Foreign Body Aspiration in Adults. Ali Bin Sarwar Zubairi Aga Khan University, Ali.Zubairi@Aku.Edu

eCommons@AKU

Department of Medicine Department of Medicine

May 2006 Foreign body aspiration in adults. Ali Bin Sarwar Zubairi Aga Khan University, [email protected]

Haque A. S Aga Khan University

Husain S. J Aga Khan University

Javaid Khan THE AGA KHAN UNIVERSITY, [email protected]

Follow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_med_med Part of the Pulmonology Commons

Recommended Citation Zubairi, A., S, H. A., J, H. S., Khan, J. (2006). Foreign body aspiration in adults.. Singapore medical journal., 47(5), 415-418. Available at: http://ecommons.aku.edu/pakistan_fhs_mc_med_med/317 Case Report Singapore Med J 2006; 47(5) : 415

Foreign body aspiration in adults Zubairi A B, Haque A S, Husain S J, Khan J A

ABSTRACT CASE REPORTS Foreign body aspiration is not an uncommon Case One problem, particularly in children, the elderly, A 46-year-old woman presented with an eight-day and those with predisposing factors like history of distressing dry cough along with a three- neurological impairment. In adults, regional day history of fever. On physical examination, she differences exist in the type of foreign body was febrile and appeared toxic. Chest examination aspirated. We report four cases of foreign revealed right basal dullness to percussion and body aspiration in South Asian adults, three reduced breath sounds. A chest radiograph showed a of which were related to the widespread right lower lobe collapse. On further inquiry, it was habit of chewing stimulant seeds such as revealed that eight days ago, she had experienced betel nuts (two) and tamarind seed (one). It severe acute cough and choking while chewing betel is important for clinicians to maintain a high quid. A fibreoptic bronchoscopic examination showed index of suspicion for the diagnosis of foreign a foreign body in the bronchus intermedius with body inhalation in the appropriate clinical surrounding oedema. An ensuing rigid bronchoscopy setting. Bronchoscopy is necessary not only allowed the successful removal of a large betel nut. for the diagnosis but also for the removal of The patient recovered with no residual symptoms foreign body from the bronchial tree. Once and re-expansion of the right lower lobe. the foreign body is removed, the improvement in symptoms is usually dramatic, making it Case Two rewarding for any physician to manage. A 62-year-old woman was admitted with a two-month history of cough, intermittent fever and dyspnoea. She Keywords: betel nut, bronchoscopy, foreign had received multiple courses of different antibiotics body aspiration, stimulant seeds, tamarind during this period. On physical examination, wheezes seed and crackles were present on the right side of the chest. Singapore Med J 2006; 47(5):415-418 A chest radiograph revealed right mid-zone infiltrates with no significant collapse. A flexible fibreoptic Department of Pulmonary and bronchoscopy was done to evaluate the aetiology of Critical Care Medicine INTRODUCTION The Aga Khan her symptoms. This showed a foreign body impacted University Hospital Foreign body aspiration is a condition seen all over in the bronchus intermedius. A subsequent rigid PO Box 3500 the world. It can present in a variety of ways, ranging Stadium Road bronchoscopy, allowed the successful removal of the Karachi 74800 from no or trivial symptoms to irreversible damage foreign body, which was later identified as a betel nut. Pakistan (1) to the lung which may be life- threatening . Foreign She recovered with no lasting consequences. Zubairi A B, MD, FCCP body aspiration in adults is more common in the Assistant Professor setting of advanced age, underlying neurological Case Three Haque A S, MBBS, MRCP disorder, poor dentition, alcohol consumption and A 55-year-old woman with asthma presented Assistant Professor sedative use(2,3). In the absence of predisposing with a six- month history of chronic cough and Husain S J, MD, FCCP factors, children are reported to be at a higher risk than intermittent fever. She had received multiple courses Assistant Professor adults. In children the aspirated material is usually an of antibiotics, with partial improvement of her Khan J A, MBBS, FRCPE object like toys, screws and other household items. symptoms. On examination, she was febrile and Professor Aspiration of organic material such as nuts, seeds, had unilateral wheeze along with basal crackles on Correspondence to: (4) Dr Ali Bin Sarwar Zubairi vegetables and bones have been described in adults . right side. Her chest radiograph was suggestive of Tel: (92) 21 4859 4682/5 We report four adult cases of foreign body aspiration right lower lobe bronchiectasis and partial collapse Fax: (92) 21 493 4294 Email: ali.zubairi@ where there were no underlying risk factors. (Fig.1). On fibreoptic bronchoscopy, a brownish black aku.edu Singapore Med J 2006; 47(5) : 416

endobronchial mass was seen in right lower lobe bronchus (Fig. 2). An endobronchial biopsy was done which revealed vegetable matter. She subsequently underwent a rigid bronchoscopy and removal of the foreign body from the right lower lobe bronchus. The foreign body was conﬁrmed to be a tamarind seed. She recovered from her pneumonia. However, she had signiﬁcant residual bronchiectasis.

Case Four A 19-year-old man from northern Pakistan was referred with a two-year history of productive cough Fig. 1 Chest radiograph shows right lower lobe bronchiectasis and intermittent fever. During this period, he had and partial collapse. received multiple antibiotics and two courses of anti- tuberculous therapy without any benefit. His chest radiograph showed extensive left- sided fibrosis along with cavitations (Fig. 3). Sputum smears were negative for acid-fast bacilli (AFB). On flexible bronchoscopy, the plastic feed of a fountain pen lodged in left lower lobe bronchus was identified (Fig. 4). On close questioning, the patient recalled an event three years ago, where he had intractable cough that lasted two weeks after inhaling “part of a fountain pen”. A surgical consult was sought and the patient underwent a partial lingular and a complete left lower lobe resection due to extensive bronchiectasis. He recovered completely without any significant residual complaints. Fig. 2 Brochoscopical photograph shows a black endobronchial mass-like lesion (vegetable material) impacted in right lower lobe bronchus. DISCUSSION Our four cases of foreign body aspiration, two with betel nuts, one with tamarind seed and one with plastic feed of a fountain pen, demonstrate the potential considerable morbidity associated with this condition. Three of our patients presented many months after the inhalation episode, and one did not even remember the initial episode. The diagnosis was missed previously in all cases, and in one case, two courses of anti-tuberculous therapy were given

Fig. 3 Chest radiograph shows extensive left-sided ﬁbrosis. Fig. 4 Photograph shows the plastic feed of a fountain pen. Singapore Med J 2006; 47(5) : 417

based on clinical and radiological suspicion. The high bony fragments were the most common foreign rate of initial alternate diagnosis and the empirical body aspirated in adults(10). A possible explanation treatment of common conditions is not infrequently may be that Chinese eat viand (meat and bone) seen in cases of foreign body aspiration. Our cases with rice using chopsticks, which requires a highlight the potential diagnostic challenge posed suction, usually generated by an inspiratory effort, by this condition, and illustrate the importance of as a consequence of which risk of aspiration obtaining a good history and maintaining a high index is increased. Limper and Prakash reported that of clinical suspicion to arrive at the correct diagnosis. food particles were the most common foreign Tracheobronchial obstruction by a foreign body body aspirated in their series of North American was first described as a cause of wheezing by Struthers cohorts(11). Consistent with previous series, our in 1852(5). In adults, the most commonly aspirated patients also presented late, with the presence of material are food particles. Significant neurological symptoms for many months in three of our patients. impairment, alcohol and drug intoxication and poor Lan found that only six out of 46 patients had dentition are identified risk factors for such events presentation within one week of aspiration(12). This in adults. However, as seen in our series, foreign delay not uncommonly occurs because the episode body aspiration can occur, even in the absence of of aspiration is either asymptomatic or causes identifiable risk factors. Foreign bodies that are able minimal symptoms. In adults, a probable reason for to pass through the vocal cords often lodge at the lack of acute symptoms may be the larger calibre carina and right main stem bronchus(5). of airways resulting in most foreign bodies lodging In many Asian countries, including Taiwan, and obstructing more distal airways(13). Because India and Pakistan, betel nut (Areca nut) is chewed of the delayed presentation, all of our patients by itself and in various scented preparations(6,7). It had an abnormal chest radiograph and associated is also consumed in the form of betel quid, which complications such as localised bronchiectasis, consists of betel leaf, areca nut, sweetener, slaked lung fibrosis and recurrent pneumonia. The lime, condiments, and sometimes, tobacco. Betel nut initial diagnosis and localisation of the foreign inhalation is common in South East Asia. In a series of bodies in all our cases was confirmed by flexible 52 Pakistani children with foreign body aspiration, 29 bronchoscopy. Studies have reported high success cases were due to betel nuts(8). The manner in which rates with flexible bronchoscopy for the removal of nuts are introduced into the mouth places the user at foreign objects(14,15). However, in our series, three high risk of aspiration. The nut mixture, which usually patients required rigid bronchoscopy to remove consist of many small particles, is first spread onto the the foreign body and in one patient, thoracotomy palm, following which a sharp flicking movement of and lobar resection were done. This was due to the the arm and wrist, with the neck partially extended and consistency and the size of the aspirated material. an accompanying inspiratory effort, causes the nuts to The betel nuts and tamarind seeds are of a large size be tossed into the oral cavity at a high velocity. The and are slippery, thus preventing the forceps or the net effect of these actions is that particles of varying basket from capture and removal of the object. sizes are predisposed to enter the airways. In conclusion, foreign body aspiration can occur Nut aspiration is recognised as a public health in adults in certain ethnic/ subgroups of South Asian issue in some parts of the world. A study on population, in the absence of any predisposing Pakistani school-aged children found that 74% of factors. A delay in presentation or recognition may the children were using areca nut. The reasons for lead to serious complications, emphasising the this widespread use were aggressive marketing, easy importance of early diagnosis in this potentially availability, and a lack of school education among dangerous but completely reversible condition. parents(8). In another study from Turkey, hazelnut Foreign body aspiration should always be considered aspiration was responsible for 26% of all foreign in the aetiology of recurrent pulmonary infections, bodies aspirations, and the peak correlated with haemoptysis, lung abscess, middle lobe syndrome, hazelnut harvest season(9). To our knowledge, there and bronchiectasis, all of which may necessitate a has been no case report of tamarind seed aspiration. surgical resection. Tamarind seed is part of the tamarind fruit, which is a paste-like fruit and is usually chewed. The seed ACKNOWLEDGEMENT itself is extremely smooth and slippery and thereby We are thankful to Saulat Fatimi, MD, Assistant increases the likelihood of aspiration. Professor of Cardiothoracic Surgery at the Aga Regional differences exist in the kind of foreign Khan University, for providing assistance in the bodies aspirated worldwide. In a study from China, management of our cases Singapore Med J 2006; 47(5) : 418

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