Accidental aspiration of a scarf pin is a well-recognized hazard among the Muslim and Arab girls and women.1–5 In the Arab countries, the head scarf worn by women is called a hijaab or lehaaf. Just as in our patient, the accidental inhalation of the pin tends to happen when a woman is adjusting her scarf with her hands while holding the pin between her teeth. Spontaneous expectoration of an inhaled foreign body is unusual, and flexible or rigid bronchoscopy is required to remove it.
A 14-year-old girl was admitted after accidental aspiration of a scarf pin. The accident happened a few hours before the hospital admission as she was holding the pin between her front teeth while adjusting her head scarf. She was on rescue salbutamol metered dose inhaler for mild asthma, and she had a history of seasonal allergic rhinitis. At the time of the accident, her asthma was well controlled.
A chest radiograph revealed the scarf pin lodged in the posterior segmental bronchus of left lower lobe (Fig. 1). She underwent a flexible bronchoscopy under sedation (intravenous midazolam 5 mg and fentanyl 100 mcg) The bronchoscope tube was inserted through her mouth with usual precautions to facilitate removal of the foreign body. The inhaled pin was observed in the posterior segmental bronchus of left lower lobe, with its sharp end pointing cephalad. It was grabbed by a smooth biopsy forceps, and the bronchoscope with the forceps holding the pin was pulled out in a piggyback manner (en mass). Unfortunately, the pin slipped out of the grasp of the forceps in the mid-trachea and had fallen back into the bronchus intermedius. A forceps with a better grip, such as an “alligator biopsy forceps,” was not available. Hence, a second attempt at removing the pin with the same forceps was made. This time the pin was successfully brought up to the larynx. At this point, the patient suffered a bout of cough resulting in the pin slipping out of the jaws of the forceps. The pin was now visible in the throat. It was actually coughed up by the patient, and its sharp end became embedded in the soft tissue of the nasopharynx.
Four hours later, patient underwent a nasopharyngoscopy under general anesthesia, by an otolaryngologist to find that the pin was no longer lodged in her throat. A subsequent chest radiograph revealed that the foreign body was reaspirated into the lower trachea (Fig. 2). It was then positioned obliquely across the main carina with the lower (blunt) end in the proximal left main bronchus.
A rigid bronchoscopy was planned to retrieve the pin. Incidentally, while waiting for the rigid bronchoscopy, the patient spontaneously coughed the pin out through her mouth. She was given a short course of augmentin 500/125 mg 3 times daily for 3 days as a prophylaxis against lower respiratory infection. She did not suffer any undue sequelae.
Aspiration of a wide range of small objects has been described, especially in children, including bits of plastic toys, pen caps, small coins, teeth and dental fillings, and food particles and nuts. Aspiration of teeth may sometimes occur as a complication of maxillofacial trauma.6 Although foreign body inhalation is a leading cause of accidental death in early childhood, it occasionally leads to death even in adults.7 Ongoing cough and/or breathlessness, due to a concurrent respiratory illness such as chronic obstructive pulmonary disease or acute community acquired pneumonia, has been postulated as a potential risk factor for foreign body aspiration.8 A relatively large foreign body can be life threatening, as it may block the trachea and cause asphyxiation.8,9 The risk of such an event seems to be greater in children than in adults because of their smaller airway caliber.
We had difficulty in removing the pin by flexible bronchoscopy performed under sedation. This was mainly because we did not have an appropriate accessory such as an “alligator” or a “rat-tooth” forceps. The plain biopsy forceps did not provide a firm grip and the pin kept slipping out from its grasp. Retrieval of the pin could have been much easier and quicker if an alligator forceps was used. Furthermore, it would have prevented the complications of the pin getting lodged in the pharynx and then reaspirated. A range of accessories for the flexible bronchoscope is now available for retrieval of inhaled foreign bodies, including “rat-tooth” forceps, alligator forceps, wire baskets, and magnetic and cryo probes. We believe having access to the right accessories is essential before attempting removal of a foreign body.
A group from Egypt has proposed a novel method of removal of scarf pins by means of a rigid bronchoscope that does not need a grabbing forceps.10 It involves tilting the patient’s head down and advancing the rigid scope to a level beyond the distal end of the pin, so that the whole pin falls into the lumen of the scope tube. It can then be removed safely by using postural drainage and suction. The obvious advantage of this method is that there is no risk of trauma from the sharp (free) end of the pin as it is pulled out. The authors have highlighted a number of other advantages including a short time required for the procedure and good results in retrieving both sharp objects and friable organic rounded foreign bodies. However, this technique may not be successful if the sharp end of the inhaled pin is embedded in the bronchial wall or if the ball of the pin has gone in first and has become stuck underneath a cartilage ring in a more distal (segmental or subsegmental) bronchus. Harischandra et al11 suggested that during pin extraction, it is important to grab the sharp end within the jaws of the retrieving forceps and/or within the lumen of the rigid bronchoscope to protect against any trauma to the bronchial wall and upper airway. For any foreign bodies in adolescents and adults lodged at a level below the trachea, we tend to perform a flexible bronchoscopy first. Whether it is a flexible or a rigid procedure, the bronchoscopist (S.M.T.) always aims to grab the sharp end of an inhaled pin with the forceps to reduce the risk of iatrogenic trauma during the procedure.
In our patient, the pin, at initial presentation, was probably not readily accessible by means of a rigid bronchoscope as it was lodged in the posterior segmental bronchus of the left lower lobe. However, retrieval from its new position in the lower trachea after reaspiration would have been possible by means of the Egyptian technique using a rigid bronchoscope.10 Fortunately, the patient coughed the pin out spontaneously and did not require a rigid bronchoscopy.
The complications and difficulties linked to bronchoscopic retrieval of foreign bodies are well documented and include pneumothorax, bleeding, bronchial trauma and perforation, trauma to the upper airway and larynx, lower respiratory tract infection, and noncardiogenic pulmonary edema. Maddali et al12 reviewed the outcomes of foreign body retrieval by means of a rigid bronchoscope in children and identified 2 important factors related to potential complications: prolongation of the bronchoscopic procedure beyond 30 minutes and the use of intravenous instead of inhalational induction of anesthesia.
To our knowledge, spontaneous expectoration of an inhaled scarf pin has not been described before. It would be unusual for an aspirated object to be coughed up spontaneously from the level of lower trachea and main carina (Fig. 2). In this case, it was even more surprising that the object was a pin with its sharp end pointing upward, and yet she still managed to successfully cough it out after reaspiration. A more plausible outcome would be the sharp end of the pin getting embedded into the tracheal wall or larynx as it moved upward because of coughing effort.
A recent review of 12,979 pediatric cases of foreign body inhalation into the tracheobronchial tree highlighted that the incidence of aspiration into the right side is higher compared with that into the left side (52% vs. 33%).3 Furthermore, most (81%) aspirated objects in children are organic materials such as nuts and food particles. We believe that the side of the bronchial tree to which a foreign body ends up landing after aspiration depends largely on the posture of the patient at the time of the accident and the type and shape of the aspirated object. Inhaled pins seem to go down more into the left bronchial tree, whereas more rounded objects such as nuts may be more likely to end up landing on the right side.3,4 This could simply be due to the fact that pins, especially if the ball of the pin goes in first, fall down vertically under the effect of gravity with their lower end eventually hitting the wall of the left main stem bronchus, as the lower trachea wears slightly to the right and takes the main carina with it to the right side. In contrast, more rounded objects, such as nuts, tend to roll down and end up in the right bronchial tree as the right main stem is more in line with the lower trachea compared with the left main stem. Hamad et al13 looked specifically at inhaled head scarf pins. They reported that of 73 cases of scarf pin inhalation, 37 (50.7%) fell into the left bronchial tree and 24 (32.9%) into the right bronchial tree, whereas 12 (16.4%) were stuck in the trachea. They also reported that a majority of them (n=66) were successfully removed in the first bronchoscopic trial. Nevertheless, 5 cases needed a second bronchoscopy and 2 patients required a thoracotomy after failed bronchoscopies.
Rigid bronchoscopy is preferred by many experts over a flexible procedure for retrieval of a tracheobronchial foreign body, especially in children.10,14 Unfortunately, the expertise to perform rigid bronchoscopies has become increasingly limited to a few centers, mainly those with a regional thoracic surgery unit. In addition, it requires general anesthesia as opposed to moderate sedation only for a flexible bronchoscopy.
Certainly, a large, asphyxiating foreign body blocking the trachea is a life-threatening emergency and has to be removed forthwith by means of a rigid bronchoscope, as flexible bronchoscopy is unlikely to be immediately successful in this situation.15 However, if facilities for a rigid bronchoscopy are not locally available, a catastrophic outcome may be averted by simply bagging a patient who is apparently choking on a central foreign body that cannot be removed with the “Heimlich Maneuver.” The pressure of bagging to provide ventilation may dislodge the obstructing object from the trachea and push it down to a relatively safer position in a bronchus on either the right or the left side.4,8 Our experience, and that of several other authors, is that most inhaled foreign bodies lodged beyond the level of trachea can be successfully removed with flexible bronchoscopy.4,15,16 A successful outcome, however, depends greatly on the availability of appropriate accessories and the overall expertise of the operator.17
In summary, we describe a case of accidental inhalation of a scarf pin in a young girl. We had difficulty in removing the object by means of the flexible bronchoscope mainly because of the nonavailability of an appropriate grabbing tool, namely, a rat-tooth or an alligator forceps. Although the flexible procedure managed to bring the pin out into the upper airway, it was reaspirated by the patient into the lower trachea. Incidentally, and quite unexpectedly, the patient coughed the pin out spontaneously, thus avoiding further interventions.
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