RADIOLOGY IN THE ED
Metallic Foreign Body Aspiration Case of a Blowgun Dart in the Left Main Stem Bronchus Ruby Lukse, MD,* Rebecca C. Winter, MD,† and Avrum N. Pollock, MD, FRCPC† Key Words: airway foreign body, blowgun darts, chest radiography From the *Department of Radiology, Staten Island University Hospital, Staten Island, NY and †Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA. Disclosure: The authors declare no conflict of interest. Reprints: Avrum N. Pollock, MD, FRCPC, Department of Radiology, Division of Neuroradiology, Children’s Hospital of Philadelphia, Room 2115, Wood Building, 324 South 34th Street, Philadelphia, PA, 19104 (e‐mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0749-5161
PRESENTATION A 12-year-old male adolescent with a medical history of asthma presented to an outside hospital for suspicion of foreign body aspiration. The patient admitted fashioning a blowgun dart from a sewing needle wrapped in a shoelace based on instructions that he had observed while viewing a YouTube video. He reported that he had accidentally aspirated the dart through a homemade air gun instead of his intent to expel it. At the outside hospital, direct laryngoscopy was performed. The dart was incompletely visualized in the hypopharynx and could not be successfully removed. Before his transfer to our institution, he received an albuterol nebulizer for a brief episode of mild desaturation and coughing.
RADIOLOGY FINDINGS Frontal and lateral chest radiographs (Figs. 1A, B) demonstrated a 2.8-cm linear radioopaque/high-attenuation foreign body within the left main stem bronchus, without evidence of pneumomediastinum or pneumothorax. There was, however, some platelike subsegmental atelectasis within the left middle to lower lung.
Contrast-enhanced computer tomographic scan (CT) was performed to exclude bronchial perforation and vascular injury before bronchoscopic foreign body retrieval. Coronal CT images at the level of the main stem bronchi demonstrate a thin, linear foreign body in the left main stem bronchus with adjacent mucous plugging (Fig. 2).
DISCUSSION Foreign body aspiration is a potentially life-threatening emergency commonly encountered in the pediatric population. There must be a high clinical suspicion for foreign body aspiration based upon the patient’s age, clinical history, and symptoms.1 In children younger than 3 years, most airway foreign bodies are radiolucent (nonradioopaque) items such as food material.1 Adolescents and young adults, on the other hand, are more likely to aspirate metallic foreign bodies.2 Historically, young female adolescents were more likely than their male counterparts to inadvertently aspirate sharp, metallic foreign bodies.3 For example, straight pins, used by young adolescents for purposes of securing religious headscarves, have been inadvertently inhaled.4 Although infrequent, there have been increasing reports in recent years of male adolescents accidentally aspirating homemade blowgun darts made from needles attached to cotton strands, such as this, where the cotton strand used was that of a shoelace. The rising incidence of blowgun dart aspiration has been attributed to increasingly available information on the Internet describing how to make these darts, but without sufficient accompanying safety warnings.2 Patients with airway foreign bodies may present with coughing, dyspnea, and wheezing. Symptoms may subside despite persistence of a foreign body in the airway.1
FIGURE 1. A and B, Dart in the left main stem bronchus. Frontal (A) and lateral (B) radiographs of the chest demonstrate a 2.8-cm linear radioopaque foreign body (arrows) within the left main stem bronchus. Subsegmental atelectasis of the left middle and lower lung is also present.
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Pediatric Emergency Care • Volume 30, Number 8, August 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Pediatric Emergency Care • Volume 30, Number 8, August 2014
Metallic Foreign Body Aspiration
FIGURE 2. Dart in the left main stem bronchus (LMSB). Coronal reformation (A) and axial (B) contrast-enhanced CT images demonstrates a thin, linear foreign body within the left main stem bronchus (arrows). Note the upstream mucous plugging within the LMSB (arrowheads) in comparison with its normally aerated counterpart on the right (asterisk).
Clinical presentation often depends on the size of the foreign body and site of impaction that occurs within the airway.4 Needles or pins are usually pursed in the mouth or in a blowgun with the needle tip pointed outward. As in our case, inadvertent forceful inspiration propels a needle into the airway, resulting in the needle point lying superiorly. During the respiratory cycle, the needle progresses with “ratchetlike action” further downward into the bronchi, along the path of least resistance.3 Unlike adults, in which most foreign bodies tend to impact in the more vertically oriented right main stem bronchus, negative pressure and a relatively narrow lumen of the left main stem bronchus in children and adolescents create increased “negative suction pressure” causing the thin needle to enter the left bronchus.4 Chest radiography is the initial imaging modality of choice in suspected cases of metallic airway foreign bodies due to their radioopaque nature. Radiologic findings of airway obstruction may not manifest in the acute setting because of the narrow barrel of an aspirated blowgun dart.4 Emphysema, atelectasis, and pneumonia are seen more commonly on chest radiography in case of delayed presentation of airway foreign bodies.1 Mucous plugging as well as cotton strands attached to the end of the dart may contribute to these findings.
© 2014 Lippincott Williams & Wilkins
A strong history, supplemented with radiographic findings suggestive of foreign body aspiration, is the primary indication for bronchoscopy.1 Prompt recognition of airway foreign bodies and early intervention are necessary to prevent possible complications and even death.
REFERENCES 1. Sersar SI, Rizk WH, Bilal M, et al. Inhaled foreign bodies: presentation, management and value of history and plain chest radiography in delayed presentation. Otolaryngol Head Neck Surg. 2006;134:92–99. 2. Walz PC, Scholes MA, Merz MN, et al. The internet, adolescent males, and homemade blowgun darts: a recipe for foreign body aspiration. Pediatrics. 2013;132:e519–e521. 3. Ludemann JP, Riding KH. Choking on pins, needles and a blowdart: aspiration of sharp, metallic foreign bodies secondary to careless behavior in seven adolescents. Int J Pediatr Otorhinolaryngol. 2007;71:307–310. 4. Ragab A, Ebied OM, Zaiat S. Scarf pins sharp metallic tracheobronchial foreign bodies: presentation and management. Int J Pediatr Otorhinolaryngol. 2007;71:769–773.
www.pec-online.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Metallic Foreign Body Aspiration Case of a Blowgun Dart in the Left Main Stem Bronchus Ruby Lukse, MD,* Rebecca C. Winter, MD,† and Avrum N. Pollock, MD, FRCPC† Key Words: airway foreign body, blowgun darts, chest radiography From the *Department of Radiology, Staten Island University Hospital, Staten Island, NY and †Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA. Disclosure: The authors declare no conflict of interest. Reprints: Avrum N. Pollock, MD, FRCPC, Department of Radiology, Division of Neuroradiology, Children’s Hospital of Philadelphia, Room 2115, Wood Building, 324 South 34th Street, Philadelphia, PA, 19104 (e‐mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0749-5161
PRESENTATION A 12-year-old male adolescent with a medical history of asthma presented to an outside hospital for suspicion of foreign body aspiration. The patient admitted fashioning a blowgun dart from a sewing needle wrapped in a shoelace based on instructions that he had observed while viewing a YouTube video. He reported that he had accidentally aspirated the dart through a homemade air gun instead of his intent to expel it. At the outside hospital, direct laryngoscopy was performed. The dart was incompletely visualized in the hypopharynx and could not be successfully removed. Before his transfer to our institution, he received an albuterol nebulizer for a brief episode of mild desaturation and coughing.
RADIOLOGY FINDINGS Frontal and lateral chest radiographs (Figs. 1A, B) demonstrated a 2.8-cm linear radioopaque/high-attenuation foreign body within the left main stem bronchus, without evidence of pneumomediastinum or pneumothorax. There was, however, some platelike subsegmental atelectasis within the left middle to lower lung.
Contrast-enhanced computer tomographic scan (CT) was performed to exclude bronchial perforation and vascular injury before bronchoscopic foreign body retrieval. Coronal CT images at the level of the main stem bronchi demonstrate a thin, linear foreign body in the left main stem bronchus with adjacent mucous plugging (Fig. 2).
DISCUSSION Foreign body aspiration is a potentially life-threatening emergency commonly encountered in the pediatric population. There must be a high clinical suspicion for foreign body aspiration based upon the patient’s age, clinical history, and symptoms.1 In children younger than 3 years, most airway foreign bodies are radiolucent (nonradioopaque) items such as food material.1 Adolescents and young adults, on the other hand, are more likely to aspirate metallic foreign bodies.2 Historically, young female adolescents were more likely than their male counterparts to inadvertently aspirate sharp, metallic foreign bodies.3 For example, straight pins, used by young adolescents for purposes of securing religious headscarves, have been inadvertently inhaled.4 Although infrequent, there have been increasing reports in recent years of male adolescents accidentally aspirating homemade blowgun darts made from needles attached to cotton strands, such as this, where the cotton strand used was that of a shoelace. The rising incidence of blowgun dart aspiration has been attributed to increasingly available information on the Internet describing how to make these darts, but without sufficient accompanying safety warnings.2 Patients with airway foreign bodies may present with coughing, dyspnea, and wheezing. Symptoms may subside despite persistence of a foreign body in the airway.1
FIGURE 1. A and B, Dart in the left main stem bronchus. Frontal (A) and lateral (B) radiographs of the chest demonstrate a 2.8-cm linear radioopaque foreign body (arrows) within the left main stem bronchus. Subsegmental atelectasis of the left middle and lower lung is also present.
586
www.pec-online.com
Pediatric Emergency Care • Volume 30, Number 8, August 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Pediatric Emergency Care • Volume 30, Number 8, August 2014
Metallic Foreign Body Aspiration
FIGURE 2. Dart in the left main stem bronchus (LMSB). Coronal reformation (A) and axial (B) contrast-enhanced CT images demonstrates a thin, linear foreign body within the left main stem bronchus (arrows). Note the upstream mucous plugging within the LMSB (arrowheads) in comparison with its normally aerated counterpart on the right (asterisk).
Clinical presentation often depends on the size of the foreign body and site of impaction that occurs within the airway.4 Needles or pins are usually pursed in the mouth or in a blowgun with the needle tip pointed outward. As in our case, inadvertent forceful inspiration propels a needle into the airway, resulting in the needle point lying superiorly. During the respiratory cycle, the needle progresses with “ratchetlike action” further downward into the bronchi, along the path of least resistance.3 Unlike adults, in which most foreign bodies tend to impact in the more vertically oriented right main stem bronchus, negative pressure and a relatively narrow lumen of the left main stem bronchus in children and adolescents create increased “negative suction pressure” causing the thin needle to enter the left bronchus.4 Chest radiography is the initial imaging modality of choice in suspected cases of metallic airway foreign bodies due to their radioopaque nature. Radiologic findings of airway obstruction may not manifest in the acute setting because of the narrow barrel of an aspirated blowgun dart.4 Emphysema, atelectasis, and pneumonia are seen more commonly on chest radiography in case of delayed presentation of airway foreign bodies.1 Mucous plugging as well as cotton strands attached to the end of the dart may contribute to these findings.
© 2014 Lippincott Williams & Wilkins
A strong history, supplemented with radiographic findings suggestive of foreign body aspiration, is the primary indication for bronchoscopy.1 Prompt recognition of airway foreign bodies and early intervention are necessary to prevent possible complications and even death.
REFERENCES 1. Sersar SI, Rizk WH, Bilal M, et al. Inhaled foreign bodies: presentation, management and value of history and plain chest radiography in delayed presentation. Otolaryngol Head Neck Surg. 2006;134:92–99. 2. Walz PC, Scholes MA, Merz MN, et al. The internet, adolescent males, and homemade blowgun darts: a recipe for foreign body aspiration. Pediatrics. 2013;132:e519–e521. 3. Ludemann JP, Riding KH. Choking on pins, needles and a blowdart: aspiration of sharp, metallic foreign bodies secondary to careless behavior in seven adolescents. Int J Pediatr Otorhinolaryngol. 2007;71:307–310. 4. Ragab A, Ebied OM, Zaiat S. Scarf pins sharp metallic tracheobronchial foreign bodies: presentation and management. Int J Pediatr Otorhinolaryngol. 2007;71:769–773.
www.pec-online.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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