Contents lists available at ScienceDirect Visual Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/visj Foreign body ingestion or aspiration? Nikma Fadlati Umar a , Mohd Zulfakar Mazlan b , Baharudin Abdullah a, ⁎ a Department of Otorhinolaryngology-Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia b Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia ARTICLE INFO Keywords: Children Foreign body Ingestion Aspiration 1. Visual case discussion A 16 years old teenager presented to the emergency department complaining of ingesting a push pin needle 1 week ago. The needle was used to remove food remnants from his teeth after meal. At that time, he started to cough and accidentally ingested the needle. He claimed to experience productive cough 2 days prior to the incident. He was able to consume orally but experienced dysphagia and odynophagia at the area below his thyroid cartilage. He had no chest pain, wheezing, stridor nor fever. His cough had improved upon review at the emer- gency department. His throat, neck and chest examination showed normal findings. Neck X-ray was normal but chest x-ray (ante- roposterior view) showed suspicious foreign body at the level of T5 area (Fig. 1). Rigid esophagoscopy and bronchoscopy were performed under general anaesthesia. Esophagoscopy proceeded until 38 cm from upper incisor but no foreign body was seen. Bronchoscopy revealed a needle stuck at the carina of bronchus. The knob of the needle was pointing cranially into the lumen of the bronchus and the sharp end of needle placed caudally and most probably embedded at the bronchial wall (Fig. 2). The needle was successfully removed using a foreign body forcep inserted via the rigid bronchoscopy tube (Fig. 3). Post opera- tively, he had no shortness of breath nor chest pain. He was discharged well from the ward after 2 days of hospitalization.Foreign body could occur at any age, though it is more commonly seen in the paediatric population. It may present with a history of foreign body ingestion and maybe asymptomatic until complications occur. If a patient has a for- eign body aspiration, the first stage is the acute stage when patient has coughing and possibly respiratory distress. Then the second stage starts, when the foreign body lodged at a particular area, and the symptoms cease. At this stage the patient becomes asymptomatic. When complications occur, it progresses to the third stage. At this final stage, chest examination demonstrates decreased breath sounds, wheezing, retractions of the rib cage, and tracheal snap though sometimes it can also be normal. The site of lodgement of the foreign body depends on the anatomic structure of the tracheobronchial tree and the body pos- ture of the person at the time of aspiration. 1 The management of FB ingestion or aspiration is prompt removal once diagnosed. 2 Whether foreign body has been ingested or aspirated may be difficult to elicit from the patient's history alone and further assessment is warranted. Foreign body can be identified in radiography in about 25% of patients. Identification of foreign body is more sensitive using chest computed tomography. Besides the identification of the foreign body, chest computed tomography can also give additional findings such as at- electasis, focal hyperlucency, bronchiectasis, lobar consolidation, tree- in-bud infiltrates, ipsilateral pleural effusion, ipsilateral hilar adeno- pathy and thickened bronchial walls. 3 Generally, both flexible bronchoscopy and rigid bronchoscopy are used as the initial procedure for evaluation and management of foreign aspiration. However, rigid bronchoscopy is the gold standard for removal of foreign body in paediatric patient and preferred in cases of acute respiratory distress. Therefore, rigid bronchoscopy should always be available as a backup for any cases in which flexible bronchoscopy is chosen as the initial procedure. 3 Questions 1. Foreign body aspiration occurs only in children A. True B. False 2. What is the stage when foreign body aspiration is asymptomatic? https://doi.org/10.1016/j.visj.2020.100770 Received 4 February 2020; Accepted 14 April 2020 ⁎ Corresponding author. E-mail address: baharudin@usm.my (B. Abdullah). Visual Journal of Emergency Medicine 21 (2020) 100770 2405-4690/ © 2020 Elsevier Inc. All rights reserved. T