Open Journal of Pediatrics, 2011, 1, 90-93
doi:10.4236/ojped.2011.14021 Published Online December 2011 (http://www.SciRP.org/journal/ojped/
Published Online December 2011 in SciRes. http://www.scirp.org/journal/OJPed
Aspiration of foreign bodies that allow air passage through
Demet Can1, Ozge Yilmaz2*, Suna Asilsoy1, Saniye Gulle1, Hasan Yuksel2
1Department of Pediatric Allergy, Behcet Uz Children’s Hospital, Izmir, Turkey;
2Department of Pediatric Allergy and Pulmonology, Medical Faculty, Celal Bayar University, Manisa, Turkey.
Received 6 September 2011; revised 17 October 2011; accepted 3 November 2011.
Foreign body aspiration is commonly encountered in
children. In cases that foreign body does not disturb
respiratory physiology, clinical and radiological di-
agnosis may be delayed leading to severe complica-
tions. Four cases with aspiration of a foreign body
not obstructing ventilation and without typical clini-
cal and radiological findings are discussed.
Keywords: Foreign Body; Aspiration; Children; Ventila-
tion; Air Passage
Foreign body aspiration is commonly encountered in
children particularly less than three years age. Fourty
eight patients were diagnosed with foreign body in the
Emergency department of our hospital in 2005 and for-
eign body was removed in 44. Among 50% these cases,
foreign body was located in left main bronchus. History
was suggestive in 67% of the children while radiological
findings supported the diagnosis in 83% [1,2].
Although history and radiological findings leads to
early diagnosis in many cases, delay in diagnosis leading
to severe complications is not rare either. Delay is espe-
cially prominent when the foreign body does not cause
airway obstruction therefore not disturb respiratory
physiology. Four cases with aspiration of a foreign body
that allow passage of air and therefore not obstructing
ventilation and not causing significant clinical and ra-
diological findings are discussed below.
2. CASE REPORT
2.1. Case 1
Twelve year old boy followed up for allergic asthma for
three years had presented with cough and dyspnea to the
Emergency department a month ago. He had been play-
ing with a pen cap before the symptoms started and told
this to the Emergency Department physician. Physical
findings during that visit included bilateral ronchi, pro-
longed expirium and tachpnea. His findings disappeared
in short time after initiation of bronchodilator treatment.
Both the chest X-ray and lung CT did not suggest for-
eign body aspiration. Upon fast resolution of clinical
findings and absence of radiological findings, diagnosis
of foreign body aspiration was ruled out and he was dis-
charged with the diagnosis of an acute asthma exacerba-
tion. However, the patient reported coughing up the pen
cap three weeks after discharge. The foreign body that
was coughed up had a hole inside that allowed air pas-
2.2. Case 2
Thirteen year old boy was hospitalized with symptoms
of fever, productive cough and dyspnea. Past history
revealed hospitalization due to pneumonia and pleuritis
one year ago. Respiratory sounds were absent on the
left side and decreased on the right side of the chest.
Bronchial (tubular) breath sounds and fine rales were
heard. White blood cell count (WBC) was increased to
21,900/mm3 and erythrocyte sedimentation rate was 70
mm/hour. CRP was 15.5. Plain chest radiography sug-
gested bronchiectasis and lung CT demonstrated left
sided bronchiectasis (Figure 1). Immunoglobulin levels,
tuberculin skin test and alpha1 anti-trypsin levels were
normal. Sputum and blood cultures failed to reveal an
infectious etiology. A piece of a whistle was seen in the
left main bronchus during bronchoscopy and removed.
The parents then remembered that he had had sudden
cough and cyanosis when trying to blow out the plastic
part inside the whistle. They had presented to a health
care center where plain chest radiography was found to
be normal. The foreign body that was removed allowed
air passage at the midline.
2.3. Case 3
Two year old girl was hospitalized three times before she
was sent for rigid bronchoscopy to another hospital. First
hospitalization was at the age of 13 months with the di-
agnosis of acute bronchiolitis when she first had fever
D. Can et al. / Open Journal of Pediatrics 1 (2011) 90-93 91
Figure 1. Lung CT of case 2 demonstrating left sided bronchiectasis.
and dyspnea. Past history revealed hospitalization in
another hospital for a week at the age of 36 days with the
diagnosis of bronchopneumonia. Body weight was 10.7
kg (50% - 75%, height was 74 cm (50% - 75%). She had
tachycardia (162/minute), tachypnea (48/minute). Sub-
costal, intercostal retractions and prolonged expiration
time were detected. Bilateral hyperaeration was noticed
in the plain radiograph (Figure 2). Nebulized salbutamol
was administered and she was discharged on fifth day of
hospitalization upon resolving of the clinical findings.
She was hospitalized seven months after this because she
had had four wheezing episodes after the first hospitali-
Figure 2. Bilateral hyperaeration in the plain chest radiograph
of case 3.
zation. Lung auscultation revealed rhonchi. Serum levels
of immunoglobulins, sweat chloride test and gastroe-
sophageal reflux scintigraphy was normal. Plain chest
radiography was normal but thorax CT was taken due to
the persistence of auscultation findings on right side of
chest. Focal area of atelectasis was detected on right
lower lobe. Radiological findings were not found con-
sistent with foreign body aspiration by the Radiologists.
She was discharged and was started on inhaled steroids.
Two months later, she was hospitalized again upon per-
sistence of auscultation findings on the right side of
chest. AngioCT revealed focal areas of narrowing in
right middle and lower lobes that were interpreted in
favor of bronchomalacia. Therefore the patient was sent
to another center for rigid bronchoscopy during which a
foreign body (plastic flower) was removed from right
2.4. Case 4
Fourteen year old boy presented with cough. He had
been hospitalized for treatment of lower respiratory tract
infection many times for the last 6 months. Past medical
and family histories were non-remarkable. Physical ex-
amination revealed bilateral fine rales and rhonchi that
were more pronounced in the right lower lung fields.
Complete blood count and serum biochemistry were
normal. Immunoglobulin A, G and M values were in the
normal ranges. Plain chest radiography demonstrated
infiltration in the right middle lobe. Lung CT revealed
right middle and lower lobe infiltration and mediastinal
opyright © 2011 SciRes. OJPed
D. Can et al. / Open Journal of Pediatrics 1 (2011) 90-93
shift. Bronchial wall irregularity was seen in the seg-
mental bronchus of the right upper lobe anterior segment
and main bronchus of the right middle lobe. Flexible
fiberoptic bronchoscopy was performed for diagnostic
purposes and foreign body lodged right below enterance
of right middle lobe was suspected. Pediatric surgery
was called in during the same session for rigid broncho-
scopy since the patient had received general anesthesia.
They could not reach the foreign body in that session
and interpreted the image as granulation tissue. However,
upon questioning of the family again for foreign body
aspiration, the child remembered swallowing a plastic
pencil tip seven years ago. They had presented to a phy-
sician but aspiration was not thought at that time because
plain radiography was normal. Upon this information,
rigid bronchoscopy was performed once again and the
foreign body was removed (Fi gure 3).
Foreign body aspiration that is most commonly encoun-
tered in pre-school children, is a life threatening emer-
gency, however, it may go unrecognized for prolonged
periods of time due to vague clinical and radiological
findings in some cases [3,4]. Considering that most
commonly aspirated foreign bodies in children include
organic material including peanuts not causing complete
obstruction, careful evaluation is especially important
for prompt diagnosis .
Aspiration of a foreign body may result in immediate
choking when lodged in larynx or may lead to complete
obstruction of air entry into a lung segment [5,6]. Re-
tained foreign body in the airway leads to local me-
chanical effects, chemical reactions and inflammation.
An animal study has demonstrated that initial reaction to
the presence of foreign body in the airway is polymer-
phonuclear leukocyte infiltration and edema which is
followed by mononuclear leukocyte and macrophage
infiltration. These findings have been interpreted as ini-
tiation of acute inflammation as early as three days after
aspiration and progression to chronic inflammation as
Figure 3. Foreign body aspirated by case 4.
early as ten days. Moreover, bronchiectatic changes were
observed when a month has passed after aspiration .
Presenting symptoms of foreign body aspiration may
vary from vague to specific and include cough, wheeze,
dyspnea and fever. Physical examination may reveal
focal wheezing or decreased air entry but the findings
may also reveal generalized wheezing or it may be com-
pletely normal . Similarly plain radiographs of chest
may reveal unilateral hyperinflation, atelectasis, con-
solidation or mediastinal shift if there is complete ob-
struction of airflow by the foreign body or they may be
normal especially if there is no obstruction to airflow [5,
8]. Therefore, it is impossible to exclude diagnosis of
foreign body aspiration with a normal radiograph . In
the presented cases, two of them had findings suggestive
of bronchiectasis in plain radiographs which was con-
firmed by computerized tomography (CT). Two patients
had normal plain radiography findings. One of the latter
two had persistent findings on physical examination and
therefore underwent CT that demonstrated focal atelec-
Diagnosis of foreign body aspiration is usually sug-
gested with clinical history and radiological findings .
Foreign body is encountered only in 5% of cases that
undergo flexible bronchoscopy without a prior suspicion
of aspiration [3,5]. Considering that early removal of
aspirated foreign bodies is necessary to avoid the patho-
logical progress from inflammation that initiates at third
day to development of bronchiectasis after 30 days, high
suspicion even in cases with vague clinical or radiologi-
cal findings is required [7,8]. Four cases presented in
this report highlight the importance of aspiration of for-
eign bodies that do not cause complete obstruction since
these cases may easily be overlooked and bronchoscopy
may be delayed. In three of these cases clinical findings
were not suggestive of foreign body aspiration due to the
nature of the foreign body that allowed air passage. One
patient was lucky to cough up the aspirated material but
the other three presented with bronchiectasis, pneumonia
or bronchoconstriction findings . Although the clini-
cal findings may be milder without complete airway
obstruction, induction of inflammation is still expected
to progress thus making early and prompt diagnosis es-
sential for prevention of complications. Therefore, high
clinical suspicion and use of flexible bronchoscopy as
the initial technique of evaluation in patients with sus-
pected foreign body aspiration is prompted. Moreover,
Flexible bronchoscopy provides detailed information
about the nature and localization of the foreign body as
well as the characteristics of airway mucosa .
Detection of a foreign body aspirated into the airway
should be followed by removal as soon as possible to
prevent the inflammatory reaction and development of
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D. Can et al. / Open Journal of Pediatrics 1 (2011) 90-93
Copyright © 2011 SciRes.
granulation tissue . Although, flexible bronchoscopy
is very often used for evaluation of airway in suspected
cases of foreign body aspiration, rigid bronchoscopy
remains the method of choice for removal due to the
wide working channel. There are a limited number of
reports of foreign body removal by flexible broncho-
scopy . With the exception of the case who has
coughed up the foreign body, in all three cases the for-
eign body was removed with rigid bronchoscopy.
In conclusion, diagnosis of foreign body aspiration
was delayed in all the cases presented in this report due
to the non-obstructing nature of the foreign body. Air
passage through the foreign body delayed appearance of
radiological clues. These cases were reported to empha-
size the importance of early consideration of broncho-
scopy in cases with persistent findings even in the ab-
sence of supporting clinical and radiological clues of
foreign body aspiration.
 Cotton, R.T. and Rutter, M.J. (2006) Foreign body aspi-
ration. In: Chernick, V., Boat, T.F., Wilmott, R.W., et al.,
Eds., Kendig’s Disorders of Respiratory Tract in Children,
5th Edition, Saunders, Philadelphia, 610-615.
 Ağın, H., Büber, B., Apa, H., Asilsoy, S., Gulez, N. and
Atlıhan, F. (2007) Çocuklarda yabancı cisim aspirasyonu.
Ege Pediatri Bülteni, 14, 101-106.
 Ramírez-Figueroa, J.L., Gochicoa-Rangel, L.G., Ramírez-
San Juan, D.H. and Vargas, M.H. (2005) Foreign body
removal by flexible fiberoptic bronchoscopy in infants
and children. Pediatric Pulmonology, 40, 392-397.
 Ibrahim Sersar, S., Hamza, U.A., AbdelHameed, W.A.,
AbulMaaty, R.A., Gowaeli, N.N., Moussa, S.A., et al.
(2005) Inhaled foreign bodies: Management according to
early or late presentation. European Journal of Cardio-
Thoracic Surgery, 28, 369-374.
 Karakoc, F., Cakir, E., Ersu, R., Uyan, Z.S., Colak, B.,
Karadag, B., et al. (2007) Late diagnosis of foreign body
aspiration in children with chronic respiratory symptoms.
International Journal of Pediatric Otorhinolaryngology,
71, 241-246. doi:10.1016/j.ijporl.2006.10.006
 Bloom, D.C., Christenson, T.E., Manning, S.C., Eksteen,
E.C., Perkins, J.A., Inglis, A.F., et al. (2005) Plastic la-
ryngeal foreign bodies in children: A diagnostic chal-
lenge. International Journal of Pediatric Otorhinolaryn-
gology, 69, 657-662. doi:10.1016/j.ijporl.2004.12.006
 Yildizeli, B., Zonuzi, F., Yuksel, M., Kodalli, N.,
Cakalagaoglu, F. and Kullu, S. (2002) Effects of intrab-
ronchial foreign body retention. Pediatric Pulmonology,
33, 362-367. doi:10.1002/ppul.10116
 Daines, C.L., Wood, R.E. and Boesch, R.P. (2002) For-
eign body aspiration: An important etiology of respira-
tory symptoms in children. Journal of Allergy and Clini-
cal Immunology, 121, 1297-1298.
 Pinzoni, F., Boniotti, C., Molinaro, S.M., Baraldi, A. and
Berlucchi, M. (2007) Inhaled foreign bodies in pediatric
patients: Review of personal experience. International
Journal of Pediatric Otorhinolaryngology, 71, 1897-