered 1 day, that between 24 and 48 hours was considered 2 days, and so on.
Chest CT was performed immediately before or within 2 hours after admission. Children who could not cooperate were give retention enema sedation with chloral hydrate 0.5 mL/kg. After admission, surgical preparations were made, such as fasting the patient, paying close attention to changes in the patient’s breathing and temperature, and reducing irritation (blood test, electrocardiography, etc) to prevent the children from crying and reduce the possibility of foreign body movement. The majority of patients underwent rigid bronchoscopy on the day of admission. A small number of patients were administered antibiotics for 1 to 3 days before surgery due to prolonged foreign body retention that was associated with bronchopneumonia or fever. After anesthesia was administered, the endoscope-assisted bronchoscope was passed through the trachea and bronchus to remove the foreign body and the normal side was then checked to ensure that no foreign body remained. All patients received atomization inhalation postoperatively to reduce irritation of the respiratory mucosa by the rigid bronchoscopy. Antibiotics were administered to patients with bronchial pneumonia or bronchial granulation formation. If no abnormal diaphragmatic oscillation was noted on chest radiography combined with fluoroscopy, the patient was discharged from the hospital on the second postoperative day.
The statistical analysis was performed using SPSS 25 (IBM Corp). The diagnostic evaluation test was used to compare the diagnostic efficacy of a history of foreign body inhalation and chest CT. Cox regression analysis was used to analyze the factors related to the length of hospitalization and time from admission to operation. P values less than .05 were considered statistically significant.
Among the 300 children, the male:female ratio was 193:107 and the patient ages ranged from 6 months to 12 years (median age: 19 months). Among them, 284 children (94.7%) were less than 3 years old, while the other 16 children (5.3%) were 3 to 12 years old. Of all 300 children, 295 cases (98.3%) had a history of foreign body. Tracheobronchial foreign bodies were confirmed by rigid bronchoscopy in 291 cases (97.0%; Figure 1), including 287 cases of bronchial foreign bodies and 4 cases of foreign bodies in the trachea. The remaining 9 cases (3.0%) showed bronchopneumonia. The first foreign body removal using rigid bronchoscopy failed in 3 children due to severe bronchopneumonia or intraoperative, so a second operation was required. Two children underwent tracheotomy: one was in a vegetative state who inhaled false teeth, while the other was a pupil who inhaled a plastic pen cap. Ventricular fibrillation occurred in one child during surgery, but there were no complications or sequelae after the rescue. Abnormal lower respiratory tract symptoms were observed before surgery in 202 patients (67.3%), of whom 127 (42.3%) showed emphysema (Figure 2), 15 (5.0%) showed atelectasis, 99 (33.0%) showed bronchopneumonia, 35 (11.7%) showed the formation of bronchial granulation, 2 showed pleural effusion, and 1 showed pneumomediastinum and pneumothorax. A total of 152 cases (50.7%) involved the left bronchus, 136 (45.3%) involved the right bronchus, 8 (2.7%) were bilateral (Figure 2), and 5 (1.3%) involved the trachea. Of the 300 foreign bodies, 280 (93.3%) were of plant origin, 11 (3.7%) were of animal origin, 2 (0.7%) were metal materials, and 7 (2.3%) were other objects (plastic products, unknown composition) (Table 1). The retention time of foreign bodies ranged from 2 hours to 60 days, with a mean duration of 1 day; the duration of hospitalization was 1 to 16 days (mean: 2 days); the time from admission to operation was 1 to 12 days (mean: 1 day); and the operation duration was 5 to 85 minutes (median: 20 minutes; Table 1).
Of the 300 patients, 295 (98.3%) had a confirmed history of foreign body inhalation, while the other 5 (1.7%) had an uncertain history. Computed tomography yielded accurate findings in 284 cases (94.7%) and incorrect findings in 16 cases (5.3%). The diagnostic accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and kappa consistency test values were compared between a history of foreign body inhalation and chest CT; the corresponding values were 96.0%, 98.6%, 11.1%, 97.3%, and 20.0% for a history of foreign body inhalation and 97.7%, 97.6%, 100%, 100%, and 56.3% for chest CT, respectively (Table 2). The areas under the curve of foreign body history, chest CT, and a combined diagnosis were 0.549, 0.988, and 0.989, respectively. The accuracy of a combined diagnosis (Az = 0.989 ± 0.005) was higher than that of a single diagnosis (Table 3).
The multivariate analysis of Cox regression revealed that the factors influencing the length of hospitalization were the time from admission to operation, operation duration, presence of bronchopneumonia, and formation of bronchial granulation (P < .05; Table 4). The factors influencing the time from admission to operation was the presence of bronchopneumonia (P < .05; Table 4). The factors influencing the operation duration were the presence of bronchopneumonia and the species of the foreign body (P < .05; Table 4). These findings showed that preoperative bronchopneumonia was related to the duration of hospitalization, time from admission to operation, and operation duration.
Tracheobronchial foreign bodies represent an emergency that may be life-threatening and often occurs in children, with 65% to 75% of cases reported in children aged 0 to 3 years.8,9 A history of foreign body inhalation is the basis of diagnosis, whereas lung auscultation may lead to a misdiagnosis. Imaging is an important diagnostic method. We found that chest CT was a feasible examination method that could accurately identify foreign bodies, locate foreign bodies, and find preoperative respiratory tract complications to help make a clear diagnosis and guide treatment. The incidence of airway foreign bodies was 6.6 per 10 000 children in the United States.10 The high incidence in children is related to factors such as anatomy, physiology, diet, family education, and curiosity of young children. Previous studies reported that peanuts and sunflower seeds are the most frequently reported foreign bodies.11,12 In this study, plant foreign bodies accounted for 90.7% of cases, which was consistent with previous reports, and were commonly peanuts and sunflower seeds. The type of foreign bodies changes with age; TFBs in children less than 3 years old were mostly of plant origin, while those in children older than 3 years were of metal or plastic origin. Previous studies reported that TFBs are more common in males than in females.13,14 The proportions of male (n = 193) and female (n = 107) patients in this study were similar to those reported previously.
Anatomically, foreign body incarceration occurs more easily in the right bronchus because it has a more vertical path and wider lumen than the left bronchus. Zhong et al15 also reported the presence of many foreign bodies in the right bronchus. This study found more bronchial foreign bodies on the left side (152 cases) than on the right side (136 cases); 8 cases were bilateral, of which 7 (87.5%) were unilateral foreign bodies on preoperative chest CT. The possible reasons for the greater incidence of left bronchial foreign bodies were as follows: the angles between the trachea and the bronchus are the same before 15 years of age, so foreign bodies are found on both sides at the same frequency16; the angle of the left bronchus was sharper in about one-fifth of people17; and we suspected that the foreign bodies might move when the children were crying or other activities stimulated coughing.
A history of foreign body inhalation is the key to diagnosing bronchial foreign bodies.18 Most patients have a definite history of foreign body inhalation, while a small number have an unclear history with complaints of a repeated irritating cough, wheezing, fever, and so on. At this point, a chest CT or X-ray examination is needed. However, about 30% of cases involving foreign bodies showed no abnormalities on chest radiography.19 Chest CT can more clearly detect whether foreign bodies cause airway obstruction than chest X-ray and identify related complications such as emphysema and atelectasis.20 A previous study reported that the sensitivity of chest CT was 98%.21 Chest CT can help assess and identify TFBs in patients with an unclear foreign body history or persistent irritating cough, which reduces the risk of unnecessary bronchoscopy and general anesthesia. This study showed that chest CT was helpful at improving the diagnostic accuracy of TFBs. In addition, according to our experiences, preoperative chest CT can help identify bronchopneumonia, allowing affected patients to receive short-term antibiotic treatment before surgery, which can help reduce intraoperative bleeding, shorten the operation time, and reduce the need for a secondary surgery.
Bronchoscopy is the gold standard for the diagnosis and treatment of TFBs.22 Unfortunately, otorhinolaryngologists perform only rigid bronchoscopy, whereas respiratory medicine and pediatric providers use fiberbronchoscopy. In this study, 291 (97.0%) children were confirmed to have TFBs by rigid bronchoscopy, 295 (98.3%) had a clear history of foreign bodies, and 284 (94.7%) had an accurate diagnosis made on chest CT (including the correct position of the foreign bodies). We compared the diagnostic accuracy, sensitivity, and specificity between a history of foreign body inhalation and chest CT; the values were 96.0%, 98.6%, and 11.1% and 97.7%, 97.6%, and 100%, respectively. The accuracy and sensitivity of the 2 methods were good, the specificity of chest CT was higher than a history of foreign body inhalation, and the possibility of a missed diagnosis was very low. We cannot deny the importance of a foreign body inhalation history, which has always been the earliest and most direct basis for diagnosis. A preoperative chest CT examination helps reduce unnecessary bronchoscopy in patients with an unclear history of foreign bodies.
Complications caused by foreign body obstruction of the lower respiratory tract may include emphysema, atelectasis, bronchopneumonia, bronchitis, pneumothorax, pleural effusion, and even suffocation and death8,23; emphysema is the most common complication.24 Previous studies reported that the complications of foreign body obstruction in the lower respiratory tract are related to the species of the foreign body and the duration of retention.11 Previous studies demonstrated that oil release state and retention time are associated with local granuloma formation.25 In this study, 202 patients (67.3%) showed lower respiratory tract complications before surgery, and some had more than 1 complication; of them, 127 (42.3%) showed emphysema, 99 (33.0%) showed bronchopneumonia, 35 (11.7%) showed bronchial granulation formation, and 15 (5.0%) showed atelectasis. A sputum bolt or bronchial granulation formation may appear as a local high-density area in the bronchial region on chest CT and is a factor influencing the diagnostic accuracy of chest CT; similarly, foreign body movement can also influence the diagnostic accuracy of CT. A previous study found that LRTIs influenced the hospitalization time.15 In this study, we found that bronchopneumonia could influence the duration of hospitalization and can be related to the time from admission to operation and the operation duration.
In this study, the operation duration was 5 to 85 minutes (median: 20 minutes); the length of hospitalization was 1 to 16 days (median: 2 days), shorter than 4.3 days.14 On the first day after admission, 257 patients (85.7%) underwent rigid bronchoscopy surgery, including 155 (94.5% [155/164]) in whom the foreign body retention time did not exceed 24 hours. Cox regression analysis found that the factors influencing the length of hospital stay were the time from admission to operation, duration of operation, presence of pneumonia, and formation of bronchial granulation. A low level of education and less medical knowledge were also associated with a high incidence of TFBs. And finally, surgeon and anesthesiologist experience and skill influence the operation duration to a certain extent.
There are some limitations to this study. First, it was retrospective and performed in a single department of a single center. Second, all patients underwent rigid bronchoscopy, and those who underwent flexible bronchoscopy in other departments of our center were not included. Third, the relationship between surgery duration and surgeon and anesthesiologist skill levels was not analyzed. A more detailed classification analysis of this comparison will be required in future studies. Large-scale studies encompassing multiple centers and departments in different regions may yield more convincing data.
Tracheobronchial foreign bodies are a common clinical emergency in children that can be life-threatening. Timely and accurate diagnosis and treatment can help reduce the incidence of lower respiratory tract complications. A detailed history, adequate physical examination, and preoperative imaging examinations are helpful for improving diagnostic accuracy. Preoperative bronchopneumonia in children with TFBs will increase the risk of surgery and cost of treatment, prolonging the duration of hospitalization.
The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request. This retrospectively study was approved and consented by the ethics committee of Yantai Yuhuangding Hospital.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Yan Wang https://orcid.org/0000-0002-3107-4614
1 Department of Otolaryngology–Head and Neck Surgery, Yantai Yuhuangding Hospital, Qingdao University, Yantai, Shandong, China
Received: March 19, 2021; revised: May 17, 2021; accepted: May 18, 2021
Corresponding Author:Xicheng Song, MD, Department of Otolaryngology–Head and Neck Surgery, Yantai Yuhuangding Hospital, Qingdao University, No. 20 Yuhuangding East Road, Yantai, Shandong, China.Email: songxicheng70@163.com
