Foreign body aspiration in two young infants: the devil in the
carpet…
Foreign body aspiration (FBA) is rare in children below 6 months of age
as they don’t crawl yet and don’t have the pincer grips but aspiration
is not impossible.
A 6–month old female baby was collected by her mother from the creche,
when she noticed the baby had difficulty breathing, inability to cough
and a weak soft cry. The baby was admitted at the local hospital with
increasing stridor, severe sternal recession and respiratory distress.
She failed both high-flow nasal cannula ( HFNC ) oxygen and continuous
positive airway pressure (CPAP) needing intubation. After intubation
with 3.5 mm endotracheal tube (ETT), it was noted that the ETT was very
high on the chest X-ray. It was attempted to push it deeper but was not
successful. The chest x-ray showed a soft-tissue density foreign body in
the subglottic region (blue arrow) with visible subglottic oedema of the
soft tissues and a ‘steepling’ appearance of the airway. (figure 1 a)
Under vision with a laryngoscope an obstruction was seen just below the
cords. Intubation was achieved with a 3.0 mm ETT past the obstruction
after failed attempts to remove it with a magill forceps. The chest
x-ray after intubation showed that the right middle and lower lobes were
hyper-expanded compared to previously, and compared to the left lung
suggesting a ball valve type obstruction of the bronchus intermedius.
(figure 1 b) The child was referred to a tertiary hospital pediatric
intensive care unit (PICU). Bronchoscopy was performed with a 2.2 mm
fibre bronchoscope via 3.0 mm ETT, shortly after admission to the PICU.
A foreign body (FB) was identified as a so called “devils thorn”, that
was located at the opening of the right main bronchus (RMB) causing
obstruction of the RMB. (figure 1 c) The child was transferred to the
bronchoscopy theatre for removal of the thorn. The ETT was removed and
replaced with LMA size 1.5. Removal was attempted with spiral basket
with a 4.0 mm video bronchoscopy. The thorn was moved into the basket
after several attempts as it was very slippery and coated in mucus.
(figure 1 d) The following problem encountered was that the thorn could
not pass through the subglottic area, which was very swollen and
inflamed after previous attempts to remove it. The thorn was moved into
the subglottic area with the basket and then was removed with a rigid
alligator forceps under vision with a video laryngoscope. (figure 1 e)
The airway was evaluated with bronchoscope to determine any damage from
removal or induced by the FB. There was significant damage to the
subglottic area and the patient was re-intubated. (figure 1 f)
Dexamethasone was given 0.6 mg/kg and oral prednisone 2mg/kg /day was
given for 5 days. The child was extubated in bronchoscopy theatre after
72h, and bronchoscopy performed. There was remaining damage to the
subglottic area and granulation tissue on the cords. Extubation was
successful and an upper airway scope was repeated 1 week later due to
ongoing hoarseness. There was still granulation tissue present on the
cords but improving.
The second case was a 5-month-old male who presented with new onset of
stridor and respiratory distress. The child’s mom came home after work
to find her child unwell and refusing to feed. That evening she reported
noisy breathing and a loud cough. There was no history of previous
stridor, but the infant did have fever suggestive of croup. The child
was admitted to PICU on HFNC with the diagnosis of croup and received
dexamethasone 0.6 mg /kg, adrenaline nebulations and IV Ampicillin. The
lateral of the neck demonstrated a soft tissue density (blue arrow) in
the subglottic region at the level of the C6 vertebral body with
pre-vertebral soft tissue swelling extending from C2 to T1 .(figure 2 a)
An upper airway flexible scope was done, demonstrating some swelling
subglottic with a buldge and possible tear in the right vocal cord. The
airway obstruction progressed and intubation was needed. A 3.5 mm ETT
could be passed through the cords but could not be passed through the
subglottic area. The child was moved to theatre for bronchoscopy and
possible tracheostomy. A devil’s thorn was found about 1 cm below the
subglottic area causing near complete obstruction.(figure 2 b) This was
removed with a rigid alligator forceps with difficulty due to its size.
(figure 2c-e)
The parents of the both cases gave consent for the publication of these
case reports.
In these 2 cases the children probably inhaled the thorn while playing
on the floor. Typically, these types of thorns get stuck in the sole of
people’s shoes especially in the summer, thus bringing them into their
households. The name, devil’s thorn, comes from the shape of the seed,
which is a robust oval parcel adorned with two sharp vertical-facing
thorns. These thorns are reminiscent of the horns of the devil, and the
plant’s scientific name (Dicerocaryum eriocarpum ) also stems from
the word “dikera”, which means “two horns”. The devil’s thorn
contains saponins. These are chemicals that react with water to produce
a slimy mucilage that acts like soap which probably explains the
difficulty in grasping them. FBA occurs mostly in children younger than
3 years, with a peak incidence between 1 and 2 years of age. [1]
Na’ara et al have reported that 15% of all cases of FBA were in infants
younger than 1 year. Death due to FBA is more frequent in infants and
foreign body aspiration is the most common cause of mortality owing to
unintentional injury in children less than 1 year of age. [2]
Schramm et al have reported that in Germany the mortality rate among
cases of FBA in children aged 1–15 years were between 1% and 1.5%
compared to children younger than 1 year where it was between 3% and
4.5%. [3] Laryngeal foreign bodies may mimic croup especially in
very young children. [4] For children at the lower end of the
expected age group for croup , the diagnosis should be carefully
considered. In young children with croup not responding accordingly, or
with acute presentation, subglottic foreign bodies must be considered.
In both cases FBA was not originally considered due to the age of the
children, their inability to crawl and the lack of a witness during the
acute episode of aspiration. Both children were placed on the floor
during the course of the day to play.
The management of FB inhalation in young infants is challenging due to
small airways and because smaller bronchoscopes must be used. Both rigid
and flexible bronchoscopy should be available when FB removal is
attempted.[5]
Very young children presenting with stridor, atypical croup
presentation, and not responding accordingly, subglottic foreign body
aspiration should be considered. These may not always be visible with
bedside flexible endoscopy and may need investigation under anesthesia.
Devils thorn aspiration has rarely been reported in young infants, and
because children are left on the floor covered by carpets , it may be a
danger lurking where they have been deposited unknowingly by the shoes
people wear.
Keywords : Foreign body aspiration, Bronchoscopy, Basket, Devils
thorn, subglottic
Pierre Goussard PhD1, Marc Merven
FCORL(SA)2, Noor Parker FC Paed1Andre Gie PhD1, Chantelle Myburgh FC
Paed1, Savvas Andronikou PhD3,4Riegart Wagenaar FC Cardio 5
1Department of Paediatrics and Child Health, Faculty
of Medicine and Health Sciences, Stellenbosch University and Tygerberg
Hospital, Cape Town, South Africa.
2Department of Otorhinolaryngology, Tygerberg
Hospital, Faculty of Health Sciences, University of Stellenbosch, Cape
Town, South Africa
3Department of Pediatric Radiology, The Children’s
Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
4Department of Radiology, Perelman School, of
Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
5Department of Surgical Sciences, Division of
Cardiothoracic Surgery, Stellenbosch University, and Tygerberg Hospital,
Tygerberg, South Africa
Conflict of interest statement : None