Surgical treatment of awn aspiration causing bronchopleural fistula and bronchiectasis: case reports

Abstract

BackgroundAspiration of grass inflorescences is an extremely rare phenomenon with potential diagnostic difficulties. Due to its special shape, each coughing and respiratory action helps its migration towards the periphery of lung, resulting late-onset, life-threatening complications. The diagnosis has some difficulties for the reason that soon after the aspiration initial symptoms, such as coughing, wheezing or vomiting disappear and bronchoscopy is mostly negative. At least serious complications such as tension pneumothorax, bronchopleurocutaneous fistula or even spontaneous percutan elimination may develope.Case presentationWe present two cases of pleuropneumonia resulting from aspiration of the head of barley grass. Soon after the accidents initial symptoms diminished, inflammatory markers improved and bronchoscopy was unable to confirm the presence of awn. Despite of conservative treatment (antibiotics, physiotherapy, bronchodilators, expectorants, and inhalation) localized pulmonary inflammation developed after 1 and 9 months showed up on chest computed tomography. After ineffective conservative treatment, surgical resections became inevitable in order to remove chronically inflamed parts (lobectomy, segmentectomy) and foreign bodies. Both patients recovered and were discharged home after successful interventions.ConclusionsDue to its peculiar shape and behaviour, awn inhalation is a special and atypical form of aspiration, thus great care and awareness is needed in its treatment. Negative bronchoscopic result does not exclude the presence of bronchial grass head. Symptomless child with negative bronchoscopy and improved inflammatory markers should be followed up thoroughly to recognize late complications in time. Regular diagnostic steps (chest ultrasound/X-ray) should be performed to localize potential chronic lung inflammation. Chest computed tomography is a valuable diagnostic tool for identifying and localising the foreign body. In cases with localized inflammation and peripheric localisation, segmentectomy can be a successful and safe alternative of lobectomy.

Migration of an aspirated grass inflorescence through the chest wall in a 3‐year‐old boy

“…We made an exception to this rule because of the elapsed time, which we considered long enough for the grass inflorescence to migrate beyond the visibility range of a bronchoscope and based on previous publications: Choremis et al 2 did not perform bronchoscopy, whereas the patient of Karagöz et al 6 underwent a negative bronchoscopy on the third day. The first bronchoscopies in the cases published by Rieth et al 3 were also negative (seventh and sixth day).…”

“…A delay between aspiration and admission is common. 2,3 His symptoms were typical, but occasionally these children develop atypical symptoms, such as abdominal pain, 2 diarrhea, 2 or soft tissue mass of the chest wall. 6 Our patient inhaled the grass inflorescence into the left main bronchus (less common compared with right-sided aspiration), 2,3,5,6 that then migrated peripherally, similar to a report by Choremis et al 2 Bronchoscopy should be performed in all cases with moderate or high suspicion of foreign body aspiration.…”

“…2,3 His symptoms were typical, but occasionally these children develop atypical symptoms, such as abdominal pain, 2 diarrhea, 2 or soft tissue mass of the chest wall. 6 Our patient inhaled the grass inflorescence into the left main bronchus (less common compared with right-sided aspiration), 2,3,5,6 that then migrated peripherally, similar to a report by Choremis et al 2 Bronchoscopy should be performed in all cases with moderate or high suspicion of foreign body aspiration. We made an exception to this rule because of the elapsed time, which we considered long enough for the grass inflorescence to migrate beyond the visibility range of a bronchoscope and based on previous publications: Choremis et al 2 did not perform bronchoscopy, whereas the patient of Karagöz et al 6 underwent a negative bronchoscopy on the third day.…”

“…1 Conversely, aspiration of longitudinal organic foreign bodies, such as grass inflorescence, occurs infrequently, despite grass being indigenous and ubiquitous. The structure of aspirated grass determines their behavior and the pathological changes they cause in the respiratory tract 2,3 ; specifically, "lodging" and "extrusive" types of grass spikes were described by Jackson. 4 A 3-year-old boy was admitted because of a persistent cough of Infiltrate of the left lower lobe could be seen on repeat CT scan, with improved aeration of the previously noted infiltrated segments ( Figure 1B).…”

“…5 Gender is typical as well; with male predominance. 2,3,5,6 His aspiration was witnessed, but in most cases, the fact that aspiration is not supported by history at the first encounter, renders the diagnosis more challenging.…”