ARTICLE IN PRESS

doi:10.1510/icvts.2009.207548

New Ideas
Case Report
Interactive CardioVascular and Thoracic Surgery (2009) 187–190
www.icvts.org

Institutional report - Thoracic non-oncologic

Protocol
Headscarf pin tracheobronchial aspiration: a distinct clinical entity
Nael Al-Sarraf*, Hassan Jamal-Eddine, Fatma Khaja, Adel K. Ayed
Department of Thoracic Surgery, Chest Disease Hospital, Kuwait

Received 16 March 2009; received in revised form 3 May 2009; accepted 5 May 2009

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Abstract

Institutional
Reportfrom https://academic.oup.com/icvts/article/9/2/187/729055
Foreign body (FB) aspiration is commonly seen in children and less commonly in the elderly. However, due to some social and cultural
factors, a distinct group of tracheobronchial FB aspiration is increasingly recognized. We sought to assess our experience with such entity.
A retrospective review of all cases with veil pin tracheobronchial FB aspiration in a single center over a 13-year period was carried out.
There were 35 cases of headscarf tracheobronchial FB aspiration. All were females with mean age of 14 years. All patients experienced
coughing and all had positive chest radiography findings. Commonest anatomical location was right main bronchus (32%) followed by left
main bronchus (23%). Tracheal pins occurred in 17%. Rigid bronchoscopy was used more often than flexible bronchoscopy (83% vs. 17%,
respectively). Repeat bronchoscopy was required in two cases (6%). Thoracotomy was required in one patient (3%). There were no

Negative
Results
complications or hospital deaths. Headscarf pin aspiration is seen in middle-aged women who inappropriately place the pins between their
lips prior to securing their veils. Bronchoscopy is the treatment modality of choice and surgery is rarely required. Preventative educational
strategies should be implemented to reduce such an avoidable risk.
䊚 2009 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Follow-up
Paper
Keywords: Bronchoscopy; Foreign body; Tracheobronchial aspiration

Best Evidence
1. Introduction examination followed-up with chest radiography prior to

Topic
undergoing bronchoscopy. FB was removed by either rigid
Foreign body (FB) aspiration remains a common but large- bronchoscopy (Karl Storz, Tuttlingen, Germany) or flexible
ly preventable problem. It is commonly encountered in bronchoscopy (Lucera, Olympus, Japan). Rigid broncho-

Proposal for Bail-

children at a young age w1x and in the elderly due to an scopy was performed under general anesthesia while flex-

out Procedure
underlying medical condition w2x. However, there is a dis- ible bronchoscopy was performed under intravenous
tinct group of patients who are recently being recognized sedation and local anesthesia. In all cases, 1 mg of atropine

by guest
and are at risk. These patients include women wearing was administered intramuscularly 30 min prior to the pro-
headscarves and inappropriately placing the safety pin in cedure and patients were sedated with 2–5 mg of intrave-

Progress
their mouth prior to securing the veils leading to an nous midazolam (0.05 mgykg). In flexible bronchoscopy,

on 16Report
Work in
accidental FB aspiration w3–8x. In contrast to other forms local anesthesia was administered to the patients before
of FB aspiration, this group often presents early and the and during the procedure via the instillation of 2% lidocaine

June 2024
diagnosis is made solely on radiography due to the radio- solution. Lidocaine was administered via a nebulizer or
opaque nature of the safety pins. The use of bronchoscopy directly through the bronchoscope in a ‘spray as you go

has dramatically reduced the need for thoracotomies. In
this paper, we analyze our experience over 13 years with
such entity, together with our short-term outcome.
2. Materials and methods
State-of-the-art
fashion’. The trans-oral route was used for both flexible
and rigid bronchoscopy. The type of instruments used
include: grasping forceps, alligator type forceps, and bas-
ket. The patient is normally positioned in a supine position
in 258 Trendelenburg position. Appropriate airway control
Communication

was maintained through the bronchoscope as we have

All patients with sharp object FB aspiration treated in the
Brief

previously reported w9x. All cases (with the exception of

Department of Thoracic Surgery at chest disease hospital
one patient who had surgery) were treated as day cases.
between the period of January 1996 and December 2008
All data are presented as percentages. Continuous variables
were retrospectively reviewed. There were a total of 48
are presented as mean with standard deviation (S.D.). This
patients with sharp object aspiration, of which 35 cases
Nomenclature

study was approved by our Institutional Review Board.

were due to headscarf pin aspiration. All of them were
females. All patients had detailed history and physical
3. Results
*Corresponding author. Al-Jabriah, P.O. Box 718, Postal Code: 46308,
Kuwait. Tel.: q965 66600543; fax: q965 24741504. There were a total of 35 patients, all were females. Ages
E-mail address: trinityq8@hotmail.com (N. Al-Sarraf). ranged from 8 to 35 years with a mean ("S.D.) of 14 ("5)
䊚 2009 Published by European Association for Cardio-Thoracic Surgery
 ARTICLE IN PRESS
188 N. Al-Sarraf et al. / Interactive CardioVascular and Thoracic Surgery (2009) 187–190
years. A summary of the anatomical distribution, type of
extraction method and short-term outcome is depicted in
Table 1. All patients initially experienced coughing and all
had normal physical examination as they were all non-
asphyxiating and non-obstructive FB aspiration. Hemoptysis
was only observed in four cases (11%). Incidence of head-
scarf tracheobronchial aspiration over the study period is
illustrated in Fig. 1. There were no complications and no
hospital mortality. Two cases required re-bronchoscopy due
to failed primary attempt, one of which required surgery
in the form of right thoracotomy and bronchotomy for a
pin impacted in the right lower lobe. The second re-
bronchoscopy patient had an initial flexible bronchoscopy
which failed to extract the FB and required a rigid bron-
choscopy to be performed (in the same setting following
general anesthesia administration).
4. Discussion
FB aspiration remains a common problem among young
children and is commonly divided into organic and inorganic
FB aspiration. Organic materials such as nuts and seeds are
the most commonly aspirated while the inorganic materials
include a wide range of objects such as plastic pieces, toy
parts, etc. w8x. Up to 85% of all FB aspiration occurs in
children. In adults, most of FB aspirations are seen in the
6th or 7th decade of life when airway protective mecha-
nisms function inadequately e.g. due to central nervous
system dysfunction, intubation or facial traumas w10x. The
younger age group is more vulnerable because of the lack
of adequate dentition and immature swallowing coordina-
tion. In addition, among children of this age, introducing
objects into their mouths is their way of exploring the
world w2, 11x. However, in recent years (Fig. 1) some
Table 1
A summary of the anatomical distribution, type of extraction method and
short-term outcome (ns35)
Variable
Side
Left
Right
Central
Anatomical location
Left main bronchus
Left lower lobe
Right main bronchus
Right lower lobe
Trachea
Type of foreign body
Pins
Safety pins
Metallic clips
Extraction method
Rigid bronchoscopy
Flexible bronchoscopy
Repeat bronchoscopy
Surgery required
Yes
No
Status at discharge
Alive
Dead
S.D., standard deviation.
traditional or social habits have become a discrete category
of FB aspiration. This is seen in women wearing headscarves
in Islamic countries because of socio-cultural and religious
tradition. Some women tend to hold the headscarf pin
between their lips while wearing headscarves using their
two hands to secure the veil. Any maneuver, such as
laughter, talking and coughing then predispose them to
aspiration, especially in the young teenage groups where
they lack experience with such maneuver w3–8x. In contrast
to other forms of FB aspiration, headscarf pin aspirations
tend to be easily diagnosed as all of these inhaled FBs are
radio-opaque w3x and, as such, can be picked up easily by
chest radiography. Furthermore, in contrast to other forms
of FB aspiration, chronic forms are rarely encountered
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because patients tend to seek medical advice quicker than
in organic FB aspiration. Therefore, diagnostic broncho-
scopy is rarely needed but rather a therapeutic intervention
is required.
Once diagnosed by means of radiography, these inhaled
pins should be removed bronchoscopically either by rigid
bronchoscopy or flexible bronchoscopy. Fluoroscopy has
been used successfully as an adjunct in cases of more
distally located pins w7x. During rigid bronchoscopy, the
pointed end of the pin should be grasped and taken into
the bronchoscope. The pointed end can harm the bronchial
mucosa or bronchial wall if the pin is grasped and pulled
from the other part of the pin. The need for thoracotomy
and bronchotomy is required in only a small number of
cases and is mainly related to failed attempts of broncho-
scopic extraction and a distal location of inhaled FB.
Factors that influence the success of bronchoscopic man-
agement include: anatomical location, the experience of
Number (%)
12 (34)
17 (49)
6 (17)
8 (23)
4 (11)
11 (32)
6 (17)
Fig. 1. Diagrammatic representation of the incidence of veil pin aspiration
6 (17)
in our population over the study period (from January 1996 to December
2008).
25 (71)
7 (20)
3 (9)
29 (83)
6 (17)
2 (6)
1 (3)
34 (97)
35 (100)
0 Fig. 2. Chest radiographs of two patients with headscarf pin tracheobronchial
foreign body aspiration. (a) Pin in the right lower lobe bronchus. (b) Pin in
the left main bronchus.
 ARTICLE IN PRESS
N. Al-Sarraf et al. / Interactive CardioVascular and Thoracic Surgery (2009) 187–190 189

New Ideas
clinician performing the procedure and the early interven- our experience has improved with dealing with this entity,
tion w3x. In our experience, we have used rigid broncho- flexible bronchoscopy has been used more often. A rigid

Case Report
scopy (29 cases, 83%) far more commonly than flexible bronchoscopy provides a greater access to the subglottic
bronchoscopy (6 cases, 17%), although in recent years, as airways ensuring correct oxygenation and easy passage of

Table 2
Summary of the advantages and disadvantages of rigid and flexible bronchoscopies in the setting of foreign body aspiration

Protocol
Type of bronchoscopy Advantages Disadvantages

Rigid bronchoscopy 1. Ideal for children and young patients 1. General anesthesia administration
2. Better airway control and more effective 2. Cannot be performed in certain
ventilation cases (e.g. mechanically ventilated
3. Efficient suctioning and control in case of patients or those with spine or skull
major airway bleed fractures)
4. Requires less experience than flexible

Downloaded
bronchoscopy in FB removal

Institutional
Flexible bronchoscopy 1. Local anesthesia 1. Difficult in young patients and

Reportfrom https://academic.oup.com/icvts/article/9/2/187/729055
2. Easy to use and safe children
3. Useful in extracting distal FB 2. Limited airway control
4. Useful in certain cases (e.g. mechanically 3. Difficult suctioning in massive
ventilated patients or those with spine or airway bleed
skull fractures) 4. Requires more experience than
5. Useful in elderly patients rigid bronchoscopy in FB removal
5. Success rates are lower in FB

Negative
removal than rigid bronchoscopy

Results
FB, foreign body.

Table 3

Follow-up
Summary of published studies dealing with sharp object foreign body aspiration (including the series of headscarf pin aspiration)

Paper
Author (year) Gender and Age range Extraction method Locations Main findings
number of (mean) years

Best Evidence
patients (n)

Topic
Kaptanoglu et al. Females only 7–21 (14.4) Rigid (ns57) Trachea (ns22) 1. No mortality
(1999) w3x (ns63) Flexible (ns2) Right lung (ns21) 2. Repeat bronchoscopy in
Laryngoscopy (ns3) Left lung (ns17) 8% (ns5)
Thoracotomy (ns1)

Proposal for Bail-

out Procedure
Murthy et al. (2001) Females only 5–6 (NyA*) Rigid bronchoscopy Trachea (2) 1. No mortality
w4x (ns6) in all cases Right lung (ns2) 2. No complication
Left lung (ns2) 3. No repeat bronchoscopy

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Sersar et al. (2006) Females (ns122) 6–40 (14) Rigid (ns114) Trachea (ns7) 1. No mortality
w5x Males (ns2) Flexible (ns0) Right lung (ns54) 2. Complication rate 35%

Progress Report
Thoracotomy (ns8) Left lung (ns63) (ns44)

Work in
3. Repeat bronchoscopy 24%
(ns30)
4. 2nd repeat bronchoscopy
11% (ns14)

State-of-the-art
Hasdiraz et al. Females only 13–35 (18.7) Rigid (ns93) Larynx (ns6) 1. No mortality
(2006) w6x (ns105) Flexible (ns4) Trachea (ns21) 2. Repeat bronchoscopy 11%
Laryngoscopy (ns6) Right lung (ns52) (ns12)
Thoracotomy (ns1) Left lung (ns26)
Spontaneous
expectoration (ns1)
Communication
Brief

Yuksel et al. (2006) Females (ns49) NyA* Rigid bronchoscopy Trachea (ns12) 1. No mortality
w7x Males (ns7) in all cases Right lung (ns20) 2. Repeat bronchoscopy 4%
Left lung (ns24) (ns2)
3. Complication rate 11%
(ns6)
Nomenclature

Gencer et al. (2007) Females only 12–23 (17.5) Flexible (ns21) Trachea (ns3) 1. No mortality
w8x (ns23) Other** (ns2) Right lung (ns11) 2. No repeat bronchoscopy
Left lung (ns9)

*Not available in the relative study.

**These two cases were initially extracted by flexible bronchoscopy but then were dropped and due to postural drainage and coughing, the patients swallowed
these two pins which were later excreted uneventfully in the stool.
 ARTICLE IN PRESS
190 N. Al-Sarraf et al. / Interactive CardioVascular and Thoracic Surgery (2009) 187–190
the telescope and grasping forceps during FB extraction. In
addition, rigid bronchoscopy allows a very efficient airway
suctioning in case of massive bleed and is not time consum-
ing. That is why it is preferred in children w11, 12x. In
adults, flexible bronchoscopy has many advantages includ-
ing its ease, safety profile and its superiority in cases of
distally located FBs w8, 11, 13x (Fig. 2a). A summary of
main advantages and disadvantages of both types of bron-
choscopy is depicted in Table 2.
Our results seem consistent with previously published
reports on pin aspiration; a summary of these reports is
depicted in Table 3. One important finding is the general
preference of rigid over flexible bronchoscopy in these
series. In addition, the condition is preponderant in females
of early teenage years due to their lack of experience when
securing the headscarves. Furthermore, the use of surgical
intervention in the form of bronchotomy or lobectomy has
been generally limited due to the success of interventional
procedures in extracting the pins. All of these sharp pins
are radio-opaque and as such, the diagnosis is generally
quicker than in cases of organic FB aspiration and chronic
cases are rarely encountered w14x. One additional note is
the general variation in the anatomical location of aspirat-
ed pin (Table 3). Reasons for this include size of main
bronchus and angle formation w12, 15x.
The main limitations of our study are two. The first
limitation is the retrospective nature of the analysis and,
as such, only an association can be reported. The second
limitation is the small volume of patients in our study.
However, within these acceptable limitations, we believe
our work will shed more light into the subject of headscarf
tracheobronchial pin aspiration.
5. Conclusion
Pin aspiration is a distinct clinical entity that is encoun-
tered in countries where headscarves are used because of
social, traditional or religious purposes. The lack of expe-
rience of these young women on occasions can predispose
them to FB aspiration. Rigid bronchoscopy is the treatment
modality of choice with flexible bronchoscopy being
increasingly used, especially in distally located pins.
Thoracotomy is rarely required. Public awareness is
required to prevent such aspiration and adequate education
of women wearing headscarves is required to avoid the
habit of placing the pins in their mouth prior to securing
their headscarves.
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