Journal of Otology & RhinologyISSN: 2324-8785

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Research Article, J Otol Rhinol Vol: 5 Issue: 1

Tracheostomies in the Management of Aspirated Foreign Bodies in Children at the University Hospital Center of Dakar

Deguenonvo REA1*, Diouf-Ba MS1, Ndiaye M1,2, Ndiaye C1, Diom ES1, Diop A1, Sy A2, Loum B3, Nao EEM3, Tending G1, Tall A1, Diallo BK1, Ndiaye IC1, Diouf R1, and Diop EM1
1ENT Clinic of National Teaching Hospital (NTH) of Fann, Faculty of Medicine of Cheikh Anta Diop University, Dakar, Senegal, West-Africa
2Research and Training Unit for Health Sciences, University of Thiès, Thiès, Senegal,West-Africa
3Former Resident at ENT Department, Faculty of Medicine - Cheikh Anta Diop University of Dakar, Senegal, West-Africa
Corresponding author : Rea Deguenonvo, MD
ENT Lecturer at Faculty of Medicine - Cheikh Anta Diop University of Dakar, Senegal, West-Africa
Tel: +221 77 656 13 21
E-mail: [email protected]
Received: November 11, 2015 Accepted: January 04, 2016 Published: January 09, 2016
Citation: Deguenonvo REA, Diouf-Ba MS, Ndiaye M, Ndiaye C, et al. (2016) Tracheostomies in the Management of Aspirated Foreign Bodies in Children at the University Hospital Center of Dakar. J Otol Rhinol 5:1. doi:10.4172/2324-8785.1000263

Abstract

Objective: To share our experience in the management of foreign body inhalation in children, describing our indications for tracheostomy and making a review of literature.
Design: Retrospective study.
Setting: Department of ORL and Head and Neck Surgery, University Hospital Center of Dakar, Senegal
Patients and Method: From 1997 to 2010, 232 children < 15 years were admitted to our ENT department with a diagnosis of aspirated foreign body, confirmed by bronchoscopy. Sixty three (63) children (population study size) underwent tracheostomies in the management of foreign body aspiration. Following data were recorded for each infant: age, sex, geographic origin, time from aspiration to hospital admission, foreign body aspiration syndrome and/or stridor, our indications of tracheostomies, endoscopic findings, decannulation delay, complications related to aspiration itself and to tracheostomy and the hospital stay.
Results:
Among 232 cases of aspirated foreign bodies taken care of in our ENT department, rigid bronchoscopy removed objects from the larynx in 57 cases (24.5%), the trachea in 36 cases (15.5%) and bronchus in 139 cases (60%). The most common type of foreign body was organic (146 cases, 63%) and peanuts (81 cases, 35%) were predominent. Tracheostomies were performed in 63 cases (27%). Within this group (population study), the median age was 3 years ranged from 5 months to 12 years. The male female ratio was 1.4 (37 boys and 26 girls). Median time to admission was 10 days ranged from 24 hours to 4 months. Rigid bronchoscopy had located foreign bodies in the larynx in 29 cases (46%), in the trachea in 13 cases (21%) and in the bronchus in 21 cases (33%). According to the type of foreign bodies, there were food items in 47 cases (74%) and inorganic objects in 13 cases (21%). Indications of tracheostomies were stridor for 50 cases (86%), intubation in 4 cases (6%) and laryngeal edema in 9 cases (14%). Median decannulation delay was 7 days ranged from 1 day to 2 months. Median hospital stay was 26 days ranged from 1 day to 4 months. Complications of tracheostomies like tracheal stenosis and emphysema were present respectively in one. Complications related to foreign body like bilateral pneumothorax, recurrent pneumonia and bronchitis occurred respectively in one case. Open surgical retrieval of foreign body like bronchotomy was required in 2 cases. We regretted 8 cases of death, a rate of 3.5% in relation to all foreign bodies managed in the chart.
Conclusion: Foreign body aspiration is a life-threatening emergency. Early diagnosis and foreign body removal through bronchoscopy is required to avoid complications. In our conditions, tracheostomy had a critical place. We reported the highest rate of tracheostomies performed in the management of aspirated foreign bodies in the literature. The reduction of this rate could be a good mean to appreciate the improvement of management of foreign body aspiration in our countries.
 

Keywords: Tracheostomy; Foreign body; Aspiration syndrome; Children; Airway; Bronchoscopy

Keywords

Tracheostomy; Foreign body; Aspiration syndrome; Children; Airway; Bronchoscopy

Introduction

Foreign body aspiration is a life-threatening emergency requiring immediate intervention [1]. It most commonly affects young children, with respiratory symptoms such as wheeze and cough after a chocking episode [2] Children between the ages of 6 months and 3 years are particularly susceptible because of their lack of molar teeth and their oral curiosity [3]. Larynx is the first stop before the right main bronchus. Laryngeal foreign bodies form only a small group of foreign body aspiration in children, but they are potentially more dangerous, with respect to both nature and management [4]. Tracheostomy is a life-saving procedure. Its indications are restricted in the management of airway foreign bodies [5]. In our study, we analyzed the indications of tracheostomies in the management of aspirated foreign bodies by children.

Patients and Method

Between 1 January 1997 and 31 December 2010, we conducted a retrospective study in our department. During 14 years, we recorded 63 cases of tracheostomies in the management of 232 cases of aspirated foreign body in children. In our chart, we assessed epidemiologic factors (age, sex, geographic origin and distances covered to reach our department), clinical findings (time to admission, penetration syndrome, physical examination results), bronchoscopic findings, indications of tracheostomies, decannulation delay, complications (related to foreign bodies, to bronchoscopy and to tracheostomy) and hospital stay. Inclusion criteria were: children aged younger than 15 years old, aspirated foreign body diagnosed through rigid bronchoscopy, achievement of tracheostomy. Exclusion criteria were penetration syndrome without rigid bronchoscopy, tracheostomized children without foreign body removed by bronchoscopy. Data were recorded from medical files, surgical procedures reports and were analyzed by the software Epi info 6.1

Results

During 14 years, 232 cases of aspirated foreign bodies of lower respiratory tract in children were diagnosed through rigid bronchoscopy under general anesthesia. The male to female ratio was 1.2:1 (127 boys and 105 girls). The most common site of location was the bronchus in 139 cases (60%). Foreign bodies were impacted in the larynx in 57 cases (24.5%) and the trachea in 36 cases (15.5%). According to the type, organic foreign bodies were encountered in 146 cases (63%). Peanuts and fishbones were predominant with respectively 81 cases (35%) and 26 cases (11%). Tracheostomies were performed in 63 cases (27%) mainly under local anesthesia (55 cases, 87%). Our study deals the “tracheostomized” children in the management of aspirated foreign bodies. Median age was 3 years ranged from 5 months to 12 years (Figure 1). The male to female ratio was 1.4:1 with 37 boys (59%) and 26 girls. Only 16 children (26%) came from Dakar while the 45 children left (71.4%) were from other regions and even another country (Islamic Republic of Mauritania). The median distance covered was 162.5 miles by “out Dakar” patients (Table 1). Median time to admission was 10 days ranged from 24 hours to 4 months. Only 21 children (33%) were admitted within the first 24 hours in our department (Figure 2). Foreign body aspiration syndrome was witnessed by parents in 59 cases (89%) and stridor remarked in 50 cases (80%). Laryngotracheobronchospy located the foreign bodies in the larynx in 29 cases (46%), in the trachea in 13 cases (21%) and in the bronchus in 21 cases (33%). According to the type, the most common foreign body was organic (47 cases, 74%). Peanuts and fishbones were predominant with respectively 14 cases (22.2%) and 13 cases (20.6%). Most of the objects inhaled in this “tracheostomized” children group were removed through rigid bronchoscopy (61 cases, 97%), only two of them (a popgun and a bead) required open surgical retrieval through bronchotomy in the Cardiovascular and Thoracic Surgery department. Our bronchoscopic equipement was obsolete (more than 30 years). We performed 54 tracheostomies prior to bronchoscopy (86%) while post-bronchoscopic tracheostomies were done in 9 cases (14%) (Table 2). In two cases, the foreign bodies were removed through tracheostomy (retrograde fashion) because of their size (a rock and a bead). Median decannulation delay was 7 days, ranged from 1 day to 2 months. Only 14 “tracheostomized” children (36%) were weaned from their canula within 4 days. Complications related to tracheostomies were tracheal stenosis, subcutaneous emphysema and mucus plugging canula respectively in 1, 2 and 2 cases. Morbidity related to bronchoscopy included laryngeal edema (mucosal edema) in 9 cases (14%) and 2 indications of bronchotomies because of unsuccessful bronchoscopic retrieval of a bead and a popgun. Unfortunately, 8 cases of death occured (3.5%, n=232) (Table 3).
Figure 1: Bar chart of ages of tracheostomized children with foreign body aspiration (n=63).
Figure 2: Bar chart of delays to admission (time from aspiration syndrome to hospital admission).
Table 1: Geographic origin of tracheostomized children with aspirated foreign bodies.
Table 2: Presenting patient numbers and percentage with our indications of tracheostomy in the management of aspirated foreign bodies by children.
Table 3: Presenting data of the 8 cases of mortality in the management of aspirated foreign bodies.

Discussion

Foreign body aspirations from childhood are frequently emergency conditions especially in less than 3 years age, comprising an important proportion of accidental deaths [6-8]. In this study, median age was 3 years and the ages 1 to 3 years were predominantly affected. The male to female ratio depends on the study. We had a slight male predominance (sex ratio = 1.4) in the “tracheostomized” group (n=63) as recorded from aspirated foreign bodies (n=232) managed in the same period (sex ratio = 1.2.). Bittencourt et al. [9] remarked that the differences in the distribution according to sex and age group are not significant as related to different countries but the type of foreign body aspirated is related to local eating habits [9]. Foreign body aspiration syndrome was elicited from parents in 89% in our study while in the 11% children left; parents did not witness this syndrome. Chiu et al. [10] and Oguz et al. [11-15] had shown that parents had ignored forgotten the choking episodes until questioned further or after the foreign bodies were removed at bronchoscopy respectively in 41% and 49%. Stridor is an ominous sign that indicates a laryngeal or tracheal occlusion. In our chart, we performed tracheostomies under local anesthesia because of severe respiratory distress probably due to laryngeal obstruction (“emergency” tracheostomies). Rigid bronchoscopy had removed laryngeal and tracheal foreign bodies in 67%. Thrirtythree (33) percent bronchial foreign bodies found during bronchoscopy could lead to the dislodgement and migration of objects during tracheostomy under local anesthesia as Diop et al. [16] explained.
In literature, indications of tracheostomies are well defined in the management of aspirated foreign bodies: acute airway obstruction from a subglottic foreign body or a foreign body too large to be removed through the glottis without risking dislodgement and a sudden distal obstruction, as well as in avoiding laceration and potentially permanent injury to the vocal cords and subglottis in case of sharp impacted foreign bodies [5,17-19]. Singh et al. [12] either recommend tracheostomy in infants with longstanding subglottic foreign bodies with associated granulation tissue that tends to bleed on touch, in order to secure the airway. In our study, tracheostomies prior to bronchoscopy were commonly performed for severe respiratory distress in 80% (emergency tracheostomies) with high suspicion of laryngeal foreign body. Meanwhile, emergency tracheostomy kept children alive and gave us time to handle to rigid bronchoscopy because there was no anesthetist on duty in our department. Beside this main indication of tracheostomy before bronchoscopy, children underwent “intubation” or “deliberate” tracheostomies (6%), to secure the airway because of high risk of laryngospasma during bronchoscopic attempts to remove laryngeal foreign bodies. To manage post-bronchoscopic complications such as laryngeal edema, Aytac et al. [13] performed tracheostomy. In our ENT department, there is no Pediatrician Intensive Care Unit (PICU). Thus, post-bronchoscopic laryngeal edema was managed with security tracheostomies and steroids. In case of mucosal edema or laryngeal edema remarked during last bronchoscopic review, “security” tracheostomies were done in the operating theatre. The same principle was applied with immediate stridor after extubation. For Berkowitz et al. [14] postbronchoscopic laryngeal edema required endotracheal intubation. During our study, only two centers owned a rigid bronchoscopic equipment for aspirated foreign body removal in Senegal and were located in Dakar: University Hospital Center and Hospital Principal of Dakar (HPD). This situation could explain both long median time to admission for out Dakar patients (10 days) and long median distances covered (162.5 miles) to reach the referral center once diagnosis was made. The difference between these two centers in the extraction of airway was that no tracheostomy was achieved at HPD wherein a Pediatrician Intensive Care Unit (PICU) was available as Sissiko et al. explained [20]. In our study, tracheostomy was used to remove, in a retrograde fashion, sharp or irregular foreign bodies as a rock and a bead. Some case reports emphasized on such indication of tracheostomy [21,22]. In our work, decannulation delay was long due to complications related to tracheostomies like tracheal stenosis. Other complications like emphysema and mucus plugging were encountered. Even tracheostomy is a life-saving tool in the management of such life-threatening situation, as foreign body aspiration, it provides complications. Rigid bronchoscopy remains the treatment of choice. As Chevalier-Jackson [22]. Said: « Any foreign bodies of appreciable size that has gone down through the natural passages, can be bronchoscopically removed the same way » [22]. However our equipment was obsolete and bronchoscopies not always age-appropriated and graspers not always adequate for the type of foreign bodies. It is important to use age-appropriated and adequate equipment to ensure comfortability and safety during bronchoscopy. Mortality rate related to aspirated foreign bodies was high in our study compared to others studies less than 1%. Shortage of equipment and the bad work conditions could explain this fact. While tracheostomy is rarely used in general practice in the management of children diagnosed as aspirated foreign bodies, it was critical in their extraction in our conditions. Only few authors had reported tracheostomies prior and after bronchoscopy (Table 4).
Table 4: Comparision with others studies with tracheostomy in the management of aspirated foreign bodies.

Conclusion

Foreign body aspiration is a life-threatening emergency. Regarding our conditions tracheostomy was indicated. We reported one of the highest rates of tracheostomies in the management of laryngotracheobronchial foreign bodies. The reduction of this rate could be a good mean to assess improvement of extraction of aspirated foreign bodies in our department.

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