Volume 3, Issue 2 , Pages 57-60, March 2008
Christmas decorations may become aerodigestive foreign bodies
Article Outline
Summary
We present two cases of foreign body aspiration that occurred during the 2004–2005 Christmas season. In one 8-month-old boy, the hardware from a Christmas tree ornament became a supraglottic foreign body. In another 10-month-old boy, a metallic sticker in the shape of a Christmas tree traveled from the glottis to the nasopharynx and back to the glottis. The winter holidays are a time when children may have less supervision and greater exposure to potential aerodigestive foreign bodies. It is especially important that parents are vigilant and that physicians are perceptive of the symptoms of foreign body aspiration, especially during the holiday season.
Keywords: Foreign body aspiration, Laryngeal foreign body, Christmas, Stridor, Holidays, Upper airway obstruction
1. Introduction
In 2005, the United States National Safety Council reported that choking was the fourth leading cause of accidental death in children. Choking is most lethal in children less than 1 year of age [1]. Surprisingly, there are only three reports in the literature of airway foreign bodies specific to seasonal holidays [using the National Institutes of Health PubMED MEDLINE search engine (www.ncbi.nlm.nih.gov)]. We are concerned that during holidays when the primary care taker is busy, choking might be more prevalent. Sadly, in Vancouver, during the late 1990s, a toddler died from aspirating a handful of peanuts that were placed on a coffee table at a Christmas party. This report illustrates two other choking incidents that occurred during the winter holidays in British Columbia and our efforts to raise public awareness through the media.
2. Case reports
2.1. Case 1
An 8-month-old boy presented to a regional hospital on Christmas day 2004 after choking on a Christmas tree ornament. This was a typical glass ornament with metal hardware. It was unclear to his parents whether or not the glass bulb had shattered and been inhaled or swallowed. He initially presented with no respiratory distress, stridor, cyanosis or increased work of breathing. His oxygen saturations at that time were about 97% maintained on room air. Cervical X-rays at a regional hospital showed the metallic hollow hardware lodged in the supraglottic larynx (Fig. 1). He was urgently transferred to BC Children's hospital. Approximately 15
min prior to arrival, he suddenly became much more stridulous. Hyperextension of his neck improved his airway and on arrival to BC Children's hospital, he was taken emergently to the operative room.
Fig. 1.
Hardware from a Christmas tree bulb lodged in the supraglottis of an 8-month-old boy.
General anesthesia was induced with mask inhalants and a propofol drip by the anesthesiologist. The patient continued to breath spontaneously. The Jacko laryngoscope and Magill forceps were used to remove the foreign body from the supraglottic larynx. There was minimal blood loss and no oxygen desaturation.
Subsequent rigid laryngo-bronchoscopy showed mild edema and abrasions of the aryepiglottic folds. The vocal cords, subglottic larynx, trachea and main bronchi were normal. The patient was intubated orotracheally by the anesthetist. Rigid esophagoscopy was normal; no broken glass was visualized. The patient was extubated and had persistent mild stridor. He was given 0.25mg/kg of i.v. dexamethasone to prevent further supraglottic edema. The next morning his stridor had resolved and he was discharged home and had a full recovery.
2.2. Case 2
A 10-month-old boy from rural BC was transferred from a regional hospital to BC Children's Hospital in late December 2004 with a history of choking and difficulty breathing for almost 2 days (because bad weather had delayed transfer). Just prior to his presentation his mother reported that he had been crawling around the living room floor and went behind the sofa when he “choked on something”. He seemed to have difficulty swallowing and breathing, so she called emergency services right away. The parent had no idea what the foreign body might have been. The ambulance crew saw no foreign object in his mouth. He was mildly stridulous, but not in respiratory distress.
Chest and neck X-rays at the regional hospital showed no radiopaque object. The patient was urgently transferred to BC Children's Hospital. On arrival, he was in mild respiratory distress, mildly stridulous and was sitting with his mouth open and drooling.
In the operating room, he underwent an unremarkable rigid laryngoscopy and intubation. Flexible esophagogastroduodenoscopy was completely normal. However, shortly after extubation, he developed dysphonia, he continued to drool and remained mildly stridorous. His lungs remained clear. We were then consulted and arranged a rigid laryngobronchoscopy. To our surprise, a small, Christmas tree-shaped flexible silver coated plastic was found to be sitting parallel to his right vocal cord with the edge stuck in the cord. The sticker was removed with alligator forceps and the patient had a full recovery. In retrospect, we believe that the sticker traveled from his glottis to his nasopharyx with a cough before the first intubation and then dropped back to his glottis after extubation.
3. Discussion
There are several different reasons why young children are at high risk of choking. Anatomically, infant and toddlers do not possess a full set of teeth and their larynx is not fully developed and is still descending in the neck. Cognitively, young children are often unable to distinguish objects that are edible from inedible and they also tend to be distracted while eating. They also tend to walk and talk while eating and be unsteady; the tendency to fall increases the chances of aspiration. Moreover, a child's curiosity for their environment is explored through oral contact. Nearly any object that an infant or toddler can hold may be a choking hazard.
The two cases presented illustrate partial laryngeal obstruction from a foreign body. Whereas hollow metal objects such as hardware with prongs or multi-barbed fishhooks may become stuck in the supraglottis and are readily diagnosed by X-ray, thin and flat objects lodged in the sagittal plane between the vocal folds can partially obstruct the larynx and be more difficult to diagnose. Examples include metallic stickers, stiff plastic packaging, pencil shavings or egg shells. These objects cause dysphonia, croupy cough, stridor and varying degrees of dyspnea. Dysphonia and absence of fever are the key signs that differentiate partial laryngeal obstruction from a foreign body from croup. Biphasic stridor will exist when the foreign body is located between the glottis and the chest in the extrathoracic trachea.
In some cases, a child may cough, gag and try to clear the throat. This can convert a partial obstruction to a complete obstruction in which case the child is unable to cough or speak. Recognition of a child in complete airway obstruction is vital. In fact, complete obstruction of the larynx or trachea by a foreign body is common among young infants, especially those younger than 1 year of age [2]. Globular objects like hot dogs, candies, nuts and grapes, balloons, balls and marbles are the most common causes of complete airway obstruction in children [3], [4]. A handful of nuts consumed rapidly can also be lethal. The child usually dies unless the foreign body is quickly removed or expelled via the Heimlich maneuver.
Our 8-month-old patient was easy to diagnose but our 10-month-old patient proved to be a more challenging because his foreign body was radiolucent and probably migrated to the nasopharynx then back to the larynx. In several toddlers presenting after a coughing paroxysm in the past, we have found fir tree twigs in the nasopharynx. Thin nonmetallic foreign bodies in the larynx are often a diagnostic challenge. One retrospective study looked at 1874 patients who had undergone direct laryngoscopy and/or bronchoscopy from January 1997 to September 2003, in which 105 aspirated foreign bodies were detected. Of the nine laryngeal foreign bodies which were found, the average time to diagnosis and treatment was 11.6 days. Thin plastic foreign bodies took on average 17.6 days to diagnose whereas metal and food foreign bodies took on average 1.6 days to diagnose [5]. The standard first diagnostic test for a suspected airway foreign body is inspiratory and expiratory chest radiography and posteroanterior and lateral views of the airway. More than 90% of foreign bodies however are radiolucent [6]. Thus foreign body aspiration usually cannot be excluded with standard radiographs alone. Inspiratory and expiratory views can suggest a bronchial foreign body if they cause air trapping. Thin laryngeal foreign bodies may mimic croup radiographically. Often a clue to diagnosis is progressive stridor and dysphonia despite steroids or racemic epinephrine. Flexible laryngoscopy may be diagnostic for a thin laryngeal foreign body.
Management of the patient in partial airway obstruction is less difficult if proper preparation is taken. Paul Holinger, who may have been taught this dictum by Chevalier Jackson, wrote: “if two hours are spent in such preparation, the safe endoscopic removal of the foreign body may take only two minutes. But if only two minutes are taken for preparation, the endoscopist may find himself attempting makeshift ineffective procedures for the next frustrating two hours [7]”. Few cases of foreign body aspiration are a true emergency and whenever possible, some time should spent gathering information and preparing rather then making immediate attempts at the foreign body. Only cases of complete airway obstruction necessitate a Heimlich maneuver or immediate removal with a rigid laryngoscope and forceps.
Even though this case presents two choking hazards during the winter holiday season, choking hazards are present during other holidays as well, such as Halloween and Mardi Gras. Nut fragment within chocolate candies can be lodged into the bronchi. Probably the most potentially lethal candy available in the world are Mini-cup jelly products. Consequently, we are hoping through media attention and education we can increase the awareness of choking hazards during the holiday season and reduce the number of preventable choking incidents. The weeks before major holidays are an opportunity to enlist the media to help physicians educate caregivers at choking hazards and choking prevention. In 2005, before Halloween and again before Christmas we worked with our Safe Start Program and media relations department in our hospital to submit a press release regarding holiday and year-round choking hazards and choking prevention. A number of television and radio news interviews were then conducted and aired. Over the next 4 months there was a modest decrease in the number of cases of foreign body aspiration presenting to our hospital compared to the same 4 months in the previous winter (from 11 cases to 9). Unfortunately, cases of foreign body aspiration at our hospital are again on the rise.
In terms of educating the public, more needs to be done. We feel that children need to be educated about choking in schools. We will be creating interactive computerized learning modules for children in grades 5 and 12 that will create awareness concerning choking hazards and choking prevention. Within one generation, this should provide the basis for systemic change with respect to society's knowledge about choking. We feel these measures are necessary to make a broad and lasting impact.
References
- National Safety Council: Report on Injury Facts 2005–2006, 2006 ed., National Safety Council, Illinois, 2006.
- . Pediatric tracheobronchial foreign bodies: historical review from the John Hopkins Hospital. Ann. Otol. Rhinol. Laryngol. 1996;105:555–561
- . Deaths due to foreign body aspiration in children: the continuing hazard of toy balloons. J. Forensic. Sci. 1996;41:247–252
- . Management of foreign bodies of the airway. In: Shields TW, LoCicero J, Ponn RB editor. General Thoracic Surgery. 5th ed.. Philadelphia: Lippencott Williams & Wilkens; 2000;p. 853–862
- Plastic laryngeal foreign bodies in children: a diagnostic challenge. Int. J. Pediatr. Otorhinolaryngol. 2005;69:657–662
- . Bronchoscopy for aspirated foreign bodies in children. Experience in 131 cases. Arch. Surg. 1988;123:885–888
- . Foreign body of the air and food passages. Trans. Am. Acad. Ophthalmol. Otolaryngol. 1962;66:193
PII: S1871-4048(07)00080-9
doi:10.1016/j.pedex.2007.10.003
© 2007 Elsevier Ireland Ltd. All rights reserved.
Volume 3, Issue 2 , Pages 57-60, March 2008
