Some instructive anecdotes from the Aero Digestive Tract Foreign

Body service at a large children’s hospital.

Balakrishnan D, Balachandran K, Anbalagan S.

Balakrishnan D, BSc MS DLO PhD

Balachandran K, MS DLO
Anbalagan S, MS DLO
Formerly, at the Institute of Child Health & Hospital for Children, Madras Medical College, Chennai
600008. Corresponding author: D. Balakrishnan balaent@gmail.com

Foreign bodies present themselves in various masquerades. Three case histories are described here to
illustrate this point. A high index of suspicion and a proactive approach are required. The anaesthetic
technology is safer now, than ever before. The ENT surgeon must always be ready to do a bronchoscopy.
In every journal and in every ENT academic conference, you will find anecdotal references. Each such
anecdote gives information on how a particular surgeon surmounted a particular difficulty. Three clinical
vignettes are described below. They amply illustrate the above pearls of wisdom. Such valuable
information will bail you out, in a distant time of your life, when you get a similar patient.

Case 1 – Oedema caused by a FB, mistaken for angio oedema

HB., a one and half year old male child, had taken some fish on the evening of 21March this year. By ten
o’clock that night, he developed difficulty in breathing and a diagnosis of hypersensitivity was made and
the child was admitted in a corporate hospital in Chennai, and treated appropriately. On the seventh
day, the dyspnoea and respiratory obstruction became very severe. A fibre optic bronchoscopy was
done at this time. The larynx was found to be grossly oedematous and a tiny end of a fish bone was seen
buried among the oedema. The child was referred to the Institute of Child Health & Hospital for Children
(ICH&HC). Within the hour, a rigid bronchoscopy was done. The anaesthesiologist skillfully administered
general anaesthesia with skeletal muscle paralysis and maintained the oxygenation by Sander’s jet
ventilation method. The foreign body was found in the sub glottic region and was removed, albeit, with
some difficulty (Figs. 1 and 2). Thus, a tracheostomy was avoided. The child started recovering very fast
and was sent home in two days.

Case 2 – A forgotten episode of aspiration

K.A., an eight year old boy was recently admitted in ICH&HC with a history of generalized convulsions.
He had been having cough, breathlessness and fever during the previous one week. An x-ray of the
chest, taken as part of the general work up, showed a collapse of the left lung and hyper ventilation of
the right lung. An emergency rigid endoscopy was done - which revealed a cylindrical plastic cap of a ball
point pen nesting in the left main bronchus, causing all this havoc. After removal of the same, the child
recovered fast and went home in four days (Figs. 3 to 5).

Though initially, history of aspiration was not forthcoming, on retrospective questioning, the boy
admitted that he used to habitually keep pen caps in his mouth and that ten days earlier, it had slipped
inside. At that time, he had only some transient coughing episode and had no further distress and
promptly forgotten the episode.

Case 3 – Irritant foreign bodies presenting with retained secretions

DK, a ten month old child was admitted in the paediatric wards of ICH&HC, with a diagnosis of
pneumonitis and breathlessness since two days. A chest x-ray showed patchy areas in both the lungs. A
rigid bronchoscopy was done to clear the secretions. On suctioning the copious secretions, a pepper
kernel was found in the right main bronchus. A few days after removal of this FB, the pneumonitis
cleared rapidly. Closer questioning of the family members revealed that the elder sibling, aged two
years, had solicitously fed the infant with a snack three days earlier.

Case 4 – Irritant foreign bodies presenting as granulomas and malignancies

Similar irritant foreign bodies may present in any of the caverns of the ENT region. A button cell, used
ubiquitously nowadays, is a notorious example. This cell is also called Silver cell or Lithium cell and
contains contains Silver oxide and Lithium or Zinc. Once the seal is corroded by the body fluids, they leak
very frequently and are great irritants. The senior author recollects one such button cell inside the nasal
cavity of a three year old boy. It had remained unrecognized until it caused profuse granulations and
was mistaken for malignancy, by two different senior and well experienced paediatric surgeons. The
senior author was asked to take a biopsy for confirmation. During the attempt to take a tissue sample
with a nasal endoscope, a button cell was fortuously divined and removed. This particular child
happened to be the son of a popular actor and after several years, the senior author still gets priority
admission passes for premiere shows of films.

Discussion

The lessons to be learnt from the above episodes are many. (1)The parents may not come forth with a
proper history (2) Red herrings might present themselves and mislead you (3) you must always have a
high index of suspicion (4)Never hesitate to do a bronchoscopy (5) Equip yourself by learning the
technique (6)Nowadays, the anaesthesiology techniques have become exemplary. Additionally, convince
the anesthesiologist in your team, to be prepared to give Sander’s technique and also spontaneous
breathing anaesthetic technique.
Fig 1. Plain x ray of the neck of an eighteen month old baby, who presented with sudden onset stridor,
clinically diagnosed as angio oedema. The arrow points to the narrowing of the airway.

Fig 2. The same child as shown in the fig 1. On the seventh day after the onset of stridor, after doing a
bronchoscopy, a Fish bone was removed from the larynx.
Fig 3. Eight year old boy who inhaled the cap of a sketch pen and forgot the same. The inset shows the p

Fig 4. The chest x rays of the child in fig 3. Before the removal of the FB, the right lung is highly aerated
(compensatory emphysema). The left lung is collapsed. After removal, both lungs show equal aeration.

Fig 4. The chest x rays of the child in fig 3. Before the removal of the FB, the right lung is highly aerated
(compensatory emphysema). The left lung is collapsed. After removal, both lungs show equal aeration.