A Retrospective Review of Foreign Body Inhalation in the Asir Region

Introduction

Foreign body aspiration is a common problem in children,¹ and the most common cause of accidental death in the home in children under six years of age.² It is estimated that almost 600 children under 15 years of age die per year in the USA following aspiration of foreign bodies.³ In fact, choking on food has been the cause of between 2500 to 3900 deaths per year in the USA, when taking both children and adults into consideration.⁴ The most common foreign body inhaled by Saudi children in the Eastern region has been reported to be watermelon seeds, and in Western countries, it is said to be peanuts.⁴ In Saudi Arabia, as in many other countries, there are no available statistics regarding the contribution of foreign body aspiration as a cause of death. This is probably due to the fact that many patients succumb well before reaching the hospital. This paper looks at the regional experience, and compares it with other studies to obtain an overview of the problem in the Kingdom as a whole.

MATERIALS AND METHODS

This is a retrospective study of foreign body inhalation in the Asir Central Hospital. We reviewed the medical records of 83 pediatric patients admitted between February 1990 and January 1996 with the diagnosis of foreign body inhalation. Of the 83 patients, 23 were found to have incomplete records and were, therefore, excluded from the study. Analysis of the 60 remaining records showed all the patients to be in the pediatric age group (under seven years). Chest x-ray and complete blood count were performed on all patients when they arrived at the emergency department. In all patients, the foreign bodies were removed under general anesthesia with controlled ventilation, using Karl Storz pediatric rigid bronchoscope. The size of the bronchoscope (external diameter) varied from 3.5 mm to 5 mm, and was selected according to the age of the patient. Bronchoscopy was performed by the ENT surgeon in all 45 cases referred to the hospital. In the other 15 cases, the decision was made jointly by the pediatrician and the ENT surgeon. Antibiotic, oxygen and steam inhalation were administered according to the time elapsed since the aspiration, and difficulties encountered during foreign body removal.

RESULTS

Of the sixty patients in the study, 38 were male (63%) and 22 female (37%). Their ages ranged between six months and seven years, with a mean of 2.5 years. Fifty-four of the patients (90%) were under the age of three. The total population of the Asir region is approximately 1.5 million, which gives an incidence rate of 1.6:100,000 per year. Coughing and choking were the most common presenting symptoms, with wheezing and diminished air entry the most common clinical findings, occurring in 35% of the patients. Fifty-seven percent of the patients had normal chest x-ray findings, perhaps due to the fact that most foreign bodies encountered are radiolucent, and 17% showed lobar collapse. Opaque foreign bodies were seen in 10% of the patients, while pneumonia and atelectasis occurred in 10% and 7%, respectively. During bronchoscopy, 37 of the patients (61.5%) had the foreign body in the right main bronchus, 21 (35%) had theirs in the left main bronchus and two (3.5%) in the trachea. Most of the foreign bodies aspirated were organic in nature. Watermelon seeds were found in 18 of the cases (30%), and were the most common foreign body encountered. The next most common were pieces of nuts and corn seed, each with eight cases (30%). The most common inorganic foreign bodies were beads and stones; others included earrings, plastic and needles. The time interval between aspiration and removal of the foreign bodies ranged betweeen 24 hours and four months, while 30% of the cases were seen within the first 24 hours. In eight cases, the delay ranged between five days and four months. There was no mortality.

DISCUSSION

Our review of foreign bodies in airways confirms the view of others that the highest incidence of foreign body inhalation occurs in the under-three-year age group.⁵ In this study, 90% of the patients were under three years of age. This peak incidence in early childhood is, of course, related to the fact that children are in the habit of putting objects into their mouth to determine their texture and taste, and to chew on when teething.⁶ It is important to educate parents on the potential risks involved in foreign body inhalation, and advise them to keep small objects away from children. The male to female ratio in our study (1.7:1) is not significantly different from previously reported cases (2:1 and 1.82:1).^6,11 Radiographic findings were often not very helpful, especially in radiolucent foreign bodies, which accounted for 34 (57%) of our cases. For this reason, bronchoscopy is indicated when the clinical history is strongly suggestive of foreign body inhalation. Pneumatic changes were seen in those cases where the diagnosis was made late. Most of the foreign bodies found in our analysis were organic in nature. In contrast to reports from Western countries, where peanuts were the most commonly encountered foreign bodies,⁷ our findings agree with those of Ashoor et al.,⁵ Romulo⁷ and Yousry,⁸ who found that the most common foreign bodies encountered in the Middle East were watermelon seeds. This may be related to the cultural and social habits throughout the Middle East. The inorganic foreign bodies were mostly stones, beads and pieces of plastic.

This study, like most other studies on the subject, shows the right main bronchus as the main site of foreign body lodgement.⁹ This is related to the fact that the right main bronchus is larger than the left and the interbronchial septum projects to the left. The effect of inspiratory air current also determines the site of final impact.^10,11 This paper highlights the importance of public education regarding the dangers of allowing young children to eat seeds, and aims to increase awareness in medical practitioners for early referral of patients suspected of foreign body inhalation.