Cotton Ball Aspiration Leading to Pulmonary Complications in a Child

Introduction

Foreign body aspiration (FBA) is a common pediatric emergency and remains a significant cause of death in children. According to the National Safety Council, in 2016, the rate of fatal choking in American children over 5 years of age in the general population was 0.43 per 100 000 [1]. The mortality rate from FBA ranges from approximately 0% to 1.8%, and FBA is the fourth leading cause of death in preschool-aged and younger children [2,3]. Bronchial foreign bodies can be misdiagnosed or neglected and can persist for years in airways. Those “forgotten foreign bodies” can lead to serious complications, including pneumothorax, mediastinal emphysema, endotracheal hemorrhage, asphyxia, and systemic infection. Respiratory and cardiac arrest can occur when the foreign body obstructs the lumen or is difficult to remove, which impacts the quality of life of patients or threatens their lives. Therefore, early diagnosis and treatment are imperative to prevent death and serious complications. Here, we report a case of cotton ball inhalation due to parental negligence after oral tooth extraction in which the possibility of FBA was denied by the parents when the patient was sent to the hospital.

Case Report

A 5-year-old boy who was previously healthy presented to a local hospital with cough for 6 days and fever for 4 days. Laboratory findings indicated an elevated white blood cell count; therefore, cefprozil was given for treatment. However, the symptoms of the child did not significantly improve. To further clarify the etiology, a chest computed tomography (CT) scan was performed. CT examination revealed left pulmonary atelectasis (Figure 1A, 1B). To clarify the etiology, the boy was referred to our hospital for treatment. When the child was sent to the Emergency Department of our hospital, auscultation revealed that the breath sounds of the left lung were reduced. After much questioning, the parents of the child denied the possibility of foreign body inhalation events. Then, the patient was admitted to the hospital with a diagnosis of acute pneumonia and atelectasis. After admission, 0.75 mg/kg ceftriaxone was given as an anti-infective treatment. The next day, after discussion in the department, the possibility of a foreign body was considered. Considering that chest CT revealed a left lung atelectasis, we thought that the volume of the foreign body would be relatively large, and after consultation with the ear-nose-throat doctor, direct laryngoscopy, bronchoscopy, and removal of the left lung foreign body was performed. Direct laryngoscopy did not reveal obvious abnormalities in the throat. Rigid bronchoscopy was performed again, and a yellow-white foreign body was revealed in the left main bronchus. After seeing the extracted cotton ball (Figure 2), the parents were able to recall that the patient had undergone tooth extraction 1 month earlier and had a severe choking cough; however, the parents did not bring the boy to the doctor. The patient returned safely to the ward after surgery, and nebulized budesonide and ipratropium bromide were administered. On the first postoperative day, the child’s temperature returned to normal. On the third postoperative day, the patient’s cough improved, his chest radiograph improved significantly, and he was discharged (Figures 3, 4). After admission, all conditions and surgical treatments were conducted, with the consent of the patient’s parents.

Discussion

FBA is a common and life-threatening event. Most cases occur in the population under 5 years of age (60%–80%), approximately 15% of cases occur in the population between 5 and 15 years of age, approximately 6% of cases occur in the population over 15 years of age, and it is more common in boys than in girls [4]. Nuts and seeds are considered the most common aspirated foreign bodies in most countries. However, in our study, we showed that a nonfood item was lodged in the left main bronchus of a 5-year-old boy. Our finding agreed with that of Bin Xu, whose study showed that inedible foreign bodies are more common in older children, with a mean age of 5.22 years [5]. Children’s nature is to like to explore the unknown world. Also, it is commonly believed that boys, compared with girls, tend to show more curiosity in exploring their environment. Therefore, individuals and society need to develop relevant preventive strategies to reduce the risk of FBA and prevent adverse consequences. Three of these strategies are as follows. (1) Parental education: Parents should be educated about the causes and hazards of this condition. Parents should supervise their children closely, especially parents with children younger than 36 months. Parents should be advised to not offer hard round foods and toys containing small parts to younger children. (2) Changes should be made to the design of products, especially food and toys, to reduce the risk of suffocation. (3) Regulations should be established to prevent the marketing of dangerous products to children. In our study, we identified a foreign body in the left main bronchus. This finding was different from that of Parvar et al, who reported that the right bronchus was the most common location [6]. The tendency of the right bronchus is to be more vertical and shorter and to have a lower angle than the left bronchus [7]. However, some other studies have suggested that FBA more frequently occurs in the left bronchus [8,9]. According to Kumar et al, incidence of FBA can be found on either side with equal frequency because the angles of the mainstem bronchi to the trachea are identical until the age of 15 years, and the location of the foreign body mostly depends upon the physical position at the time of inhalation [10]. Therefore, further data collection may be necessary for our analysis.

A correct medical history is crucial for the correct diagnosis of FBA, as a lack of a witness to the choking event can delay diagnosis. The main symptoms of FBA are fever, cough, and wheezing. Also, reduced or diminished breath sounds can be auscultated in the lungs. Moreover, some patients can have no abnormalities on physical examination or chest X-ray. In the present case, the boy experienced cough and fever within approximately 1 week, the Emergency Department physician noted decreased breath sounds in the left lung, and local CT revealed left pulmonary atelectasis. Thus, if the history of FBA is unclear, but persistent pulmonary infections are present, and radiological findings, such as atelectasis, bronchiectasis, obstructive emphysema, or mediastinal shift are present, bronchoscopy examination needs be done to exclude FBA. To quote the dictum of Chevalier Jackson, ‘‘In suspected cases of foreign body of air passages, bronchoscopy must be done, as failure to do bronchoscopy is more disastrous than complications of bronchoscopy’’ [2]. In addition, improvements in medical knowledge, medical skills, and medical staff education, especially in the training of primary care doctors, will help early identification of FBA and reduce treatment delays.

Bronchoscopy is still the first-line option for FBA. The main treatment methods for tracheobronchial foreign body removal are rigid bronchoscopy and flexible bronchoscopy. As the foreign body in our patient was located in the left main bronchus, which is not far from the main bronchus, the volume of the foreign body was relatively large. Finally, rigid bronchoscopy was performed on the child. Dorterler et al showed that, compared with flexible bronchoscopy, rigid bronchoscopy can provide good ventilation during the procedure and has a success rate of essentially 100%, with the help of an experienced physician [11]. However, rigid bronchoscopy also has the disadvantage of high complication rates. Laryngeal edema, injury to the vocal cords, airway laceration and perforation, hypoxemia-induced cardiac ischemia, and arrhythmias are the main manifestations [12]. In recent years, with the continuous improvement of flexible bronchoscopy and anesthetic techniques, the use flexible bronchoscopy slowly began to increase. Flexible bronchoscopy can be used to easily reach a far distance distally, and there are fewer incidences of adverse events associated with its use [13]. An increasing number of researchers choose flexible bronchoscopy as first-line option for FBA. Recently, cryotherapy has emerged as a new approach for foreign body removal for those foreign bodies located distally, where removal by forceps or baskets is difficult or even impossible. Eventually, surgical intervention may be considered when none of the above treatments are effective, with the most frequent surgical strategy being a bronchotomy or pulmonary resection. However, children are at high risk of mortality and complications following pneumonectomy. The surgical intervention strategy needs to be prudent for this particular population of patients. Therefore, in practice, deciding whether to use rigid bronchoscopy, flexible bronchoscopy, or surgery can depend on the experience of the bronchoscopist, the type and location of the foreign body, and the facilities needed to perform the procedure.

There is controversy as to whether delayed treatment is associated with poor prognosis. Lee et al reviewed the cases of 49 children under 3 years of age who underwent rigid bronchoscopy for suspected FBA at a single tertiary institution. The study revealed that early diagnosis, rapid hospitalization, and rapid surgery after hospitalization improved the prognosis of patients with FBA [14]. The predictor of poor outcomes was found to be the length of procedure time. Any factor that prolongs the duration of surgery can lead to an increase in inflammation and other complications. These factors include the type of foreign body, site of foreign body entrapment, accidents during the operation, and experience of the operator and the anesthesiologist. Therefore, clinicians need to continuously improve medical knowledge and skills in practice.

Conclusions

FBA is one of the most common fatal events in childhood. The medical history of FBA is vitally important for diagnosis. An unknown history of FBA greatly impedes clinical diagnosis. If patients present with recurrent pulmonary infection, reduced breath sounds in the lungs, atelectasis on CT, bronchiectasis, obstructive emphysema, or mediastinal shift, FBA should be considered. In conclusion, bronchoscopy examination is the first choice for treatment.