Case Report

A 33 yr old white male who was previously fit and well presented to the Accident & emergency department with the symptoms of foreign body sensation in the throat following a meal. He denied any problems with breathing or any difficulty with swallowing. He also denied any violent attacks of coughing or haemoptysis. Clinical examination was unremarkable. He was afebrile and breath sounds were equally heard bilaterally. Surprisingly soft tissue neck X-ray revealed a foreign body in the trachea. He underwent rigid endoscopy and a chicken bone was removed. Patient was discharged the following day.

Figure 1

Figure 2

Discussion

The diagnosis and management of foreign body aspiration is extremely important. Missed or delayed diagnosis can result in respiratory difficulties ranging from chronic wheezing or recurrent pneumonia to life threatening airway obstruction or lung abscess.

History: The first known fatality attributed to aspiration is said to be the Greek poet Anacreon who died in 475 BC after aspirating a grape seed. In 400 BC Hippocrates recognized aspiration as a clinical problem in ‘‘Dangers of Aspiration'‘. John hunter performed the first known scientific aspiration in a cat in 1781. Sir James Y. Simpson attributed the first well documented anesthesia related death in 1848. A significant advancement in bronchoscopy was achieved by introduction of Hopkins telescope in 1976 (₁).

Incidence: Several studies have been undertaken and no conclusive incidence was reported. But extremes of the age group are more prone for foreign body aspiration. Children who are less than 3 yrs are most at risk (₁).

Physiology: Aspiration in a healthy individual is prevented by involuntary muscular mechanisms. As food is voluntarily moved from mouth to pharynx by the tongue, the involuntary mechanisms of swallowing are initiated. The soft palate is pulled upward and posteriorly to close the posterior nares preventing reflex of food into nasal cavities. The palatopharyngeal folds move medially to form a sagital slit, which allows only well, chewed food to pass through easily. The epiglottis moves downwards to close the glottis. False cords and true cords approximate. The entire larynx moves upward & forwards stretching the opening of the oesophagus & upper oesophageal sphincter relaxes. The superior constrictor muscles contract, which propels the food into oesophagus (₁).

Clinical features: The initial symptoms of aspiration of solid material vary depending on the size of the particles. Large objects, such as poorly chewed meat may lodge in upper end of oesophagus, but if they become impacted in larynx or trachea it will result in abrupt respiratory distress. Apnoea, cyanosis, loss of consciousness and death ensures unless the foreign body is dislodged (₂). However, aspiration of small foreign bodies is less dramatic. Cough is the initial manifestation. Dyspnoea, chest pain, wheezing, fever, nausea or vomiting may follow this.

Lemberg et al (₃) reported the following symptoms

Figure 3

Physical examination may show no abnormalities in large proportion of these cases.

Mc Guirt et al (₄) reported the following physical findings

Figure 4

Radiographic studies are essential in these cases. Standard chest X-ray is useful in locating foreign bodies (₅). Metallic and other radio opaque foreign bodies are easily located. However around 10% of case may not show any abnormality (₄). Inspiratory -expiratory mediastinal shifting and mediastinal shift towards foreign body is most consistent finding on chest X-ray. In children fluoroscopy is most useful. But even fluoroscopy has shown up to 45% of false negatives. Ultrasound, CT scan and Xenoradiographic examinations have been of limited success. As neither diagnostic methods nor clinical findings are uniform, decision to examine the patient endoscopically often a clinical decision based on history. An endoscope should be used to remove foreign bodies. It is imperative to examine entire airway for any other simultaneous foreign body.

Conclusion

Tracheobronchial foreign body aspiration should be strongly suspected based on history in children and neurologically affected adults (₅). However young adults are no exception. Though the majority of patients can present dramatically with a foreign body in their airway, few can be stable with no airway compromise as demonstrated in our case. The only positive clinical finding was history and X-ray. We would suggest that anyone with a definite history of ingestion of foreign body should have lateral soft tissue X-ray of neck. If unremarkable on X-ray, then decision to examine under anesthesia by endoscopy is based on history and symptoms as often X-rays can be misleading.

Acknowledgements

Correspondence to

Mr.Shareef.M.M,7 Kiltongue cottages,Monklands Hospital,Airdrie. ML6 0JXMobile: 07884184962.Mail: shareefmm@eudoramail.com