Aspirated foreign bodies in the airway are the major present challenges for the paediatricians. Inhalation of foreign bodies is common in paediatric age group and 94 % of them occur in infants and children, with peak incidence in the age group of 1-3years and is very rare in adults¹. 

Every day millions of parents seek health care for their sick children taking them to hospitals, health centres, pharmacists, doctors, and traditional healers².Children aged 1-3 years are particularly at risk for foreign body aspiration because of their increasing independence, lessening of close parental supervision as they become older, increasing activity, curiosity because of hand – mouth interactions³.

Adults frequently have an underlying condition associated with impairment of airway protection such as mental retardation, neurological disorder, alcohol or sedative abuse^4-6. Potential complications of untreated bronchial foreign bodies include atelectasis, pneumonitis, bronchial granulomas, recurrent pneumonias, pneumomediastinum, bronchiectasis, plastic bronchitis, and bronchocutaneous or bronchovascular fistulization⁷. Laryngeal or tracheal FBs can be life threatening there should be no delay in recognizing the need for intervention in a symptomatic child. Foreign body aspiration has a wide array of presentation ranging from an apparently symptomless child with a history of aspiration to more dangerous acute respiratory distress with no history of aspiration at all. Only with strong suspicion, good clinical skills and appropriate imaging studies, a correct diagnosis of foreign body in lower respiratory tract can be made⁸. A study of US national safety council demonstrated that FB inhalation carries a mortality rate of 1.2 per 100,000 people per year⁹. The treatment of choice is prompt diagnosis and endoscopic removal.Early diagnosis is imperative to prevent mortality as well as late complications like recurrent acute respiratory distress, chronic and recurrent pneumonia, pulmonary abscess and granulation tissue^10,11.A diagnostic algorithm for foreign body aspiration recommends initial frontal and lateral chest X-rays, with additional neck films if needed. If these are inconclusive in a symptomatic patient, a chest CT should be performed; if unavailable and the child is older than 5, inspiratory-expiratory films are an alternative, while younger children should have bilateral decubitus films. HRCT and virtual bronchoscopy offer non-invasive, detailed 3D imaging that aids in both diagnosis and surgical planning, although bronchoscopy remains the definitive method despite its invasive nature and potential complications^12,13.

AIM

The study aims to evaluate the clinical profile of foreign body inhalation in children aged 1-14 years, assess the efficacy of HRCT for diagnosing tracheobronchial foreign bodies

This prospective study, conducted at the Department of Pediatrics, S. P. Medical College and PBM Hospital, Bikaner, over one year (April 2022 to December 2023), employed convenience sampling to recruit 50 pediatric patients suspected of foreign body (FB) inhalation based on clinical history and persistent chest infections. Inclusion criteria required a high level of clinical suspicion and long-standing intractable chest infections. Exclusion criteria included patients with a definitive history of FB inhalation, those unwilling to consent to the study or necessary procedures (bronchoscopy or NCCT), and patients in severe respiratory distress necessitating immediate emergency bronchoscopy.

STATISTICAL ANALYSIS:

The data was taken in terms of range, mean and standard deviation for qualitative data and in terms of frequency and percentage for quantitative data and the results were analyzed using SPSS software. Results of clinical examination, computed tomography were analyzed with respect to sensitivity, specificity, positive predictive value **and accuracy

Table 1: Distribution of study population according to their Age

Maximum 40% were in 1-3 years age group followed by 3-5 years (28%) whereas 5-7 years (12%) and below 1 years and 7-10 years of age each (8). Minimum 4% were in 10-14 years group. 

Table 2: Distribution of study population according to their socio-economic

status

Maximum 58% had lower socioeconomic followed by 40% middle and only 2% had upper socioeconomic status.

Fig 1: Distribution of study population according to their presenting complaints and according to duration of symptoms

All most all (92%) presents with cough, 80% with difficulty in breathing, 40% had fever, 30% develops wheeze, 8% had grunting and chest pain. Maximum 54% had symptoms in >2 weeks duration followed by 5 days to 2 weeks (30%) whereas minimum 16% were in 1 to 5 days.

Table 3: Distribution of study population according to HRCT finding (N=50)

Foreign body was seen in 76% cases whereas not seen in 24% of cases in HRCT. PPV ≈ 97% ,NPV = 58.33% ,Sensitivity ≈ 88% ,Specificity ≈ 87.5% Out of 38 HRCT +ve cases, on bronchoscopy 37 were +ve whereas 1 was –ve (PPV ≈ 97%) while out of 12 HRCT – ve cases, on bronchoscopy 7 were –ve whereas 5 were +ve (NPV = 58.33%). Sensitivity of HRCT was ≈ 88% and specificity was ≈ 87.5%.

Fig 2: Distribution of study population according to site of foreign body

Foreign body found maximum 52.38% in Rt. Main bronchus followed by 42.85% in Lt. main bronchus whereas minimum 4.76% in trachea.

Table 4: Distribution of study population according to type of foreign body

Maximum 61.90% had supari followed by 11.90% chana and 9.53% groundnut and wood particle each whereas minimum 7.14% had coconut piece as foreign particle.

Fig 3: Distribution of study population according to Complication and according to Length of hospital stay

We observed 4.77% patients with pneumonia, 2.38% had granuloma and bronchospasm each as complication. We also observed maximum 94% patients were discharged within 7 days whereas 6% takes more than 7 days of hospital stay.

In our study (Table 1), foreign body was seen in the maximum 40% were in the 1-3 year age group followed by 3-5 year (28%) whereas the minimum 4% were in the 10-14 year group followed by <1 year & 7-10 years age group(8%). Similarly Muhammad Junaid et al. (2020)¹⁴ found that most of the children were in 1 – 6 yr age (60%). Also Meena et al (2015)¹³ in their study found out of 60 patients the incidence of foreign body inhalation was found more between age group of 1-3 years (41.66%).Higher proportion were found by Wolach et al (1994)¹⁵ studied127 children and found 81% of the children were less than 3 years of age and Suligavi et al (2016)⁸ noted that most commonly affected were children of 1 year to 3 years of age. Whereas Mukherjee and Paul (2011)¹⁶ found Among 94 patients 70.2% i.e. 66 were within 5 years of age and most were within 2–3 years of age and Nagaraj et al (2016)¹⁷ found 88% of the patients were children below the age of 12 years. This was seen because most common age group of foreign body aspiration was found to be <10 years.

Fig1 shows maximum cases 46(92%) presents with cough, 80% with difficulty in breathing, 40% had fever, 30% develops wheeze, 8% had grunting and chest pain. Also Rekulapalli Sai Akhil et al. (2022)¹⁸ found that Cough (81.8%) and tachypnea (72.7%) were the most common clinical symptoms. Also Meena et al (2015)¹³ found cough (83.33%) as most common symptom and Suligavi et al (2016)⁸ found chronic cough and wheeze as the commonest presenting symptoms.

In this study 54% were in >2 weeks duration followed by 5 days to 2 weeks (30%) whereas minimum 16% were in 1 to 5 days (fig1 ), because we had taken suspected cases the patients were treated at lower level first then refer to tertiary center so longer duration patients were more. Similarly, Vivek Samor et al. (2020)¹⁹ found that 40% presented within 5 days to 2 weeks after inhalation. 

In our study on HRCT foreign body was seen in 76% cases whereas not seen in 24% of cases (Table 3) whereas Bai et al (2010)²⁰ found All 42 patients (100%) with tracheobronchial foreign bodies were identified on chest CT. In our study, out of 38 HRCT +ve cases, on bronchoscopy 37 were positive whereas 1 was negative (PPV ≈ 97%) while out of 12 HRCT negative cases, on bronchoscopy 7 were negative whereas 5 were positive (NPV = 58.33%) (Table 10). Sensitivity of HRCT was ≈ 88% and specificity was ≈ 87.5%.Similarly Abd-El Gawad et al (2014)²¹ found CT detected FB in 17 patients, two cases had true negative results, one case had false positive and one case had false negative results compared with conventional bronchoscopy. On bronchoscopy, foreign body was identified and extracted in 18 patients. Mukherjee and Paul (2011)¹⁶ Rigid bronchoscopy was done in all the cases for diagnostic and therapeutic purpose and foreign body was successfully retrieved in 78.7% of cases of CT positive. 

Fig2 showed that Foreign body found maximum 52.38% in Rt. Main bronchus followed by 42.85% in Lt. main bronchus whereas minimum 4.76% in trachea. SimilarlyRekulapalli Sai Akhil et al. (2022)¹⁸ Mukherjee and Paul (2011)¹⁶ and Abd-El Gawad et al (2014)²¹ found the most common site of lodgement was the right bronchus followed by the left bronchus, the trachea and other sites. Also Nagaraj et al (2016)¹⁷ found 48% of the total foreign bodies were present in right bronchus while 32% were lodged in the left bronchus and 3% at the carina. Whereas Kosucu et al (2004)²² found that the foreign body was in the left main bronchus in eight patients, in the right main bronchus in six patients and in the bronchus intermedius in one patient.

In present study 61.90% had supari followed by 11.90% chana and 9.53% groundnut and wood particle each whereas minimum 7.14% had coconut piece as foreign particle (Table 4). Similarly Rekulapalli Sai Akhil et al. (2022)¹⁸ and Vivek Samor et al. (2020)¹⁹ most commonly found groundnut (44%) followed by supari (32%) whereas Nagaraj et al (2016)¹⁷ the most common foreign body extracted was betel nut in 47% of the cases.

In fig 3 shows complications are observed 4.77% patients with pneumonia, 2.38% had granuloma and bronchospasm each as complication. Similarly Sai Akhil et al (2022)¹⁸ in their study found that complications such as pneumothorax were seen in one (4.5%) case.

In our study, we observed maximum 94% patients were discharged within 7 days whereas 6% takes more than 7 days of hospital stay. (Fig3). Similarly, Sai Akhil et al (2022)¹⁸ found that the mean duration of hospitalization was five (SD: ±2.84) days.

Accidental inhalation of both organic and non-organic FBs continues to be a cause of childhood morbidity and mortality. Prevention is best, but early recognition remains a critical factor in the treatment of FB inhalation in children. Suspected Patients should be sent to experienced centres for evaluation and management. Sensitivity and specificity of NCCT is good and reliable tool for foreign body detection.

1. Rothman BF, Boeckman CR. Foreign bodies in the larynx and tracheobronchial tree in children. A review of 225 cases. Ann Otol Rhinol Laryngol. 1980;89:434-6.
2. Siddarth. Improving the quality of care for children. Indian Pediatr. 2002;39:41-7.
3. Zerella JT, Dimler M, McGill LC, Pippus KJ. Annual meeting of the Pacific Association of Pediatric Surgeons No. 31, Maui, Hawaii, ETATA-UNIS (09/06/1998). 1998; vol 33, no 11 (137p) (15 ref) pp. 1651-1654.
4. Prakash UBS, Cortese DA. Tracheobronchial foreign bodies. In: Prakash UBS, ed. Bronchoscopy. New York: Raven Press; 1994. p. 253-78.
5. Limper AH, Prakash UBS. Tracheobronchial bodies in adults. Ann Intern Med. 1990;112:604-9.
6. Chen CH, Lai CL, Tsai TT, Lee YC, Perng RP. Foreign body aspiration into lower airway in Chinese adults. Chest. 1997;112:129-33.
7. Dehghani N, Ludemann P. Aspirated foreign bodies in children: BC Children’s Hospital emergency room protocol. BCMJ. 2008;50(5):252-256.
8. Suligavi SS, Patil MN, Doddamani SS, Hiremath CS, Fathima A. Tracheo-bronchial foreign bodies: our experience at a tertiary care hospital. Int J Otorhinolaryngol Head Neck Surg. 2016;2:116-9.
9. Spector BC. Endoscopy and removal of foreign bodies. Curr Opin Otolaryngol Head Neck Surg. 6:416-20.
10. Dunn GR, Wardrop P, Lo S, Cowan DL. Management of suspected foreign body aspiration in children. Clin Otolaryngol Allied Sci. 2002;27:384-6.
11. Hammer J. Acquired upper airway obstruction. Pediatr Respir Rev. [Year];[Volume(Issue)]:[Page numbers]. doi:[DOI]
12. Chiu CY, Wong KS, Lai SH, Hsia SH, Wu CT. Factors predicting early diagnosis of foreign body aspiration in children. Pediatr Emerg Care. 2005 Mar;21(3):161-4. doi:10.1097/01.pec.0000155958.96147.bd.
13. Meena RK, Nirwan MS, Gupta DP, Sharma MP. Clinical Study of Foreign Bodies in Tracheo-Bronchial tree with Specific Attention towards HRCT as a Diagnostic Tool in Suspected Cases. IOSR J Dent Med Sci (IOSR-JDMS). 2015;14(11):46-49.
14. Junaid M, Alam M, Khan SF, Ali S, Saeed K, Mukhtar H. Common Radiological Findings in Children with Suspected Foreign Body Inhalation. J Islamabad Med Dent Coll. 2020;9(4):280-284. doi:10.35787/jimdc.v9i4.608.
15. Wolach B, Raz A, Weinberg J, Mikulski Y, Ben Ari J, Sadan N. Aspirated foreign bodies in the respiratory tract of children: eleven years experience with 127 patients. Int J Pediatr Otorhinolaryngol. 1994 Jul;30(1):1-10.
16. Mukherjee M, Paul R. Foreign Body Aspiration: Demographic Trends and Foreign Bodies Posing a Risk. Indian J Otolaryngol Head Neck Surg. 2011;63(4):313-316. doi:10.1007/s12070-011-0150-2.
17. Nagaraj N, Sehra RN, Berwal P, Choudhary S, Deepchand, Kadela R, Raj R, Patel P. A clinical study of foreign bodies in air passages. Indian J Child Health. 2016;4(2):151-154.
18. Sai Akhil R, Priya TG, Behera BK, Biswal B, Swain SK, Rath D, Mohanty MD, Choudhury J. Clinico-Radiological Profile and Outcome of Airway Foreign Body Aspiration in Children: A Single Center Experience From a Tertiary Care Center in Eastern India. Cureus. 2022 Feb 13;14(2):e22163. doi:10.7759/cureus.22163. PMID: 35308662; PMCID: PMC8922054.
19. Samor V, Kumar V, Chand D, Gupta G, Mamta, Agarwal M. Clinical profile of tracheo-bronchial foreign body inhalation at tertiary care center. Int J Otorhinolaryngol Head Neck Surg. 2020;6:1520-3.
20. Bai W, Zhou X, Gao X, Shao C, Califano JA, Ha PK. Value of chest CT in the diagnosis and management of tracheobronchial foreign bodies. Pediatr Int. 2010;53(4):515-8.
21. Abd-ElGawad EA, Ibrahim MA, Mubarak YS. Tracheobronchial foreign body aspiration in infants & children: Diagnostic utility of multidetector CT with emphasis on virtual bronchoscopy. Egypt J Radiol Nucl Med. 2014;45:1141-1146.
22. Kosucu P, Ahmetoglu A, Koramaz I, Orhan F, Ozdemir O, Dinc H, et al. Low-dose MDCT and virtual bronchoscopy in pediatric patients with foreign body aspiration. AJR Am J Roentgenol. 2004;183(6):1771-7. doi:10.2214/ajr.183.6.01831771.