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Chronic cough fever and off and on difficulty in breathing in a 10-year-old male patient was not responding to drugs. Here we present a case of undiagnosed foreign body since 7 years in airway.
Recently, I had a very unique and most probably a very rare case in the history of medicine – a case of a foreign body (a plastic whistle) that was stuck in the air passage of a 10-year-old boy since 7 years. We do get foreign bodies in airways frequently and we have to remove it by bronchoscopy.
However, such foreign bodies are usually a few hours or days or few months old accidents happening in the life of many young children who swallow small things inadvertently. This case is unique because this foreign body went undetected for a period of 7 years; although the kid had consulted scores of doctors during this time period, it was treated as a case of bronchial asthma and tuberculosis. The patient had complaints of difficulty in breathing off and on and also history of cough and fever for which he was admitted to the local hospitals for number of times. There was a history of plastic whistle swallowed at the age of 3 years and thereafter the patient had complaints of fever, chronic cough, and difficulty in breathing. This proved that the boy had the whistle sticking in his right-side bronchus in the wind pipe for nearly 7 years, which is so unique about it. The patient belonged to a village named Matana, GirSomnath, Sutrapada, Gujarat, India. The boy had swallowed the plastic whistle when he was 3 years old, and he visited us at Rajkot when he was of 10 years.
Routine investigations included chest X-ray which revealed prominent bronchovascular markings; routine blood investigations done many times were suggestive of anemia and sometimes raised ESR up to 40 mm in the first hour, and raised total WBC was noted in some readings. CT scan of the thorax suggested a cylindrical foreign body involving the right lower lobe bronchus. On examination, decreased air entry on the right side and few basal crepts were found with SpO2 of 97%.
We did rigid bronchoscopy under general anesthesia and found that a foreign body was stuck to the right side of the bronchial wall.1-3
There was plenty of mucopus and granulation tissue all around the foreign body as it was 7 years old. The procedure was very risky as there were chances of bleeding and also chances of pneumothorax, but there was no complication. We successfully managed to remove the whole plastic whistle with all its three parts and the patient was absolutely fine after the operation, which lasted for 20 minutes. The patient was discharged from the hospital the next day.
Removing foreign body from the respiratory passage is more challenging in pediatric patients. The reasons are more than one:
Small size of the air passage
Compromised state of the patient
General anesthesia and pediatric patient’s physiology
In view of the above circumstances, time taken for the entire procedure was a very critical factor. Shorter the time taken, better would be the outcome. Symptoms produced by these foreign bodies vary in terms of their size, composition, location, and duration. In the air passage, the foreign body can migrate from right to left bronchus. Symptoms of the foreign bodies are divided into three stages:
Initial period: This lasts for a short period, and can lead to choking, gagging, and wheezing. During this period, the foreign body may be coughed out or it may lodge in the larynx or tracheobronchial tree.
Symptom-free interval: Respiratory mucosa adapts to the presence of the foreign body. This period varies with the size and nature of the foreign body.
Late phase: During this phase, the symptoms are caused by obstruction to the airway and inflammation or trauma induced by the foreign body. Most foreign bodies enter the right bronchus because it is wider and more in the line with the tracheal lumen.
In pediatric patients, the history is as important as investigations, as investigations are generally normal. Clinical examination and history plays a very important role. After removing the foreign body, inspect both bronchus (left and right) of the airway again and always for:
The remnants of the foreign body
Another foreign body
Foreign body at another site
Pediatric patients with chronic cough and fever not responding to conventional medical line of treatment should be checked for the presence of foreign bodies.
- Jackson C, Jackson CL. Disease of air and food passage of foreign body origin. Philadelphia: Saunders, 1950:13-34.
- Holinger PH, Holinger LD. Use of the open tube bronchoscope in the extraction of foreign bodies. Chest 1978;73 (Suppl 5):721-4.
- Harboyan G, Nassif R. Tracheobronchial foreign bodies: a review of 14 years experience. J Laryngol Otol. 1970;84(4):403-12.