European Journal of Cardio-thoracic Surgery 28 (2005) 369374

www.elsevier.com/locate/ejcts

Inhaled foreign bodies: management according to early

or late presentation

Cardiothoracic Surgery, Mansoura University, 35516, Egypt

b
Anaesthesia and ICU, Mansoura University, 35516, Egypt
c
ENT, Mansoura University, 35516, Egypt
d
Pediatrics, Mansoura University, 35516, Egypt

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Sameh Ibrahim Sersara,*, Usama Ali Hamzaa, Wael AbdelAziz AbdelHameeda,

Reda Ahmed AbulMaatya, NourEldean Noaman Gowaelia, Sherif Abdou Moussab,
Shawki Mahmoud AlMorsic, Muna Mohammed Hafezd

Received 24 February 2005; received in revised form 10 May 2005; accepted 11 May 2005; Available online 1 July 2005

Abstract

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Objective: This retrospective study aims to compare the early and late clinical and management aspects of tracheobronchial aspirated
foreign body (AFB), to evaluate the factors associated with delayed diagnosis of foreign body aspiration (FBA) in children and to compare
clinical, radiological and bronchoscopic findings in the patients with suspected FBA. A retrospective review of a 10-year experience (from 1995
to 2005). A 1512-bed Mansoura University Hospital and 184-bed Mansoura University Emergency Hospital. Methods: The medical records of 3300
patients who underwent bronchoscopy for suspected FBA were reviewed. The data were analysed in three groups: the patients with negative
bronchoscopy for FBA (group I), early (group II) and delayed diagnosis (group III). Foreign body was removed using the rigid bronchoscope with or
without using the extracting forceps (Egyptian novel technique [Sersar IS, Abdulla AK, Abulela SA, Elsaeid AS, Abdulmageed NA. A novel
technique to remove an inhaled foreign body without using a forceps. J Cardiovasc Dis 2004;2(4):1578] described in the hand made illustration).
Results: The majority of the patients with FBA were between 3 and 10 years of age. The penetration syndrome and decreased breath sounds
were determined in a significantly higher number of the patients with FBA. The plain chest radiography revealed radio-opaque foreign bodies
(FBs) in 23.56% of all patients with FBA. Pneumonia and atelectasis were significantly more common in the groups with negative bronchoscopy
and with delayed diagnosis (P!0.01). The FBs were most frequently of vegetable origin, such as seeds and peanuts. A significant tissue reaction
with inflammation and postbronchoscopic complications were more common in the delayed cases. The novel technique was used since then in
100 cases (4.62%) with a history of FBI (Pins and or small rounded materials). It was successful in 73 (73%) cases of non-impacted inhaled pins. Use
of forceps was needed in 21 (21%) cases. Rebronchoscopy despite using both techniques was needed in six (6%) cases within 72 h. Failed
extraction of the inhaled FB occurred in three cases (3%) for whom bronchotomy was needed. Conclusions: Bronchoscopy is indicated on
appropriate history and on suspicion. To prevent delayed diagnosis, characteristic symptoms, signs and radiological findings of FBA should be
checked in all suspected cases. As clinical and radiological findings of FBA in delayed cases may mimic other disorders, the clinician must be
aware of the likelihood of FBA.
Q 2005 Published by Elsevier B.V.
Keywords: Foreign bodies; Radiography; Bronchoscopy

1. Introduction

Children tend to place and explore most objects in

their mouths, so there is a significant risk of foreign
body aspiration (FBA). Morbidity and mortality increase in
the younger age group, presumably because children of
a young age have narrow airways and immature protective
mechanisms [2]. In one series, 78% of those who died
after FBA were between 2 months and 4 years of age [3].

* Tel.: C20 10 6166470; fax: C20 50 2265471.

E-mail address: sameh001@yahoo.com (S. Ibrahim Sersar).

1010-7940/$ - see front matter Q 2005 Published by Elsevier B.V.

doi:10.1016/j.ejcts.2005.05.013

FBA is a life-threatening emergency and requires

prompt removal, but sometimes it may remain undetected due to atypical history or misleading clinical and
radiological findings [4,5]. Delayed diagnosis can occur
when parents under-appreciated symptoms or when
physicians overlook clinical and radiological findings.
Inflammation and granulation tissue develop around the
foreign body (FB) in delayed cases, and thus it is not
uncommon for patients to be treated for other disorders
such as persistent fever, asthma or recurrent pneumonia
for a long period of time [6,7]. The diagnosis and removal
of the object becomes much more difficult in such cases.
Foreign body aspiration is one of the most common and
serious problems among children accounting for 7% of
lethal accidents in infants aged 13 years [24].

S. Ibrahim Sersar et al. / European Journal of Cardio-thoracic Surgery 28 (2005) 369374

muscle paralysis. You must tell the anaesthesiologist that

you may need very short time of anaesthesia and
paralysis with the possibility of retrials. The patients
are pre-oxygenated with 100% Oxygen mask and then the
anaesthesia is then induced by fentanyl 12 mg/kg m with
propofol 2 mg/kg m. Before the introduction of the
bronchoscope, 5% lidocine is sprayed into the trachea
under laryngoscopic control. It is maintained by propofol
infusion in a dose of 5 mgm/kg m per h with atracurium
Besilate of 0.2 mgm/kg m. The patients are ventilated
either manually with a very high flow oxygen or through a
traditional mechanical ventilation. Good anaesthesia
should provide rapid induction, good ventilation and
oxygenation, satisfactory degree of muscle relaxation
with no or minimal postoperative complications. ECG
monitoring and peripheral oxygen saturation are continuously monitored throughout the procedure.
2. Introduction of the rigid bronchoscope into the airway
very slowly till you reach the foreign body, manipulate
the bronchoscope till it completely surrounds the tip of
the FB. Push the bronchoscope distally while the FB is in
the centre of the tip of the bronchoscope, ask the
technician to lower down the head of the operative table.
Assisted by this postural drainage, the bronchoscope with
the FB in the centre of its tip are withdrawn out under
direct vision maintaining the postural drainage. It has the
following advantages:
1. Minimal or no risk of airway tear.
2. Short time is needed.
3. Can be used for sharp objects with a small diameter as
well as for friable organic FB that cannot be caught by
the forceps.
4. Can be taught to the junior staff easily in the start of
their career.
It has the following disadvantages:
1. It is not possible in all cases.
2. It needs a good cooperation and harmony between the
anaesthesia and thoracic surgery team (1).

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Coughing, choking, acute dyspnoea, and sudden onset of

wheezing are the main symptoms of foreign body aspiration.
Clinically, the problem is often apparent; however,
symptoms can subside spontaneously and quickly even
when a foreign body remains. Radiographic features depend
on the size, location, duration, and nature of the foreign
body. The chest radiograph may demonstrate a variety of
findings including air trapping, atelectasis, consolidation,
and bilateral overaeration [5].
Foreign body aspiration may result in either airway
compromise and death or serious sequels such as recurrent
pulmonary infections, atelectasis, and bronchiectasis. In
order to prevent these complications, prompt diagnosis and
removal of foreign body is mandatory [3,4,7,8].
Because of the risks of overlooked foreign body aspiration, even when there is a little suspicion or doubtful history,
bronchoscopy is often performed for both definite diagnosis
and treatment. Contrary to the general impression that
bronchoscopy is simple and safe in paediatric patients,
serious complications may occur even in experienced
hands [8,10].
Therefore, definition of ideal diagnostic methods those
minimise needless bronchoscopy for conditions that mimic
airway foreign bodies and avoid delay when patients with
foreign body require bronchoscopy is of utmost importance.
Virtual bronchoscopy is a noninvasive technique that provides
an internal view of trachea and major bronchi by threedimensional (3D) reconstruction. The volumetric imaging
data acquired by helical computed tomography (CT) can be
manipulated and additional multiplanar and 3D reconstructions can be obtained. The use of virtual bronchoscopy
technique in adults has been described [1117].
It has been reported in the evaluation of suspected
compression or narrowing of the trachea and main bronchi
and in the treatment of esophageal atresia in infants and
children [18,19].

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2. Materials and methods

From January 1995 to February 2005, the medical records

of 3300 children who underwent bronchoscopy for suspected
FBA were reviewed. Age and sex of the patients, symptoms
and signs, duration of symptoms before bronchoscopy,
radiological and bronchoscopic findings including the type
and the location of the FB were analysed in three groups. In
group I (nZ1135), patients had a negative bronchoscopy for
FB; in group II (nZ1900), patients received the diagnosis of
FBA within 1 week of aspiration; in group III (nZ265), the
diagnosis of FBA was delayed beyond 1 week after aspiration.
The diagnosis of FBA was confirmed by bronchoscopic
examination. The inhaled FB was removed using a forceps
or without using a forceps (Egyptian novel technique) which
is a new technique to remove a foreign body (FB) from the
airway using the rigid bronchoscope without using the
extracting forceps. (Illustration).
It depends on:
1. Good cooperation between the thoracic surgeon and the
anaesthesia team. You need good patient sedation and

The statistical analysis was performed mainly for groups

(2) and (3) with an analysis of variance (ANOVA) followed by
Tukeys procedure and post hoc tests chi-square tests and
Students t test for independent samples or c2. The
statistical significance level was fixed at a P-value !0.05.

Table 1
The demographic data of the patients
Data

Group 2

Group 3

P-value

Number
Age (months)
Positive bronchoscopy
Right
Left
Central
Both right and left
!1 year
13 years
310 years
O10 years
Female/male

1900
43.2 (1.5292)
C
770
984
139
7
155
609
929
207
1004/896

265
23.5 (5251)
C
53
200
6
6
103
82
63
17
128/137

!0.05
O0.05

O0.05
!0.05
!0.05
!0.05
!0.05
O0.05
O0.05
!0.05
!0.05

S. Ibrahim Sersar et al. / European Journal of Cardio-thoracic Surgery 28 (2005) 369374

371

Table 2
The clinical, radiological data and complications of the procedures

3.1. Clinical and radiological findings

Data

Group 2

Group 3

P-value

Witnessed choking
Sudden persistent cough
Tachypnoea
Fever
Decreased breath sounds
Chest X-ray
Normal chest X-ray
Pneumonia
Atelectasis
Radio-opaque FB
Duration of symptoms in days
Complications
1. Arrest
Reversible
Irreversible
2. Major airway injury
3. Barotruma
4. Failure
a. Rebronchoscopy
b. Re-rebronchoscopy
c. Bronchotomy
5. Pulmonary resections
6. Laryngeal oedema

1435 (75.52%)
1429 (75.21%)
992 (52.21%)
86 (9.55%)
841 (44.26%)
1820 (95.78%)
1148 (60.42%)
75 (3.94%)
130 (6.84%)
467 (24.57%)
(172 h)

18 (6.79%)
34 (12.38%)
40 (15.09%)
80 (30.18%)
78 (29.43%)
260 (98.11%)
91 (34.33%)
72 (27.16%)
85 (32.07%)
12 (4.52%)
73653 days

!0.05
!0.05
!0.05
!0.05
!0.05
O0.05
!0.05
!0.05
O0.05
!0.05
!0.05

60
50
10
4
5
19
19
14
7
7
19

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67
63
4
0
3
25
25
10
6
0
34

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!0.05

!0.05
O0.05
!0.05
!0.05
O0.05
!0.05
!0.05

Virtual bronchoscopy was done in three cases only as the

history was not highly suspicious and the general anaesthesia was a major concern.
The complications were recorded in 147 patients (4.45%).
They were significantly higher in groups III (P!0.01) and II
(P!0.05) than group I. They included irreversible arrest in
four cases, major airway injury requiring repair in 10 cases,
barotrauma needing an ICT in 15 cases, failure to extract the
FB in 44 cases who required rebronchoscopy, from whom 24
patients required re-rebronchoscopy. Bronchotomy was
done in 13 cases of impacted FB with distal airway
obstruction. Pulmonary resections were done in seven

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Age and sex of the patients witnessed ingestions, signs

and symptoms determined in the history, physical examinations, and duration of symptoms before bronchoscopy are
listed in Table 1. The difference was not significant for sex
distribution (PO0.05). The mean age difference was
significant between groups I and II (P!0.01). The number
of the patients under the age of 1 year was significantly
higher in group I than groups II and III (P!0.01), and
the number of the patients above the age of 3 years in group
(2) was significantly more than groups (1) and (3). The
majority of the patients with FBA were between 3 and
10 years of age (929 patients) (48.89% in group II) and
between 1 and 3 years (63 patients) (30.94% in group III).
There was no significant difference between the groups
regarding wheezing, but choking episodes and coughing were
determined in a significantly higher number of the patients
in groups II and III compared with group I (P!0.01). The
differences were significant between groups II and III for
witnessed ingestion associated with a choking episode and
coughing. Decreased breath sounds were determined in a
significantly higher proportion of patients in group III than
groups I and II (P!0.01). The relative number of the patients
who had clinical findings of pneumonia was significantly
higher in group III than groups I and II. The duration of
symptoms was significantly longer for the patients in group III
compared with the other groups (P!0.01).
A plain chest radiograph was routinely obtained in all
suspected cases, but 100 patients underwent emergency
bronchoscopic removal of the FB without undergoing prebronchoscopic radiography or coming with a CT chest and no
plain chest X-ray is done (3.03%). Paired inspiratory and
expiratory films are theoretically ideal, but were not
routinely feasible due to lack of cooperation as most of our
patients were younger than school age.
Radiological findings on plain chest radiography are
listed in Table 1. The radiographs revealed radio-opaque
FBs in 467 endobronchial tree and 12 in the oesophagus. The
number of the radio-opaque FBs was significantly higher in
group II than group III (P!0.05). Emphysema was more
common in children with FBA. Obstructive emphysema (Air
traping) was significantly higher in groups II (P!0.01) and III
(P!0.05) than group I. Atelectasis and pneumonia were
significantly more common in groups I and III compared with
group II (P!0.01). The number of normal radiographs was
significantly higher in group I than the other groups with
FBA (P!0.05). Atelectasis was determined in 317 patients
(9.6%), from whom 3.09% were negative. Fifty records of
chest fluoroscopy were found, and 41 were positive for air
trapping and mediastinal shift suggesting FBA, which was
later confirmed by bronchoscopy. Nine hundred patients
had some significant clues in their histories and/or physical
examinations, but they had negative radiographs, or the
patients were too young to cooperate to produce an
appropriate film. Two hundred and fifty computed tomography (CT) records of the chest were found. CT was
performed for the differential diagnosis of suspected cases
having atypical histories, clinical and radiological findings.

3. Results

Fig. 1. Right lower lobe collapse due to an organic FB.

S. Ibrahim Sersar et al. / European Journal of Cardio-thoracic Surgery 28 (2005) 369374

Fig. 2. Pin very distal in the right basal segmental bronchi.

3.2. Bronchoscopic findings

Fig. 4. (A) CT chest Mediastinal window showing FBI in the right upper lobe
bronchus. (B) CT chest Pulmonary window showing FBI in the right upper lobe
bronchus.

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cases and all were in group III. Laryngeal oedema was

recorded in 67 cases of whom 25 cases required temporary
tracheostomy (Table 2).

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The types of the aspirated FBs are very broad. The

majority were radiolucent 1561 patients (76.44%) and they
were most frequently of vegetable origin (Fig. 1). The most
frequent radio-opaque FB determined by plain chest radiography and bronchoscopy were pins (Fig. 2). The locations of

FBs are listed in Table 1. The majority of the FBs were located
in the bronchus and there was no statistically significant
difference for the left and the right sides for both groups. The
organic foreign bodies included peanut, organic materials,
Walnut, Carrot, Apple, Sunflower, Chickpea, peach tail,
tangrene tail, coffee bean, organic pip, crystallised fruit,
Coconut, Pistachio, Almond, Soya, Dried cereal, Popcorn.
The inorganic foreign bodies included plastics, plastic peg,
plastic pearl, toy and pins.
Review of the bronchoscopy reports showed that
significant tissue reaction was more common in group III.
While inflammation and granulation tissue around the object
with copious mucoid, purulent secretion was determined in
most of the patients in the group with delayed presentation.
In all but one of the 44 patients, the FB was removed
successfully with one trial of rigid bronchoscopes under
general anaesthesia. Only 20 patients needed bronchotomy
or pulmonary resections. Our Egyptian novel technique
(Sersar Technique) was introduced in 2004 April and was
used since then in 100 cases (4.62%) with a history of FBI
(Pins and or small rounded materials). It was successful in 73
(73%) cases of non-impacted inhaled pins and rounded
organic materials (Illustration) (Fig. 5). It is simply rigid
bronchoscopic removal of inhaled foreign bodies without
using a forceps but using the postural drainage assisted with
suction. All the patients with suspected FBI were admitted in
our centre at least for 24 h. The longest hospital stay was
24 days. In group III, it ranged from 2 to 24 days.

4. Discussion
Fig. 3. (A) Plain X-ray chest showing a nearly left total opacity with ipsilateral
mediastinal shift due to an organic FB. (BE) CT chest showing a nearly total
lung collapse with ipsilateral mediastinal shift due to an organic foreign body.

The diagnosis of FBA is elusive in delayed cases. Children

may present with no history of aspiration or atypical history
with non-specific symptoms [4,5,8,9].

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predictive one is witnessed aspiration associated with a

choking episode (penetration syndrome). Long-standing
FBs can cause significant inflammation and tissue
reactions; and with delayed presentation, additional
symptoms and signs of unresolved or recurrent pneumonia
and persistent cough may occur [810]. In our study, we
also showed that the clinical signs and symptoms of
pneumonia were found in a significantly higher number of
the patients with delayed diagnosis.
Radio-opacity of FBs prevents misinterpretation of the
symptoms and provides an early and accurate diagnosis. In
the present study, only (479 patients) 15.72% of all FBs
were radio-opaque and we also found that the number of
the radio-opaque FBs was significantly less in the group
with delayed diagnosis. The type of FB is an important
factor that determines the progress of the pathology
caused by the lodgement. As we determined in our study,
most aspirated FBs are radiolucent and most frequently of
food origin [1215]. In children younger than 3 years, 80%
of airway FBs are found to be food or other radiolucent
items [13]. If the clinician only trusts the radiological
findings and does not consider an early bronchoscopy in
patients with strong history, the diagnosis can be delayed
if there are no indirect signs indicating the presence of a
radiolucent object on the plain chest radiograph. This is
important, because the longer a FB is left in situ, the
greater the inflammatory response and the likelihood of
complications. The inflammatory response is much more
significant with food particles. Because of their oil
content, most frequently inhaled vegetable matters,
such as peanuts, seeds and nuts set up intense
inflammatory responses, thus narrowing the airway
further, causing consolidation to develop distal to the
obstruction. Obstructive emphysema is the typical indirect
radiological sign of a radiolucent inhaled object. Hyperinflation due to a check valve obstruction by the object and
reflex oligaemia due to hypoventilation cause unilateral
hyperlucent lung [2]. In our study, the most significant
indirect radiological signs of FBA we found were
emphysema, atelectasis and pneumonia. While emphysema was observed in both early and delayed presentation
of FBA, atelectasis and pneumonia were determined
significantly in higher number of the patients with delayed
diagnosis. In persistent bronchial obstruction, pneumonia
develops in 926% of cases [1719]. In the present study,
222 patients (6.72%) of which the patients with FBA had
pneumonia, but the number increased significantly with
delayed presentation (in 27.16%). In the delayed cases, the
bronchoscopic evaluation showing intense inflammatory
changes with increased granulation and mucoid secretion
confirmed our pre-bronchoscopic clinical and radiological
findings suggesting pneumonia. Plain chest radiography
shows atelectasis in approximately 25% of the patients
with FBA [1719]. In this study, atelectasis was determined in (317 cases) 9.6% of the patients with FBA, and in
the delayed cases it increased to 32.7%. With persistent
lodgement, the object may progress distally resulting in
complete endobronchial obstruction and mucosal inflammation with oedema, granulation and viscous secretion,
which aggravates the pathology and may result in
atelectasis (Figs. 3 and 4).

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Fig. 5. (1)(6) It is hand-made description of the Egyptian novel technique

(Sersar Technique) using the postural drainage.

Accurate history and a high index of suspicion are needed

to prevent delayed diagnosis and the complications.
Age of the patient is one of the significant criteria in
diagnosis of the suspected cases. As we observed in our
study, whether it is an early or delayed presentation,
approximately 52.29% of FBA (1726 patients) occur below
the age of 3 years. We found that the incidence of FBA
increases between 1 and 3 years of age. We also
determined that the possibility of negative bronchoscopy
in suspected cases is significantly high under the age of 1
year. This may be due to mucous plugs, which can mimic
FBA, causing obstruction of the bronchioles because the
airways of infants of this age are narrower. The high rate
of negative bronchoscopy may be due to the fact that CT
was unavailable or unreliable at a time in out centre; the
patients could not be trusted to return for outpatient
follow-up and we usually broaden the scope of indications
for rigid bronchoscopy.
The most common signs and symptoms of FBA are
choking, coughing, wheezing and decreased breath sounds
[12,13]. Of all these signs and symptoms, the most

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Acknowledgements
The authors present their thanks to Professor Mohammed
Mounir Elsaeid, MD, Professor Shabban A. Abulela, MD and
Professor Abed Abdel Samea Mowafy, MD for their assistance, advice and support.

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A convincing history and suspicious plain chest radiography are the two main criteria for the need for bronchoscopic
diagnosis of FBA. Most of our patients come to our
emergency hospital. Their parents are not aware with our
primary care system. They just come to the hospital whether
the emergency or the paediatric hospital where they are
referred to us. The indication for bronchotomy in our
patients was failed three trials of bronchoscopic removal
of an impacted organic FB with distal airway obstruction
whether partial or complete or failed bronchoscopic removal
of an impacted inorganic FB with or without symptoms for
fear of the inflammatory response. The indications for
pulmonary resections were not for FB but for destroyed
segment, lobe or lung and the FB was accidentally found.
In the presence of normal radiographs and a strong
history, the radiologist and clinician, depending on their
experiences and facilities, should decide whether the child
should undergo fluoroscopy or bronchoscopy. If an expiratory
film cannot be obtained due to lack of cooperation, or
negative radiological findings are present, then fluoroscopy
may help to detect the presence of a FB. If present, air
trapping and shift of mediastinal structures to the opposite
side can be easily identified at fluoroscopy. We do rigid
bronchoscopy for suspected history with any chest trouble
with persistent radiologic abnormalities. Although CT
occasionally demonstrates an opacity not visualised on the
plain film, it should not be considered as one of the initial
diagnostic methods for FBA. CT may help with the
differential diagnosis of suspected cases having atypical
histories, clinical and radiological findings with delayed
presentation and complications. The differential diagnosis in
such cases include tracheobronchial obstructions caused by
external compression of airways (e.g. enlarged lymph node,
tumours, cardiac enlargement) or intra-luminal obstructions
(e.g. tumours, granulomatous tissue, as in tuberculosis,
secretions and mucous plugs as in bacterial pneumonia,
cystic fibrosis, asthma, pulmonary abscess and acute
laryngotracheobronchitis). Virual bronchoscopy was done
for three cases. It was helpful to diagnose an endobronchial
obstruction. Rigid bronchoscopy showed the FBI as the cause
of this obstruction.
Children with FBA may present with atypical or misleading history, clinical and radiological findings. Misdiagnosis
such as asthma, pneumonia, croup and reactive airway
diseases may lead to a delayed diagnosis. To prevent
complications caused by delayed diagnosis, the clinician
must maintain a high index of suspicion. In suspected cases,
a more extensive history and physical examination should be
obtained. Regardless of radiological findings, when FBA is
the suspected diagnosis in a patient with a history of a
witnessed episode of choking, a transient cyanosis and
coughing, an early bronchoscopic examination should be
considered. Negative radiography and fluoroscopy should not
preclude bronchoscopy in patients with a strong history.

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