Foreign Body Inhalation: A shift in Clinical Pattern

Background: Foreign body inhalation is a common presentation in thoracic surgery and it is well known to present mainly in toddlers, commonly due to sun flower seeds or water melon seeds. Objectives: To determine the changes in clinical pattern of foreign body inhalation regarding the age, sex, and type of foreign body. Methods: This is a case series study of patients with foreign body inhalation admitted to Al-Jumhori teaching hospital in Mosul. The parameters used in this study are sex, age group and type of foreign body. Results: The main age group affected was adolescents, and the commonest foreign body inhaled was the veil pin. Conclusion: The bad habit of holding pins in mouth while doing other things with your hand has led to this change in clinical pattern of foreign body inhalation. Keyword: Foreign body inhalation, veil pin, adolescent females.


INTRODUCTION
Tracheobronchial foreign body inhalation (FBI) is a potentially life-threatening event, because it can block respiration by obstructing the airway, thereby impairing ventilation and oxygenation. FBI in children may be suspected on the basis of a choking episode if such an episode is witnessed by an adult or remembered by the child. In contrast, the clinical presentation of unwitnessed FBI may be subtle, and diagnosis requires careful clinical assessment and the judicious use of radiography and bronchoscopy 1 .
The first report of the removal of an airway foreign body by bronchoscopy dates back to 1897. The procedure was carried out by Gustav Killian, a doctor who was part of the clinical staff of the University of Friburg in Brisgau, Germany 1 . FBI is associated with significant morbidity and mortality. In USA, 500-3000 children every year die of foreign body inhalation 2 . 75% of cases of FBI occur in children less than 3 years old 3 -5 . In the USA, FBI is the sixth most common cause of accidental death in children 6,7 .
It is responsible for 12% of toy-related injuries in the US and accounts for 7% of accidental deaths in children<4 years old, with a peak incidence of FBI in the second year of life 5, 8 -10 . The epidemiology is similar across countries 11 . The high incidence of tracheobronchial foreign bodies in toddlers is probably due to the oral-centred focus of exploration of environment characteristic of these early childhood years 12 , coupled with the absence of molar teeth 13 . Most studies show that fewer than 15% of foreign body aspirations occur among children older than 5 years of age 14 . In adults, foreign body aspiration accounts for 20% of reported cases of aspiration 15,16 . The risk is higher in older people, especially in and after the seventh decade, probably because of a higher prevalence of aging-associated degenerative neurological and cerebrovascular disorders that can cause dysphagia and/or impaired cough reflex, and have various oral appliances 15,17,18 .
The prevalence of foreign body aspiration is more common in boys 4,10,14,19,20 .
In Western society, peanuts are the commonest foreign bodies inhaled 21, 22, 23, 24 , while watermelon seeds are the most commonly inhaled foreign bodies in Middle Eastern countries 25,26 . In Iraq the most common foreign body is sunflower seeds 5 . Older children are more likely to aspirate non-food items such as pen caps, pins and paper clips 26 .

METHODS
This is a case series study of 105 patients with Time of presentation post pin inhalation was within the first 24 hours post inhalation for most cases. Most patients were referred from other health care facilities or other primary health centers or from private clinics. These patients needed admission to the emergency department with putting up an i.v. line, i.v. drugs and all performed at least one chest x-ray prior to bronchoscopy and some needed another x-ray post-bronchoscopy. A rigid bronchoscopy was performed for all patients in the emergency operative room under general anesthesia and mechanical ventilation. Some patients needed admission to the surgical ward postoperatively for observation over night or at least few hours post scope. A few discharged immediately post bronchoscopy while some needed admission to the intensive care unit for management of bronchospasm or laryngospasm as complication of the whole event. All patients were discharged well.

Sex distribution
Females affected more than males (Figure 1).

Types of Foreign Body
The foreign bodies encountered were mainly veil pin, sun flower seed, water melon seed, beads, plastic objects and others figure 3 .

RESULTS
Analysis of data defined 7 separate patient groups based upon the age of patients (the age of patients ranged from 6 months to 58 years), and 6 separate patient groups based upon the type of the inhaled foreign body.

Age and Sex Distribution
There is a significant relation between the age and sex in which females being the main sex affected in adolescent age group with a ratio of 7:1 (36 female, 5 males). Also the adolescents are the main age group affected (39.0% of all patients).
The distribution of age and sex was shown in Figure 2 .

Distribution of Foreign Body According to Sex of Patient
There is a significant relationship between the type of foreign body and the sex of the patient, where the veil pin is strongly related to female patients, while all other types of foreign body are slightly more common in males. The main types of foreign bodies encountered according to sex are shown in Table 1 and figure 4 .

Distribution of Foreign Body According to Age of Patient
There is a significant relationship between the type of foreign body and the age of the patient, where the commonest foreign bodies in toddlers are sun flower seeds and water melon seeds, while veil pin is the most common foreign body in adolescents.
The types of foreign bodies according to the age are shown in figure 5 .     5,8,9,10 . In this study, the male percentage were 30.5% and females were 69.5%. This is also different from other studies in which the frequencies is more common in males e.g.; Ozhan Kula et al, Bittencoart and Camargos, and Joshua and Bradley Aliakbar et al 4,10,14,19,20 .
The commonest inhaled foreign body in this study was the veil pin used for fixation of veil(Hejab) representing 65 patients (61.9%) followed by sun flower seeds 18 patients(17.1%) then water melon seeds 12 patients(11.5%). This is greatly different from other studies, where in western society, peanuts are the commonest foreign bodies inhaled as seen in Wiseman NE, Stroe M, Mc Guirt et al and Black et al studies 21,22,23,24 . While watermelon seeds are the most commonly inhaled foreign bodies in Middle Eastern countries as proven by Elhassani NB and Aytac et al studies 25,26 . In Iraq the most common inhaled foreign body is sunflower seeds as seen by Sherko Saeed study 5 .
These results show significant differences in this study from others in terms of age, sex and type of inhaled foreign body. The high incidence of tracheobronchial foreign bodies in adolescent females and the significant change in the type of foreign body is due to the use of veil pin in fixation of head veil and the bad habit of putting the pin in the mouth while preparing the head veil.

CONCLUSION
Adolescent females are the most commonly affected group and the veil pin is the commonest type of inhaled FB. This is due to change in the habits of fixation of the wearied veil (Hejab) by the use of veil pin and the bad habit of holding the pin in the mouth while fixing the veil in place.

RECOMMENDATIONS
Education of the general population about the risks of putting pins in the mouth while fixing veils by the means of media and health promotion units and change to use other safe methods to fix veils (clips, .. etc.).
A simple advice to put the pin on the table or on the mirror edge rather than in the mouth can be all that is required.
These patients and these problems are burdening our health programs and health institutes with the time, cost and risks associated with managing such problem. But this dilemma can be avoided, if the public were to know the consequences or risks associated with this simple act of putting a pin or a nail or a screw in the mouth especially when talking, shouting or being in a hurry. A simple brochure or a short TV or radio advertisement may be all that it takes to save life and money. It is simple and it is dangerous but it is avoidable.