Tracheobronchial foreign body aspiration (TFBA) is a common clinical emergency, with symptoms including hoarseness, cough and dyspnea, more likely to appear in children and possibly associated with immature teeth and uncoordinated swallowing. ^[1] The anatomical structure of the right main bronchi makes foreign bodies more likely to be incarcerated. ^[2] Right bronchus is straighter and broader than the left bronchus, facilitating the deposit of foreign body on right side. ^[3] Patients with mild symptoms may delay hospital visits for longer periods of time, leading to more severe complications.

The most commonly inhaled foreign bodies include food, coins, dentures, metallic objects, plant seed, animal bone, mineral, and chemical compounds. Generally, free fatty acids of plant seed cause substantial irritation to the airway, leading to mucosal congestion, swelling and secretion, making the surgical procedure more intricate. ^[4] The symptomatic triad of choking, coughing and unilateral wheeze is present is most cases. Acute respiratory distress is fortunately uncommon but most alarming presentation of inhaled foreign body. ^[5] Long standing airway foreign body can result in spectrum of symptoms ranging from cough and wheeze to recurrent or nonresolving respiratory sequelae. The symptoms mimic other respiratory conditions like asthma, pneumonia or tracheobronchitis. The diagnosis of tracheo-broncial foreign body requires high index of suspicion. Even in absence of a positive history early therapeutic intervention is required to prevent morbidity and mortality due to delayed or missed diagnosis. ^[6]

Diagnosis of such airway foreign body (FB) is facilitated by a new imaging modality –Virtual bronchoscopy. Virtual bronchoscopy (VB) is software based three-dimensional visualization formats created from noninvasive medical imaging methods such as CT & magnetic resonance imaging, with the goal of creating views similar to minimally invasive bronchoscopy procedure. This technique offers a detailed view of the airways, with reduced risk of infection or perforation and facilitates preoperative planning for airway interventions that would otherwise not be possible. ^[7] In presence of a positive clinical diagnosis & inconclusive chest radiography, CT virtual bronchoscopy must be considered to avoid rigid bronchoscopy. Virtual bronchoscopy simulates an endoscopic view of the internal surface of the airway. It gives excellent results regarding location, severity and shape of airway narrowing.

So, any person with history suggestive or suspicious of foreign body aspiration or with clinical or radiographic evidence of tracheo-bronchial foreign body is considered an emergency and should be treated immediately.  ^[8]

Rigid bronchoscopy under general anaesthesia is gold standard treatment for tracheobronchial foreign body. Rigid bronchoscopy should be considered the definitive diagnostic and therapeutic intervention in all cases where history and clinical examination is suggestive or suspicious of airway foreign body. ^[9]

This study was undertaken to determine the proportion of FBs among all paediatric cases seen in the ENT clinic at our hospital, their clinical characteristics and demographic factors associated with this condition.

Present study was prospective study conducted in Department of ENT, Medical Sciences and Research, India. Case records of patients with confirmed tracheobronchial foreign body (TFB) aspiration were studied for last 2 years.

Cases with history of aspiration, sudden onset of breathlessness or choking sensation in a healthy person, recurrent respiratory infections with clinical or radiological evidence, and suspicion of foreign body & later had confirmed evidence of TFB were considered for present study. Patients with bronchial asthma, acute laryngo-tracheobronchitis, COPD, bronchiectasis were not considered for present study.

Clinical details (age, sex, nature, site of foreign body lodgement, duration between inhalation or symptoms and admission in a hospital), clinical signs & symptoms, investigations (X- ray chest, CT scan chest), findings of rigid/flexible bronchoscopy were noted. Data was collected and compiled using Microsoft Excel, statistical analysis was done using descriptive statistics.

60 cases satisfying study criteria were studied. Majority were children below 2 years of age (38.3%), followed by 3-4 years age group (30%). Majority of cases were male (58.3%) as compared to female (41.7%). 

Table 1: General characteristics

Characteristics     No. of cases    Percentages

                                                  Age (years)

Majority of cases had symptoms or history of dry cough (61.7%), noisy breathing (50%), respiratory distress (46.7%) and witnessed choking (30%). While among signs majority of cases had unilateral reduced air entry (53.3%), unilateral wheeze (41.7%), whistling and clicking sounds (20%) and no signs (17.31 %).

Table 2: Symptoms and Signs

                                                                                                  No. of case       Percentages

                                     Symptoms

In present study Chest X-Ray findings were consolidation (60%), lobar collapse (53.3%), hyperinflation (50%), ipsilateral emphysema (38.3%) and normal (16.7%). CT Bronchogram was not done in 45%, while in cases underwent CT were findings of foreign body/mucus plug (30%) and foreign body (25%).

Table 3: Radiological findings

  Radiological findings           No. of cases    Percentages

Chest X-Ray Findings

                                            Foreign Body                                      15                           25

In present study, location of foreign body was left main bronchus (51.7 %) followed by right main bronchus (35%), carina (8.3%) and left main and secondary bronchus (5%). Supari/betel nut (30%) was most common foreign body observed followed by peanut (28.85 %), ground nut (28.3%), plumseed (1.7 %), coconut (1.7%) and non-organic (13.3%). Intra operative granulations were present in 33.3% cases.

Table 4: Intraoperative findings

                                                   Intraoperative findings                    No. of cases         Percentages

Tracheobronchial foreign body aspiration in the pediatric population can present with varying symptoms, ranging from a mild cough to severe respiratory distress and even death. Due to delay in the diagnosis, there is significant morbidity in this population. In our study, we noted that>70% of patients were<5 years old, which was in agreement with other series reported. ^[10-17] Extracting the history from parents plays a crucial role in the diagnosis. A typical history from the parents often misleads the doctors.

The most common foreign body encountered in our series is organic. Betelnut was the most frequent one among our set of cases. Being organic and due to delayed presentation, it was always a challenge to remove these foreign bodies. The most common foreign body seen is peanut among the vegetative, but may differ from region to region. ^[18] These differences are mainly due to cultural and social habits in different places.

Diagnostic delays and misdiagnosis are not uncommon. Atypical history from patients often mis leads the doctors in making a diagnosis. Foreign body aspiration may mimic other respiratory conditions like asthma, recurrent pneumonia and bronchiolitis. Other common symptoms are fever, chronic cough, wheeze and respiratory distress. The clinician should keep suspicion of foreign body aspiration, especially when a child presents with unilateral lung pathology. The doctor’s ability to elicit the history of choking is essential, as it may predict the possibility of foreign body aspiration. Barrios et al. suggested doing bronchoscopy in all children with acute onset respiratory distress, who present with a history of choking. ^[19] The most common symptom in our series was cough, which was in agreement with the literature. ^[20]

A total of 58.8% of the patients presented after 7 days of the suspected day of aspiration. On reviewing the literature, between 2 and 23% of the patients present after 1 month. ^[21] In our series, 44.44% of the patients presented after 1 month. The retained bronchial foreign body can lead to complications like pneumonia, bronchiectasis, lung abscess and consolidation. ^[22] All patients with delayed presentation had a history of multiple admission at different hospitals, and the majority of the time were treated as a case of bronchopneumonia. One patient who presented to us after 1 year had pleural effusion for which intercoastal drainage was performed.

A total of 95% of the patients underwent flexible bronchoscopy, which helped the diagnosis. Flexible bronchoscopy helped not only to identify the level of the foreign body, but also in assessing the tracheobronchial mucosa. The role of imaging is also critical in tracheobronchial foreign body diagnosis. High resolution computed tomography of the thorax was performed in all cases to ascertain the location of the foreign body. In the majority of the times, HRCT had led to the suspicion of tracheobronchial foreign body, which also aided us to confirm the position of the foreign body. We noted that consolidation and hyperinflation were the most common findings. In the case of chronic foreign body aspiration, which is seen in delayed presentation, severe airway inflammation and granulation formation lead to complications. ^[23]

It is important to note that the management of tracheobronchial foreign bodies requires multiple specialties, including Otorhinolaryngologists, anesthesiologist and pediatric physician. Planning of the definitive management involves the teamwork of these specialties. The definitive management strategy for  tracheobronchial foreign body is rigid bronchoscopy under general anesthesia. In cases where there is a dilemma in diagnosis due to the atypical and long-standing history, there are chances of getting a negative bronchoscopy. In our study, we were able to identify, locate and remove the foreign bodies in all 17 cases. Bronchoscopy findings varied among patients. In most of our delayed presentations, there was more granulation formation and pusdischarge at the site of foreign body impaction. Removal of granulation tissue leads to bleeding, which obscures the field. One of our patients had bronchial stenosis due to long term retention of the foreign body. The foreign body was visualized below the stenotic segment. ^[24]

In our experience, delayed presentations of lower airway foreign body aspiration were always associated with mild to severe form of complications. Whenever a child presents with respiratory symptoms that do not improve with usual medications, the clinician should have a high index of suspicion. We should be more vigilant in history taking and clinical examination. Preoperative planning, multidisciplinary teamwork, surgeon expertise and technique are the key factors in avoiding complications in the definitive management. A high indexof suspicion and early intervention is needed to prevent complications.

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