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ORIGINAL ARTICLE
Year : 2003  |  Volume : 57  |  Issue : 6  |  Page : 244--248

Groundnut as the commonest foreign body of tracheobronchial tree in winter in Northern India. An analysis of fourteen cases.

SP Gulati, A Kumar, A Sachdeva, S Arora 
 Department of E.N.T., Pt. B.D. Sharma PGIMS, Rohtak 124001, India

Correspondence Address:
S P Gulati
Department of E.N.T., Pt. B.D. Sharma PGIMS, Rohtak 124001
India

Abstract

In Northern India, in an institution like ours which receives quite a number of patients from surrounding rural areas, we found groundnut as the most common foreign body of tracheobronchial tree in children particularly in winter months of October to January. This article attempts to address the potential hazard of groundnut inhalation in children.



How to cite this article:
Gulati S P, Kumar A, Sachdeva A, Arora S. Groundnut as the commonest foreign body of tracheobronchial tree in winter in Northern India. An analysis of fourteen cases. Indian J Med Sci 2003;57:244-248


How to cite this URL:
Gulati S P, Kumar A, Sachdeva A, Arora S. Groundnut as the commonest foreign body of tracheobronchial tree in winter in Northern India. An analysis of fourteen cases. Indian J Med Sci [serial online] 2003 [cited 2014 Aug 29 ];57:244-248
Available from: http://www.indianjmedsci.org/text.asp?2003/57/6/244/11928


Full Text

4In an institutional set up, it is not uncommon to receive cases of tracheobronchial foreign bodies. Only a few of them are direct referrals while majority report with variable time lag. In the third world countries, it is only the tip of iceburg that we encounter as referred cases in tertiary level institutions, while many patients fail to survive because of failure to recognise and appropriately treat the condition; chiefly because of ignorance on part both of parents as well as treating physicians. Sporadic cases of tracheobronchial foreign bodies continue to present throughout the year. In our set up, a few commonly retrieved foreign bodies being pen cap, toy whistle, fruit seeds (orange, lemon, watermelon), stone pieces, chana (Black gram), peanut, cashew nut (kaju) and Areca nut (supari). But in winter months, there is a clustering of cases with groundnut as the inhaled foreign body, particularly in this part of the country (North Indian state of Harayana). In our hospital, of the 14 bronchoscopies performed during winter months of Oct. 2000 to Jan. 2001, in 10 cases, foreign body retrieved was groundnut (locally known as Moongphali).

 PATIENTS AND METHODS



A retrospective appraisal of 14 cases of tracheobronchial foreign bodies subjected to bronchoscopy in the department of otolaryngology, Pt. B.D. Sharma PGIMS, Rohtak during Oct. 2000 to Jan. 2001, was done with respect to age and sex incidence, time of presentation, time lag in reporting to the hospital, presenting signs and symptoms, site of retrieval of foreign body from tracheobronchial tree and postoperative outcome. After complete clinical evaluation, these cases with a definite or equivocal history of foreign body aspiration were subjected to rigid bronchoscopy under general anaesthesia employing Karl Storz rigid ventilating bronchoscopes of appropriate size (2.5-6 mm), with fiberoptic illumination. Foreign bodies were retrieved using different types of metallic foreign body forceps.

 RESULTS/OBSERVATIONS



In our study, children ranged in age from 10 months to 3 years, 70% (10 patients) were in the age group of 1 to 2 years. Male female ratio was 10:4. Most cases (8 out of 10, i.e. 80%) in which the retrieved foreign body was groundnut, had reported during months of November and December. This is the time when groundnut comes in the market in this part of the country. Time lag in reporting to the hospital was 2-5 days in most of the cases (8 patients), 1 day in 2 cases, 4-6 hours in 1 case and 3 patient reported after a gap of 2-3 weeks. 12 of the patients hailed from rural background, while only 2 belonged to urban areas.

Presenting symptoms in order of frequency were persistent cough (8 patients), stridor (3 patients), persistent cough with fever (2 patients) and 1 patient presented with severe respiratory distress in gasping state, which required immediate tracheostomy. On auscultation of chest, findings were - air entry reduced on right side (7 cases), decreased on left side (3 cases), bilateral decreased with crepts and rhonchi (2 cases) and equal and near normal on both sides (2 cases). Out of 14 bronchoscopies, laryngotracheal foreign body was groundnut in 10 cases, 1 case each had a pen cap, a stone piece and a rubber piece, and in 1 case bronchoscopy didn't reveal any foreign body. Out of 10 cases, with groundnut as foreign body, in 8 cases, it was retrieved as piecemeal, in 1 case as complete half of cotyledon and in 1 case it extruded by itself from mouth along with saliva immediately following tracheostomy. Foreign body was retrieved from right bronchus in 7 cases, from left bronchus in 4 cases, 1 case each had foreign body in subglottis and carina. Postoperative period was absolutely uneventful in 8 cases, 3 cases had mild residual cough which gradually disappeared over a period of 3-4 days. 1 patient had diarrhoea probably nosocomial in origin and another with tracheostomy had difficulty in decannulation. This very case had undergone emergency tracheostomy being in severe respiratory distress. Immediately following tracheostomy a complete half cotyledon of groundnut had extruded from mouth alongwith saliva. Assuming that the foreign body has been completely removed, bronchoscopy was not done at the first instance. But later on because of difficulty in decannulation bronchoscopy was performed which revealed a big piece of outer shell of groundnut in the subglottis. It was removed and patient was successfully decannulated. One case that didn't reveal any foreign body on bronchoscopy improved with antibiotics and bronchodilators over a period of 7-8 days [Table:1].



 DISCUSSION



Groundnut was the most common foreign body of tracheobronchial tree in winter months since it is quite cheap and commonly eaten commodity and is given to appease crying children by their ignorant parents realising little its potential of tracheobronchial aspiration. In other cases, elder siblings put it in the mouth of their younger ones. In most cases it is inhaled partially chewed, since the dentition in the affected age group is not sufficiently developed.[1] We did not have any case with age more than 3 years probably because by this age, chewing mechanism has become relatively more efficient. A male preponderance in our series probably reflects more attention and care being given to them particularly in this part of the country. Bias towards male sex being significantly greater, an ill male child gets prompt medical consultation compared to a female one who are usually neglected. Male female ratio in our series was 2.5:1. Similar results have been reported by other authors.[2],[3]

A definite history of foreign body aspiration was forthcoming in 80% of cases. Delay in reporting of cases to the hospital is usually because of inappropriate diagnosis and treatment given by local practitioners, besides parental illiteracy and ignorance. These cases may present with fever due to superadded infection.

Foreign body retrieval ratio of right bronchus: left bronchus in our series was 1.7:1 (7 cases: 4 cases) while Tariq reported a ratio of 1.4:1.[4] In Jackson and Jackson series it was 1.82:1.[5] The majority of foreign bodies come to rest in the right bronchial tree, since the right main bronchus is wider than the left and interbronchial setpum projects to the left.[6]

 CONCLUSION



In our set up, groundnut has proved to be a great nuisance amongst tracheobronchial foreign bodies. It is quite cheap costwise and is commonly eaten by people in winter. Parental education regarding its potential of tracheobronchial aspiration through media (TV, radio, newspaper) and educating general practitioners for prompt referrals may help in reducing morbidity and mortality of the condition.

References

1Fernandez JI, Gutierrez SC, Alvarej MV, et al. Foreign body aspiration in childhood - A report of 210 cases. An Esp Paediatr 2000; 53: 335-338.
2Kaur K, Sonkhya N, Bapna AS. Foreign bodies in the tracheobronchial tree: A prospective study of fifty cases. Ind J Otolaryngol Head Neck Surg 2002; 54:30-34.
3Hughes C, Anthony E. Paediatric tracheobronchial foreign bodies - historical review from the John Hopkins Hospital. Ann Otol Rhinol Laryngol 1996;105: 555-561.
4Tariq P. Foreign body aspiration in children - a persistent problem. J Pak Med Assoc 1999; 49.33-36.
5Jackson C, Jackson CL. Diseases of the air and food passages of foreign body origin. Philadelphia: W.B. Saunders. 1936.
6Evans JNG. Foreign bodies in the larynx and trachea. In: Scott Brown's Otolaryngology, 5th edn, edited by A.G. Kerr, Vol.6 Paediatric Otolaryngology, edited by J.N.G. Evans, London: Butterworth, 1987, pp.438-448.