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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 3  |  Page : 356-361

Open safety pin in the pediatric airway: our experiences at a tertiary care teaching hospital


1 Department of Otorhinolaryngology and Head and Neck Surgery, Institute of Medical Sciences and Sum Hospital, Siksha “O” Anusandhan University, K8, Kalinga Nagar, Bhubaneswar 751003, Odisha, India
2 Department of Pediatrics, Institute of Medical Sciences and Sum Hospital, Siksha “O” Anusandhan University, K8, Kalinga Nagar, Bhubaneswar 751003, Odisha, India
3 Medical Research Laboratory, Institute of Medical Sciences and Sum Hospital, Siksha “O” Anusandhan University, K8, Kalinga Nagar, Bhubaneswar 751003, Odisha, India

Date of Submission12-Mar-2022
Date of Acceptance26-Jul-2022
Date of Web Publication29-Sep-2022

Correspondence Address:
Santosh K Swain
Department of Otorhinolaryngology and Head and Neck Surgery, Institute of Medical Sciences and Sum Hospital, Siksha “O” Anusandhan University, K8, Kalinga Nagar, Bhubaneswar 751003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_32_22

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  Abstract 

Background: Aspiration of an open safety pin in the airway is an extremely rare and critical condition that needs immediate and safe removal of the foreign body (FB). An open safety pin in the airway of the pediatric patient requires urgent recognition. Imaging will confirm the exact site of the open safety pin in the airway. Rigid bronchoscopy with optical forceps or grasping forceps is an ideal tool for the removal of the open safety pin from the airway. Objective: This study aims to evaluate the clinical details, management, and outcome of pediatric patients with an inhaled open safety pin in the laryngotracheal airway. Materials and Methods: This is a retrospective descriptive study done between November 2016 and December 2021. There were six children with inhaled open safety pins in the laryngotracheal airway. The diagnosis was done through proper history taking, clinical examination, and the X-ray of the neck and chest of the children. All children underwent rigid bronchoscopy with optical forceps to remove the open safety pin. Results: Out of the six children, four were boys and two were girls. Out of the six cases, four were in the proximal part of the airway and two were seen in the distal airway. The most common clinical presentation was coughing. In this study, open safety pins of the pediatric airway were removed successfully under general anesthesia with the help of a rigid bronchoscope. Conclusion: Open safety pin is rarely found in the laryngotracheal airway. Open safety pin may cause a life-threatening complication. During the removal of the open safety pin, the surgeon should maintain maximum care to not injure the surrounding structures by the sharp end of the open safety pin.

Keywords: Airway, laryngotracheal airway, open safety pin, rigid bronchoscopy


How to cite this article:
Swain SK, Choudhury J, Dubey D. Open safety pin in the pediatric airway: our experiences at a tertiary care teaching hospital. MGM J Med Sci 2022;9:356-61

How to cite this URL:
Swain SK, Choudhury J, Dubey D. Open safety pin in the pediatric airway: our experiences at a tertiary care teaching hospital. MGM J Med Sci [serial online] 2022 [cited 2022 Nov 29];9:356-61. Available from: http://www.mgmjms.com/text.asp?2022/9/3/356/357464




  Introduction Top


There are different foreign bodies (FBs) found in the ear, nose, and throat of children, which are encountered in daily clinical practice by pediatric otorhinolaryngologists. The FBs in the airway of the pediatric patient are uncommon, and specifically open safety pin is extremely rare and fatal.[1] Aspiration of FB in the airway is a serious problem and can cause significant morbidity and mortality. FB in the laryngotracheobronchial airway can lead to fatal acute respiratory failure when it causes near-complete obstruction at the laryngotracheal airway.[2] FB at the lower tracheobronchial airway can result in respiratory tract problems in the distal area because obstruction leads to ventilation failure and creates a favorable environment for infection.[2] A laryngotracheal FB is less common than bronchial ones but more dangerous as these FBs can cause choking and complete occlusion of the airway.[3] Although children with FB in tracheobronchial airway present with the symptoms of aspiration such as cough and dyspnea, FB-like open safety pin may be asymptomatic.[4] This condition should be diagnosed immediately and promptly treated to save the child.[4] This study aims to describe the clinical manifestations, management, and outcome of the fatal FB-like open safety pin in the airway of children.


  Materials and methods Top


This is a retrospective study in which six children with the aspiration of open safety pin attended the Department of Otorhinolaryngology and Head and Neck Surgery of a tertiary care teaching hospital (Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India) in eastern India from November 2016 to December 2021. This study was approved by the Institutional Ethics Committee (IEC) with reference number IEC/IMS/SOAU/42/14.07.2021. Informed consent was obtained from the parents of the study participants. The age, gender, and clinical manifestations of the participant children, as well as imaging localization of the exact site for open safety pin in the airway, were evaluated retrospectively. A detailed history was taken from the patient’s file regarding accidental inhalation of an open safety pin into the airways along with clinical symptoms such as cough, choking, and dyspnea, if any. All children (six cases) underwent an X-ray neck and chest for localization of the FB. Proper examination of the head and neck along with appropriate radiological evaluations was done for confirmation of the open safety pin in the laryngotracheobronchial airway. All of them were managed by rigid bronchoscopy. In this study, different sizes of rigid bronchoscopes were used for the removal of open safety pin from laryngotracheal airway such as Karl Storz, size 2.5, 3, and 4.5. The open safety pins were removed on an emergency basis under general anesthesia. Brief clinical profiles of the six children with the aspiration of open safety pin are given below.

Case 1

A 14-month-old male baby was brought to the emergency department for the history of open safety pin aspiration 4 h back. The child presented with a mild cough just after aspiration of a safety pin. He had no symptoms of dyspnea. A neck and chest X-ray showed an open safety pin at the upper one-third of the trachea (at the level of the fourth tracheal ring) [Figure 1]. The child was immediately shifted to the operation room and underwent rigid bronchoscopy under general anesthesia with a bronchoscope of Karl Storz, size 2.5. All the vital parameters were within normal limits. The sharp end seems to have pierced the soft tissue of the subglottic area, and the clasp was lying opposite to the epiglottis abutting the base of the laryngeal surface. The open safety pin was carefully removed with the help of optical forceps. The sharp end of the open safety pin was not visible during performing bronchoscopy procedure, so the clasp end was held with forceps and disengaged distally. The safety pin was tried to rotate so that the sharp end will be upside down for preventing injury to the vocal folds while removed. However, it was difficult to rotate the safety pin upside down in such a narrow area. The sharp end was held with forceps and removed and carefully from the laryngotracheal airway through the bronchoscope. Finally, the open safety pin was removed successfully to the outside without any complications. The post-operative period was uneventful. The child was discharged after 72 h.
Figure 1: X-ray neck and chest (lateral view) showing open safety pin at the upper part of trachea with sharp end facing upward

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Case 2

A 3-year-old boy came to the Department of Otorhinolaryngology with a history of FB ingestion 1 day back. After ingestion, he presented with a cough. Neck and chest X-rays were done which confirmed the open safety pin at the larynx. The child was planned for urgent bronchoscopy under general anesthesia. The patient was shifted to the operation room for removal of the FB. The child underwent rigid bronchoscopy (Karl Storz, size 3) with spontaneous ventilation through the attached port of the rigid bronchoscope. The sharp end of the open safety pin was carefully held with forceps and slowly removed [Figure 2]. There was no injury to the mucosa of the larynx. But post-operatively, the patient developed mild laryngospasm and was managed by steroid nebulization and steroid injection. He recovered and shifted to the pediatric intensive care unit for observation. The child was discharged after 3 days of hospital stay.
Figure 2: Open safety pin removed after rigid bronchoscopy procedure

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Case 3

An 18-month-old female child presented with a history of swallowing a safety pin 1 day prior. The child presented with only cough after swallowing a safety pin. She had no evidence of dyspnea and swallowing problems. X-ray of the neck and chest showed an open safety pin at the middle part of the trachea (at the level of the ninth tracheal ring). Immediately, the child was shifted to the operation room for rigid bronchoscopy. The child underwent rigid bronchoscopy (Karl Storz, size 3) under general anesthesia. The sharp end of the open safety pin was held with optical forceps and removed slowly. There was mild mucosal injury of the larynx during the removal of the open safety pin. Post-operative recovery of the child was uneventful and discharged after 48 h.

Case 4

A 4-year-old boy was referred to the outpatient department of the otorhinolaryngology for sudden onset of cough and dyspnea after aspiration of an FB. There was a history of accidental inhalation of a safety pin kept near the child. The child came to the outpatient department after 48 h of aspiration of FB with the symptom of cough. On clinical examination, the child presented with coughing and no evidence of dyspnea. On examination of the oral cavity, ear, nose, oropharynx, and neck were within normal limits. Immediately neck and chest X-ray was done which showed an open safety pin at the larynx where the open part was directed down [Figure 3]. The child immediately shifted to the operation room for bronchoscopy and removal of the FB. The child underwent rigid bronchoscopy (Karl Storz, size 3) and the lower blunt end was easily held by optical forceps and removed without doing any injury to the airway. The patient was given antibiotics and nebulization with bronchodilators post-operatively. The child was discharged from the hospital after 48 h.
Figure 3: X-ray neck and chest (lateral view) showing open safety pin at the larynx and upper part of trachea where sharp end facing downward and piercing the posterior wall

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Case 5

A 5-year-old boy inhaled a safety pin resulting in immediate coughing. Three hours later, he attended the emergency department of our hospital with the symptom of cough. Blood pressure was 106/70 mmHg, respiratory rate was 24/min, and oxygen saturation was 95% on room air. He had mild inspiratory stridor and on auscultation, there was bilateral equal air entry, but slightly reduced. Other systems were examined and were within normal limits. Routine blood investigations were also normal. A chest X-ray was done which revealed an open safety pin in the lower airway, particularly at the lower portion of the trachea just above the carina. The two open ends were facing down. His oxygen saturation was 100% after the administration of oxygen. Immediately, he was shifted to the operation room. Rigid bronchoscopy (Karl Storz, size 4.5), a length of 30 cm with an attached port for spontaneous ventilation, was used for bronchoscopy. He underwent rigid bronchoscopy under general anesthesia, and the blunt end of the open safety pin was held by optical forceps and removed safely. The child was discharged after 72 h.

Case 6

A 12-month-old female baby attended the outpatient department of the otorhinolaryngology for sudden onset of cough and mild dyspnea following ingestion of unknown FB. She had also presented with wheezing. Her parents brought her to the hospital after 6 h following aspiration of FB. The respiratory rate of the baby was 32/min and a pulse oximeter showed an oxygen saturation of 98% in air. There was reduced air entry into the left lungs and normal air entry into the right lungs with vesicular sounds and there was no cyanosis. Neck and chest X-ray revealed an open safety pin at the upper part of the trachea (at the level of the third tracheal ring) just below the vocal fold. The lower blunt end of the open safety pain was facing upward. The child immediately planned for rigid bronchoscopy and shifted to the operation room. She underwent rigid bronchoscopy (Karl Storz, size 2.5) under general anesthesia. The blunt end of the safety pin which faced upward was held by optical forceps and removed slowly and safely without making injury to the laryngotracheal airway. The post-operative period was uneventful and the child was discharged after 72 h.

Anesthesia

The objective of the anesthesia during rigid bronchoscopy is to maintain spontaneous respiration throughout the procedure. All the children were pre-oxygenated with 100% oxygen for 5 min. The pre-medication used in rigid bronchoscopy includes injection of glycopyrrolate (10 mg/kg IV), injection of midazolam (0.04 mg/kg IV), and injection of fentanyl (1 mg/kg IV). Then the child was sedated by injection of propofol (2 mg/kg) and bag-mask ventilation. The laryngoscopy was done and the trachea was sprayed with 1% lidocaine. Injection succinylcholine was administered to the patient once he/she was fully paralyzed and then handed over to the surgeon for rigid bronchoscopy. Sevoflurane was also used for maintenance through the side port of the bronchoscope along with 100% oxygen. After bronchoscopy, the children were given 100% oxygen via mask and simultaneously nebulized with 1:1000 adrenaline till complete awakening of the patient.


  Results Top


During this 5-year study period, six children with an open safety pin in the laryngotracheal airway were admitted to the hospital. There were four boys (two-thirds) and two girls (one-third) with a male-to-female ratio of 2:1. The age of the participating children ranged from 1 to 5 years with a mean age of 2.61 years. The most common clinical presentations among participating children were cough (100%) [Table 1]. Out of six patients, two presented with dyspnea, one presented with wheezing, and one presented with reduced air entry into the lungs [Table 2]. One patient with the open safety pin in the airway was presented with mild stridor. All the cases were diagnosed by X-ray of the neck and chest. All the children with the open safety pin in the laryngotracheobronchitis (LTB) airway underwent rigid bronchoscopy under general anesthesia. The sharp ends of the open safety pin were held by forceps. In all cases, the open safety pin was removed successfully. In one case, there was a mucosal tear in the larynx, and another case presented with laryngospasm, and no other complications were found in this study.
Table 1: Clinical profile and outcome of patients

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Table 2: Clinical presentations and chest findings in patients with inhalation of the open safety pin

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  Discussion Top


An FB is an object foreign to the location where it is found.[5] FBs in the LTB airway can be found in all age groups; however, this is commonly seen in the pediatric age group.[6] The FB in the pediatric LTB airway has a significant risk for morbidity and mortality.[7] The children usually explore the world by picking any objects nearby and putting them in their mouth. The lack of molar teeth in the children and tendency toward oral exploration and play during eating with poor coordination at the time of swallowing may lead to FB inhalation.[8] In this study, all the study participants were found in the age group of 1–5 years. The children are usually taken care of by elder siblings in slums or village areas of the Indian subcontinent. The common causes of FB aspiration are negligence of the children, illiteracy, mental infirmity of the children, talking during eating, and wearing a dental prosthesis.[9]

There are three stages of clinical manifestations after FB inhalation. The first stage of FB inhalation includes gagging, choking, and coughing at the time of aspiration. Parents or caregivers of the children usually give the history of this phase of clinical manifestations. The coughing of the patient is a protective mechanism, gradually fatigued, and ensures the second stage for a few hours. This is followed by the second stage, in which a patient presents paroxysmal cough and the possible air obstruction that happened just after aspiration of the FB, which eventually subsides. After that, an asymptomatic period occurs, which is the cause of delayed diagnosis. The third stage often results in complications such as definite obstruction of the airway or erosion or infections are associated.[10] Sometimes, FB stays for a longer period which results in granulation and narrowing of the airway.[11] Safety pins are not commonly inhaled by FBs and account for less than 3% of all FBs seen in tracheobronchial airways. There are fewer than 2% of patients who need thoracotomy and the majority of them are removed by bronchoscopy with low morbidity and mortality.[12]

Because of the increased use of synthetic dresses, toys, and equipment, the incidence of small or sharp FBs like safety pins specifically open safety pins aspiration appears to be increased.[13] Open safety pin aspiration is an emerging situation among pediatric patients worldwide.[14] As prompt surgical intervention is not always accessible to all patients, delayed cases may lead to fatal outcomes like complete obstruction of the tracheobronchial airway.

The clinical presentations of FB in the airway include coughing, hoarseness of voice, choking, gagging, cyanosis, dyspnea, and chest pain.[15] The clinical presentations of FB aspiration range from acute airway obstruction to features of complications like recurrent pneumonia and bronchiectasis.[16] However, the clinical presentations of the sharp FB-like safety pin are somewhat different. In the early phase of FB aspiration, the patients usually present with a paroxysm of the cough, choking sensation, or obstruction of the airway. Then the patient goes to the quiescent phase in which the patient is often asymptomatic. If this phase is neglected, the patient may go to the clinical phase of complications.[17] In this phase, patients are usually comfortable and have no respiratory distress. In this study, all of the pediatric patients were presented with persistent cough following inhalation of the open safety pin.

Aspiration of open safety pin needs urgent diagnosis for prompt treatment. The delay in diagnosis may happen because of the paucity of clinical symptoms. It is always required for screening and performing X-rays of the neck and chest in each case; those admitted with a history of FB inhalation or ingestion suddenly presented with cough or dyspnea.[7] In this study, an X-ray of the neck and chest was done in patients with inhalation of the open safety pin to confirm the exact location of the FB. Management of the open safety pin in the airway is often challenging for the surgeon. Sometimes, tracheostomy is required to secure the airway and safely remove the FB from the laryngotracheal airway.[7] In this study, no patient underwent a tracheostomy for securing the airway. FB in the airway of children is a challenging situation for surgeons and anesthesiologists as in pediatric patients in whom the airway is narrow and desaturation is faster.[18] The surgeon and anesthesiologist also share the common airway during the rigid bronchoscopy, so it may cause manipulation of the airway and result in the following removal of the FB. Open sharp points of safety pin are usually impinged to the mucosal injury of the subglottic region or in the trachea and so there is fear of injury to endolaryngeal structures or trachea. So multiple attempts should be avoided by the surgeon. Tracheostomy may be required if impinging open safety pin requires multiple attempts. Multiple attempts may be needed during the removal of the open safety pin to cause airway irritation and injury, resulting in surgical emphysema, precipitating hypoxia, bradycardia, hemodynamic instability, and even cardiac arrest.[19] In case of sharp FB in the airway, it is always advisable to remove the FB after closing it. Rarely, it may need a tracheostomy and it is advisable not to immediately close a tracheostomy site in pediatric patients. Intense monitoring of the cardiorespiratory system is required in the post-operative period. The endotracheal tube should be kept in situ till the airway edema subsides. Alternatively, a tracheostomy tube is kept till the subglottic edema subsides.[20]

The appropriate facilities including expert anesthetic service and open safety pin closure forceps are essential, although not readily available at all times in a hospital. In this study, optical forceps were used to remove the open safety pin. It is always better for raising awareness among parents and the public. There should be always warning labels to apply to the open safety pin and the possibility of fatal outcomes during removal from the tracheobronchial airway.[21] Parents or caregivers and the community at large should be educated properly regarding the complications of the open safety pin aspiration in the pediatric age group.

FB-like open safety pin should be removed without delay at a hospital set-up well equipped with instruments, expert surgeons, anesthetists, and healthcare staff experienced with rigid bronchoscopy. Complications of repeated rigid bronchoscopy are trauma to the larynx, bleeding, edema of the larynx, laryngospasm, bronchospasm, laceration of the tracheobronchial airway, hypoxemia, and pneumothorax.[22] Inhalation of FB is a preventable mishap. It can be prevented by giving proper awareness to the parents and the public at large. They should be taught about the dangers of these accidents and their eventualities.


  Conclusion Top


FB, specifically open safety pin in the pediatric airway, is a rare and challenging situation in clinical practice. Sometimes, the history of FB aspiration in children is not known to parents or caregivers, thus resulting in a serious situation. A high degree of suspicion is always warranted in the case of children with respiratory difficulties or sudden onset of cough. These emergencies must be managed promptly to save the life of the child. Rigid bronchoscopy with optical forceps or grasping forceps is the ideal option for the diagnosis and removal of the FB-like open safety pin, which needs great expertise of the surgeon for safe removal. All parents or caregivers should be educated to prevent such fatal incidences.

Ethical consideration

The Institutional Ethics Committee of the Institute of Medical Sciences and Sum Hospital, Bhubaneswar, Odisha, India has provided the ethical approval for undertaking the research project entitled “Open safety pin in the airway of pediatric age group: our experiences at a tertiary care teaching hospital” vide Letter No. IEC/IMS/SOAU/42/14.07/2021 dated July 14, 2021.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest



 
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Engelhardt T, Fiadjoe JE, Weiss M, Baker P, Bew S, Echeverry Marín P, et al. A framework for the management of the pediatric airway. Paediatr Anaesth 2019;29:985-92.  Back to cited text no. 16
    
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