Singapore Med J 2007; 48 (9) : 850
O r i g i n a l A r t i c l e
in children is not uncommon, and may
escape notice by the parents as well as the
physicians, because of the lack of knowledge
of the exact history and inconclusive
Foreign body inhalation
Methods: A retrospective analysis of airway
foreign bodies in 132 children (80 males
and 52 females) over a period of 20 years
was conducted. Rigid bronchoscopy under
general anaesthesia was done in 129 cases.
Results: The majority of patients (46
percent) were younger than three years of
age. Duration of symptoms varied from less
than six hours to three months. Definitive
history of foreign body inhalation or sudden
choking episodes were present in 71 children.
The foreign body was successfully removed
in 93.2 percent of the cases. Peanuts were
the commonest foreign body. Foreign bodies
were found in the right main bronchus in
62 cases, in the left main bronchus in 46
cases, and at vocal cord level in 7 cases.
Chest radiographs were normal in 46 cases.
Conclusion: Rigid bronchoscopy usually
gives good results in detecting airway
foreign bodies. It should be performed at
the earliest opportunity even when the
definitive history is not forthcoming and the
chest radiograph is inconclusive.
Keywords: airway obstruction, aspiration,
bronchoscopy, foreign body aspiration
Goel A, MBBS
Singapore Med J 2007; 48(9):850–853
Aspirated foreign bodies are responsible for a significant
amount of morbidity and mortality in children despite
the improvement in anaesthetic and endoscopical
techniques. The sudden aspiration of a foreign object
into the airway may result in acute respiratory distress,
chronic pulmonary infections, atelectasis, and even death.
As they can mimic other pathological conditions such
as croup, pneumonia and asthma, it is sometimes
mismanaged. The foreign bodies are best managed by
rigid bronchoscopy which, in experienced hands, is
very simple, almost free of complications and usually
successful. A retrospective review of our 20-year
experience of 132 cases of foreign bodies in the airway
in children was undertaken and is being presented to
share our experience.
The retrospective study was carried out in 132 children
who were admitted to the otolaryngology department
of Post Graduate Institute of Medical Sciences, Rohtak,
India, during a period of 20 years from July 1981 to
July 2001, for evaluation of foreign body aspiration. 80
of these patients were male and 52 were female. Their
ages ranged from six months to 14 years, with 46%
being below the age of three years (Table I). Duration
of symptoms ranged from less than six hours to three
months. 42.4% of patients had symptoms for 24-
72 hours, and 15.9% had symptoms of more than one
week (Table II).
Airway foreign bodies in children:
experience of 132 cases
Yadav S P S, Singh J, Aggarwal N, Goel A
Pt BD Sharma
Yadav SPS, MS,
Singh J, MBBS, MS
Aggarwal N, MBBS
Dr Neeraj Aggarwal
c/o Dr SPS Yadav,
30/9J, Medical Enclave,
Tel: (91) 93 5562 8602
Fax: (91) 12 6221 1308
Table I. Age of children with foreign bodies in the
Age (years) No. of patients Percentage (%)
< 1 6 4.5
1–3 55 41.6
4–6 22 16.9
7–10 25 18.9
> 10 24 18.1
Table II. Duration of symptoms in children with
foreign bodies in the airway.
Symptom duration No. of patients Percentage (%)
< 6 hours 4 3.0
6–12 hours 18 13.6
12–24 hours 16 12.2
1–3 days 56 42.4
3–7 days 18 13.6
1–4 weeks 13 9.9
4–12 weeks 7 5.3
Singapore Med J 2007; 48 (9) : 851
A definitive history of foreign body inhalation or
a sudden choking episode was present in 71 (53.8%)
patients. All of them developed symptoms of wheeze
and cough later on. In the remaining 61 (46.2%)
patients, there was no definitive history of foreign
body inhalation; 46 of them presented with difficulty in
respiration and cough and the remaining 15 were referred
from paediatricians for non-resolving or recurrent
segmental pneumonias. Stridor was present in 14 cases.
All the patients underwent radiological evaluation,
i.e. radiographs of the neck and chest. Three patients
presented with obstructed conditions and could not be
resuscitated. In 129 cases, bronchoscopy was carried
out under general anaesthesia. An inhalational agent
was administered first by mask, and airway control
was then shifted to a ventilating rigid bronchoscope. In
118 cases, bronchoscopy was delayed until diagnostic
evaluation and fasting was complete for general
anaesthesia. However, in 11 cases, the patients were
in acute distress and bronchoscopy was done on an
urgent basis. In 14 patients, bronchoscopy was required
more than once. Postoperatively, all the children
were treated with bronchodilators and steroids, along
Out of the 132 patients, foreign bodies were successfully
removed in 123 cases (93.2%). In two cases, foreign
bodies were removed via thoracotomy. In four cases,
mucus plug was found to be the offending endogenous
foreign body. A wide variety of foreign bodies were
removed, with peanuts being the commonest foreign
body, comprising 69 cases (Table III). Foreign bodies
were found in the right main bronchus in 62 cases and
in the left main bronchus in 46 cases. In seven cases, the
foreign body was at the vocal cord level and in four
cases each, at the subglottis and trachea, respectively.
On clinical examination, signs of rhonchi, decreased
breath sounds and intercostal retraction were present
on the side involved, in almost all the cases. However,
radiological signs were positive in 76 (57.6%) patients
only (Table IV). No serious postoperative complication
occurred, except for atelectasis in 11 cases (8.3%). All
these patients responded well to physiotherapy.
The first systematic or elaborate study of foreign bodies
in airway was attempted by Gross in his publication
“A practical treatise on foreign bodies in the air
passages” in 1854.(1) He emphasised the importance
of clinical history, especially the first paroxysm,
notably cough and a severe suffocation which occurred
with the aspiration of foreign object. In our series,
only 56.8% of the cases had such a definitive history of
foreign body inhalation. There may be a symptomless
period after first paroxysm, which may vary in duration
from few days to even months. However, subsequent
wheezing, cough, choking and sudden onset of asthma
point towards a possible foreign body aspiration.
Recurrent or non-resolving pneumonia also indicates
possibility of a foreign body aspiration. In children,
aspiration of foreign bodies lodged high in the
tracheal airway mimics
recurrence of symptoms like stridor and wheezing
after one successful treatment with antibiotics and
steroids should alert one of a possible foreign body.(2)
Our study showed a male predominance, which is
in agreement with many other studies.(3-7) The number
of foreign bodies in the right main bronchus (62)
was more, as reported earlier.(8) This is explained by
the anatomical features of the right main bronchus,
i.e. it is wider in diameter, shorter in length and has
more direct extension of the trachea than the left
We observed that the peanut is the commonest
foreign body, which is the same observation made by
almost all the previous studies,(4,5) especially vegetable
foreign bodies,(6) indicating that parents should be
educated to abstain from feeding nuts and seeds to
young children who do not have premolars or molars
and cannot grind smaller inhalable pieces effectively.
Furthermore, they have an immature protective cough
viral croup. However,
Table IV. Radiological signs in airway foreign bodies
Radiological sign No. of patients Percentage (%)
Obstructive emphysema 37 28.0
Foreign body visualised 8 6.1
Atelectasis 16 12.2
Pneumonia 15 11.3
Normal 56 42.4
Table III. Types of airway foreign bodies in children.
Foreign body No. of patients Percentage (%)
Peanut 69 52.3
Food material 16 12.2
Seed 7 5.3
Bone 2 1.5
Plastic object 20 15.1
Metallic object 6 4.5
Stone 1 0.8
Tablet 2 1.5
No foreign body detected 4 3.0
Singapore Med J 2007; 48 (9) : 852
reflex, compared to adults, as children have narrower
airways. Hence, morbidity and mortality are higher
in children.(9) The propensity of finding a peanut in
airways of children is probably due to its availability
and affordability as compared to other nuts in India.
Recent studies have shown that magnetic resonance
imaging with T1-weighted images to be useful for the
definitive diagnosis and location of peanut fragments in
the lower airway, because it appears as a high intensity
signal surrounded by the low intensity lung tissue.(10,11)
The second most common type of foreign body was
plastic objects, especially small whistles which are
present in toys and easily put in the mouth by children.
Our study showed positive radiological findings
in only 57.6% of cases, as compared to 62% each in
two recent studies.(12,13) This can be improved if chest
radiographs are taken in full expiration and inspiration.
Flouroscopy can still improve upon this by showing
air trapping or mediastinal shift, and can increase the
ratio of accurate and early diagnosis.(12-14) Obstructive
emphysema was the most common radiological sign.
This is in agreement with various studies.(3,12,13)
Killian was the first person to remove a foreign
body from an air passage in 1898. Later on,
Einhorn, Jackson, Ingels and Mashu improved the
instrumentation and brought it to its present high
state of perfection.(15) In the initial years, bronchoscopy
was performed without anaesthesia, but nowadays,
general anaesthesia has made bronchoscopy much
easier and safer. Tracheal and laryngeal foreign bodies
almost completely occluding the lumen are removed
after full oxygenation and without muscle relaxants.
However, general anaesthesia is not contraindicated
as previously believed.(4)
Urgent bronchoscopy is usually needed only in
cases when severe respiratory distress is present with
stridor, and for foreign bodies in the larynx or trachea.
In 11 of our cases, we needed urgent bronchoscopy
or laryngoscopy. Duration of symptoms after the first
episode of choking was not found to affect the final
outcome in the present series, as the majority of our
patients (85%) presented within a week, and only 5%
were of a duration between 4–12 weeks, as also
reported by Gurpinar et al.(7) 20 children who presented
between 4–12 weeks were the ones associated with
atelectasis and/or pneumonia which was managed
successfully. However, major complications are related
to size, location, type and duration of the foreign
body,(16,17) and are associated with considerable
morbidity. Early diagnosis remains the key to successful
and uncomplicated management.
Repeat bronchoscopy is needed only if the first
bronchoscopy is unsuccessful or when granulomatous
reaction is seen at the time of removal of the foreign
body or when there is persistent pneumonia. Postoperative
corticosteroids may be useful, especially in cases which
require a second procedure, to decrease the oedema
and erythema caused by the initial procedure.(17,18)
There was a maxim among paediatric bronchoscopists
that the rigid bronchoscope is better for the extraction
of foreign bodies because of its ability to control and
ventilate the airway, while removing the offending
foreign body. However, flexible bronchoscopes are now
being used by many bronchoscopists with very good
results and this has been found to be more useful in
removing the peripheral or distal foreign bodies,(5,19)
especially if aided by cinefluoroscopy. Fibreoptic
bronchoscopy may be easy, better and safe, especially
in adults.(20) Video imaging can provide a clear and
magnified view and reduces the risk of residual foreign
bodies and avoidance of repeat bronchoscopy.(21)
Although serious complications,
mediastinal emphysema, atelectasis, pneumothorax,
tracheoesophageal fistula and bronchiectasis, have
been reported after bronchoscopy,(22) in our series,
only atelectasis was observed in 11 cases, which r
esponded well to postoperative physiotherapy. In
conclusion, foreign body inhalation is not uncommon
in children and rigid bronchoscopy usually gives good
results. Bronchoscopy should be performed at the
earliest opportunity when there is suspicion of foreign
body inhalation, even in the case of a negative chest
We thankfully acknowledge the permission granted
by the Medical Superintendent for use of the hospital
1. Gross SD. A Practical Treatise On Foreign Bodies In The Air
Passages. Philadelphia: Blanchard & Lea, 1854.
2. Moskowitz D, Gardiner LJ, Sasaki CT. Foreign body aspiration
– potential misdiagnosis. Arch Otolaryngol 1982; 108:806-7.
3. Rothmann BF, Boeckman CR. Foreign bodies in the larynx and
tracheobronchial tree in children. A review of 225 cases. Ann Otol
Rhinol Laryngol 1980; 89:434-6.
4. Cohen SR, Herbert WI, Lewis GB Jr, Geller KA. Foreign bodies
in the airway. Five year retrospective study with special reference
to management. Ann Otol Rhinol Laryngol 1980; 89:437-42.
5. Swanson KL, Prakash UBS, Midthun DE, et al. Flexible
bronchoscopic management of airway foreign bodies in children.
Chest 2002; 121:1695-700.
6. Mourtaga SM, Kuhail SM, Tulaib MA. Foreign body inhalations
managed by rigid bronchoscope among children, in Shifa Hospital
– Gaza, Palestine. Ann Alquds Med 2005; 2: 53-7.
7. Gurpinar A, Kilic N, Dogruyol H. Foreign body aspiration in
children. Turk Respir J 2003; 4:131-4.
8. Black RE, Choi KJ, Syme WC, Johnson DG, Matlak ME.
Bronchoscopic removal of aspirated foreign bodies in children.
Am J Surg 1984; 148:778-81.
9. Sersar SI, Rizk WH, Bilal M, et al. Inhaled foreign bodies:
presentation, management and value of history and plain chest
radiography in delayed presentation. Otolaryngol Head Neck Surg
Singapore Med J 2007; 48 (9) : 853
10. Imaizumi H, Kaneko M, Nara S, et al. Definitive diagnosis and
location of peanuts in the airways using magnetic resonance
imaging techniques. Ann Emerg Med 1994; 23:1379-82.
11. Hisa Y, Tatemoto K, Dejima K, et al. Magnetic resonance imaging
for aspirated peanut in the bronchus. J Laryngol Otol 1994;
12. Mu LC, Sun DQ, He P. Radiological diagnosis of aspirated foreign
bodies in children: review of 343 cases. J Laryngol Otol 1990;
13. Zerella JT, Dimler M, McGill LC, Pippus KJ. Foreign body
aspiration in children: value of radiography and complications of
bronchoscopy. J Pediatr Surg 1998; 33:1651-4.
14. Tan HK, Brown K, McGill T, et al. Airway foreign bodies: a 10 year
review. Int J Pediatr Otorhinolaryngol 2000; 52:91-9.
15. Clerf LH. Historical aspects of foreign bodies in the air and food
passages. Ann Otol Rhinol Laryngol 1952; 61:5-17.
16. Saleem MM. The clinical spectrum of foreign body aspiration in
children. Int Pediatr 2004; 19:42-7.
17. Oliveira CF, Almeida JFL, Troster EJ, Vaz FA. Complications of
tracheobronchial foreign body aspiration in children: report of
5 cases and review of the literature. Rev Hosp Clin Fac Med Sao
Paulo 2002; 57:108-11.
18. Strome M. Tracheobronchial foreign bodies: An updated approach.
Ann Otol Rhinol Laryngol 1977; 86:649-54.
19. Hockstein NG, Jacobs IN. Flexible bronchoscopic removal of a
distal bronchial foreign body with cinefluoroscopic guidance. Ann
Otol Rhinol Laryngol 2004; 113:863-5.
20. Loo CM, Hsu AA, Eng P, Ong YY. Case series of bronchoscopic
removal of tracheobronchial foreign body in six adults. Ann Acad
Med Singapore 1998; 27:849-53.
21. Yang CC, Lee KS. Comparison of direct vision and video imaging
during bronchoscopy for pediatric airway foreign bodies. Ear Nose
Throat J 2003; 82:129-33.
22. Cohen SR. Unusual presentation and problems created by
mismanagement of foreign bodies in the aerodigestive tract in the
pediatric patient. Ann Otol Rhinol Laryngol 1981; 90:316-22.