Annals of Indian Academy of Otorhinolaryngology Head and Neck Surgery

CASE REPORT
Year
: 2021  |  Volume : 5  |  Issue : 1  |  Page : 46--48

Hijab pin: Carinal invasion of a migrating airway foreign body


Neha Shakrawal, Bikram Choudhury, Kapil Soni, Darwin Kaushal, Amit Goyal 
 Department of Otorhinolaryngology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Correspondence Address:
Dr. Bikram Choudhury
Department of Otorhinolaryngology, All India Institute of Medical Sciences, Jodhpur - 342 005, Rajasthan
India

Abstract

Foreign-body aspiration is a serious and deadly event which can lead to major complications. This is more common in children and if not promptly managed, can lead to significant complications. We here report a rare case of hijab pin inhalation into the trachea which migrated to the carina in a 3-year-old child which was successfully removed by rigid bronchoscopy.



How to cite this article:
Shakrawal N, Choudhury B, Soni K, Kaushal D, Goyal A. Hijab pin: Carinal invasion of a migrating airway foreign body.Ann Indian Acad Otorhinolaryngol Head Neck Surg 2021;5:46-48


How to cite this URL:
Shakrawal N, Choudhury B, Soni K, Kaushal D, Goyal A. Hijab pin: Carinal invasion of a migrating airway foreign body. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2021 [cited 2022 Jan 21 ];5:46-48
Available from: https://www.aiaohns.in/text.asp?2021/5/1/46/320573


Full Text



 Introduction



Foreign body (FB) aspiration is inhalation of any object into the respiratory tract. Depending upon the size and type of FB, they lodge at a particular place in the airway. If it is bigger, it may lodge in the tracheal lumen, while small and sharp objects can have any site of impaction. Children are more at risk of FB aspiration as they have a propensity to put objects into their oral cavity and nose. Moreover, they have underdeveloped neuromuscular reflexes and improper dentition.[1]

A distinct FB has come into existence in the Muslim community. Their women wear headscarves and secure them with sharp pins called “Hijab Pin.” Accidental aspiration of these pins when held between lips had been reported in the literature.[2] During coughing and laughing, speaking accidental airway inhalation may occur. In contrast to other foreign bodies, this can have a varied clinical presentation from being completely asymptomatic to distressing sequelae such as hemoptysis, cough, or dyspnea.[3]

This kind of FB is extremely rare in children, as they do not wear hijab, per se we report a case of accidental inhalation of a hijab pin in a 3-year-old male child while playing, which was initially in the trachea and then lodged into the carina, and was retrieved by rigid bronchoscopy.

 Case Report



A 3-year-old male child was referred to the department of otorhinolaryngology after accidental intake of a sharp FB. The child was otherwise asymptomatic, an occasional cough was reported. There was no breathing difficulty or any cyanosis seen. The vitals were stable and the child was clinically stable. He had no stridor, auscultation revealed bilateral equal air entry. An anteroposterior chest radiograph showed a long sharp FB that was lying in the trachea [Figure 1]a. To get a clear picture, a high-resolution computed tomography was advised which suggested a sharp straight hyperattenuating FB of around 3 cm in the carinal region with its distal tip impacted in the lateral wall of the right main bronchus, it had dislodged from its initial location [Figure 1]b.{Figure 1}

Rigid bronchoscopy was done using a 6 mm size bronchoscope. Anesthesia was given by intermittent ventilation. During the procedure, it was discovered that the FB had penetrated the carina and the tip was touching the lateral wall of the left main bronchus. The distal end of the FB was not visualized and further attempts to remove it were unsuccessful. The pin had penetrated the carinal soft tissue and it was lying on either side of it. The scope was then passed across the distal end of the FB on the right side and the scope itself was used to slide out the offending object gradually toward the carina. It was pulled out from behind backward until the other end was freed off the carina. The FB was around 4 cm in length with a plastic pearl at one end which had not shown up on radiology leaving us to believe that it was a needle [Figure 1]c. The repeat X-ray chest obtained on the first postoperative day was normal.

 Discussion



FB aspiration is a serious and frequent episode in children.[4] It was an extremely life-threatening condition in the prebronchoscopy era with a high degree of mortality. The advent of endoscopes has changed the management and the consequences of this occurrence. The first bronchoscopy was done in 1897 by Gustav Killian, a German otorhinolaryngologist.[5]

There are two peaks of FB aspiration, the first between 3–5 years and the second in the elderly as the age beyond 50 years. The causes attributed to this are the differences in neuromuscular reflexes, mental health problems, and dental status.[6] The usual size is 2–3 cm, with a plastic bead or pearl at the end. The right main bronchus has a greater tendency for FB aspiration as it is more in line and wider than the left. However, in the cases of sharp slender FB, there is an increased possibility of getting them impacted in the left main bronchus as well, owing to Bernoulli's phenomenon. Accidental inhalation happens when the pins are placed between the lips with simultaneous laughing, or speaking. Strong negative pressure is formed in the narrower left main bronchus leading to the lodging of FB. The main complication can be due to the sharp nature of the FB. In our case, it had migrated from the trachea to the right main bronchus and thence to the left main bronchus via the carina.

These metal foreign bodies are radiopaque and can be easily diagnosed on chest X-rays. If the delay is made between diagnosis and management, there are chances of inflammatory processes and edema setting in or secretions with crusting settling around it which can lead to granuloma formation which may further complicate the removal. However, often, a pin being long and slender does not cause obstruction and distress. The risk it poses is perforation which can predispose a patient to hemoptysis, pneumothorax, or pneumomediastinum.[7] If we do not remove them, they tend to impact the adjacent soft tissues stronger during the patients coughing episodes and if they go further in, a bronchoscopic removal may become impossible leading to a thoracoscopic or an open procedure.[7]

Dar et al. removed 31 headpins using rigid bronchoscopy.[8] The attempt of fiberoptic bronchoscopy can lead to coughing and further displacement of these foreign bodies. The other way described in the literature is the use of magnets at the tip of rigid bronchoscopy suction.[9] Reports of migration of this FB to bronchus wall and penetration of lung parenchyma are described where the patients then underwent a thoracotomy for their removal.[10]

 Conclusion



The hijab pin is used by certain social groups. This is the first report of the difficulties they may pose in the diagnosis and management, especially if a detailed history of FB ingestion, or inhalation is not available. The children of the hijab wearers, as per our case, are also prone to this accidental inhalation or ingestion of the pins. Sharp foreign bodies are dangerous due to potentially fatal complications. An intervention at the correct time by an experienced team can reduce the morbidity and mortality associated with the same. Public awareness is also important to reduce the incidence of these accidents.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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