Aspiration of foreign bodies is a relatively common problem in pediatrics. Rarely, it may lead to significant morbidity and even mortality.
When the history or the clinical presentation is highly suggestive of foreign body aspiration performing an early bronchoscopy is invaluable. Nevertheless the absence of a suggestive presentation does not rule out the diagnosis.
We describe an unusual case of a 9 months old boy transferred to our PICU with respiratory failure and cardiovascular collapse from another hospital.
He presented with severe dyspnea following a chocking episode. Despite a clinical suspicion of foreign body aspiration, repeated bronchoscopies failed to locate a foreign body. Three weeks later he developed respiratory failure and hemodynamic collapse accompanied by fever, at which point he was intubated and transferred to our PICU. After initial stabilization requiring HFOV with high pressures and significant ionotropic support, a chest CT demonstrated a large mediastinal abscess with a possible small foreign body lodged within the mediastinum. A detailed history taken from his parents was significant for the possibility of foreign body aspiration during his brother’s birthday party and therefore a repeat CT scan was done, this time clearly demonstrating an arrow-head shaped foreign body at the base of the abscess. Percutaneous drainage of the abscess produced a large amount of pus thus polymicrobial mediastinitis was diagnosed. Furthermore, a hypo-pharyngeal tear was seen on endoscopy, therefore a multidisciplinary operation was inevitable and eventually a thoracotomy was performed during which a rupture in the apex of the left lung was observed and a plastic 0.7X1.5 cm candle holder was removed. An endoscopic repair of the hypo-pharyngeal rupture failed hence an additional operation by a trans-cervical approach was done.
Unfortunately, despite the heroic efforts of the team our patient eventually succumbed to the infectious and hemodynamic complications.
In conclusion, aspiration of foreign bodies in children can result in significant morbidity with severe complications, particularly when diagnosis and treatment are delayed.
Therefore a high index of suspicion should be maintained and lead to prompt extensive diagnostic work-up including bronchoscopy and advanced imaging.
With a significant history and a persuasive clinical presentation negative bronchoscopies cannot rule out the possibility of an unusual location of a foreign body.
