What's the Diagnosis?

Visual Diagnosis           

Column Editor: Joe Julian, MD, MPHTM, FAAP | Hospitalist, Internal Medicine - Pediatrics | Clinical Associate Professor, Internal Medicine and Pediatrics, UMKC School of Medicine

A previously healthy 22-month-old male is seen at urgent care for coughing and wheezing. Approximately five days prior to presentation, the patient fell off a chair while eating hazelnuts. He had some initial choking and crying after the fall. He developed a cough and wheezing over the next few days. There was no associated fever, vomiting, decrease in oral intake, or change in activity level. Medical attention was sought due to the progressive respiratory symptoms.

Vital signs were notable for a respiratory rate of 30 and an oxygen saturation of 94% on room air. Patient was non-toxic in appearance and in no acute distress. Wheezing was audible without a stethoscope but there was no increased work of breathing, retractions, grunting or stridor. Lung sounds on the right were clear. Lung sounds on the left were severely diminished. The remainder of the examination was unremarkable.

Chest radiography was obtained with expiratory view.

Inspiration (above)

Expiration (above)

Which of the following is the most appropriate next step in management?

A. Obtain computed tomography imaging of chest and neck

B. Consult otolaryngology (ENT) for bronchoscopy

C. Administer nebulized albuterol and IV dexamethasone

D. Prescribe oral prednisone course and discharge

Answer: B. Consult otolaryngology (ENT) for bronchoscopy

The most appropriate next step in management is to consult ENT for rigid bronchoscopy. This patient had a classic presentation for foreign body aspiration (history of choking episode, acute coughing and focal wheezing/loss of aeration on exam) in an appropriate age group (< 3 years old). Additionally, radiographic imaging shows persistent expiratory hyperlucency of the left lung field with a slight tracheal shift to the right, which is concerning for fixed air trapping (likely from obstruction in left bronchus). If the story alone is not convincing, the imaging strongly adds more supporting evidence. This patient requires a rigid bronchoscopy with ENT to retrieve the presumed foreign body.

Further imaging with computed tomography (CT) is unlikely to change management. While very sensitive, specific and having the ability to detect radiolucent items not seen on plain radiography, this patient already has a high preprocedural probability of having a left bronchial foreign body. CT imaging is likely only to delay intervention for this patient. It may be more appropriate for more uncertain cases (especially if procedural support is not available) and can reduce the risk of an unnecessary bronchoscopy.

The wheezing is related to the ball-valve effect of the foreign body and not an asthmatic process. While steroids and bronchodilators may be used in certain instances, they are not first-line treatments. Discharging this patient on oral steroids is wholly inappropriate and the long-term complications of a retained foreign body (pneumonia, bronchiectasis, atelectasis) can be quite significant.

This patient underwent rigid bronchoscopy with ENT on hospital day one. A hazelnut was found in the left mainstem bronchus with granulation tissue and significant edema. Due to the amount of edema present, the nut could not be extracted.

The patient was transferred to the pediatric intensive care unit for observation given the severity of obstruction. He was started on dexamethasone and nebulized albuterol as needed. Nebulized racemic albuterol was given immediately prior to a repeat rigid bronchoscopy on hospital day two. Intraoperative pictures are shown below. The hazelnut migrated and was located in the left lower bronchus. It was successfully removed with a ureteral stone basket. There were copious purulent secretions distally which were suctioned. The patient was discharged on hospital day three and completed a course of oral amoxicillin-clavulanate for presumed post-obstructive pneumonia.

References:

1. Gibbons AT, et al. Avoiding unnecessary bronchoscopy in children with suspected foreign body aspiration using computed tomography. J Pediatr Surg. 2020; 55(1): 176-181.
2. Green SS. Ingested and aspirated foreign bodies. Pediatr Rev. 2015; 36(10): 430-436.
3. Hammer AR and Schroeder JW. Nelson Textbook of Pediatrics. 21st ed. Philadelphia: Elsevier; c2020. Chapter 414, Foreign Bodies in the Airway; p2211-2212.e1.
4. Lowe DA, Vasquez R and Maniaci V. Foreign body aspiration in children. Clin Ped Emerg Med. 2015; 16: 140-148.
5. Sink JR, et al. Predictors of foreign body aspiration in children. Otolaryngol Head Neck Surg. 2016; 155(3): 501-507.