The Internet, Adolescent Males, and Homemade Blowgun Darts: A Recipe for Foreign Body Aspiration

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The Internet, Adolescent Males, and Homemade

Blowgun Darts: A Recipe for Foreign Body Aspiration

abstract

We describe our experience with blowgun dart aspiration via an illus-trative case series and review the resources available to teach children how to construct these objects. A 15-year-old boy presented with cough, wheeze, and eventually admitted to aspiration of a homemade blowgun dart. This instance heightened the awareness of our experience with blowgun dart aspiration as 3 cases presented within a 3-month period. Patients uniformly presented with cough and reported aspiration, and wheezing was noted in 2 of the 3. Although all ultimately admitted their behavior, 2 were initially reluctant to admit aspirating the blowgun dart. Radiographicfindings of a needle-shaped metallic airway foreign body were consistent in all patients. Each admitted tofinding instruc-tions for blowgun dart construction on the Internet. Emergent rigid bronchoscopy with blowgun dart removal resulted in symptom reso-lution in all without complication. This represents the largest series of blowgun dart aspiration to date. During deep inhalation, when prepar-ing to propel a blowgun dart, the vocal folds maximally abduct, leadprepar-ing to increased risk for aspiration. Twenty websites were identified pro-viding instructions for the construction of homemade blowgun darts. With the accessibility of the Internet and number of instructional web-sites, this clinical entity may become more common in the future. Un-fortunately, only a few of the websites provide any safety warnings. Certainly, prompt treatment can result in good outcomes; however, se-rious potential complications, including death, could occur especially given the hesitance our patients showed in divulging the truth of the inciting event.Pediatrics2013;132:e519–e521

AUTHORS:Patrick C. Walz, MD,a,b_{Melissa A. Scholes, MD,}b,c Meredith N. Merz, MD,a,b_{Charles A. Elmaraghy, MD,}a,b_and Kris R. Jatana, MDa,b

a_{Department of Otolaryngology-Head and Neck Surgery, The}

Wexner Medical Center at Ohio State University, Columbus, Ohio;

b_{Department of Pediatric Otolaryngology-Head and Neck Surgery,}

Nationwide Children’s Hospital, Columbus, Ohio; andc_Department

of Otolaryngology-Head and Neck Surgery, Children’s Hospital Colorado, Denver, Colorado

KEY WORDS

foreign body aspiration, cough, blowgun dart, airway obstruction Dr Walz conceptualized the study, conducted data collection and literature review, and drafted the initial manuscript; Dr Scholes conducted data collection and literature review; Dr Merz conducted data collection and reviewed and revised the manuscript; Dr Elmaraghy conducted data collection and reviewed and revised the manuscript; Dr Jatana conceptualized the study, obtained institutional review board approval, conducted data collection, and reviewed and revised the manuscript; all authors approved theﬁnal manuscript as submitted.

www.pediatrics.org/cgi/doi/10.1542/peds.2012-3340 doi:10.1542/peds.2012-3340

Accepted for publication Apr 8, 2013

Address correspondence to Kris R. Jatana, MD, Pediatric Otolaryngology, Nationwide Children’s Hospital, 555 South 18th St, Suite 2A, Columbus, OH 43205. E-mail: Kris.Jatana@nationwidechildrens. org

FINANCIAL DISCLOSURE:The authors have indicated they have noﬁnancial relationships relevant to this article to disclose. FUNDING:No external funding.

PEDIATRICS Volume 132, Number 2, August 2013 e519

CASE REPORT

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Foreign body aspiration is a relatively common occurrence in the pediatric population with the majority of these events taking place in theﬁrst 4 years of life and involving peanuts or other or-ganic materials.1 _{In the adolescent}

subpopulation, however, the aspirated object is more likely a metallic foreign body. Previous small series have ad-vocated for increased education of this demographic to decrease such occur-rences,2_{but our institution has noted}

a recent increased incidence of ado-lescent metallic foreign body aspira-tion, especially in males. While multiple authors have reported their series of turban or scarf pin aspiration in adolescent females,2–10_{the number of}

re-ported blowgun dart aspirations in ado-lescent males has remained small.2,11,12

These aspiration events pose a diag-nostic challenge as this subset of patients may be reluctant to divulge the details leading to presentation. Also, blowgun dart aspiration poses a ther-apeutic challenge as these foreign bodies may become lodged in the air-way mucosa, potentially requiring thoracotomy for removal.1,10 _{Here we}

present the largest series of blowgun dart aspiration in the literature to date, discussing the demographics, present-ing symptoms, method of treatment, and outcomes. Institutional review board approval was obtained for this study.

CASE PRESENTATION

A 15-year-old otherwise healthy boy presented to the emergency depart-ment with a 3-hour history of cough. He reported a sudden onset of cough that began while playing in his room with his siblings. Anterior-posterior and lateral radiographs revealed a linear radi-opaque foreign body in the left main bronchus. Upon further questioning, the patient reported constructing a homemade blowgun using instructions found on the Internet. Rather than

exhaling to propel the dart, the pa-tient inadvertently inhaled initially, aspirating the blowgun dart. The patient was taken to the operating room for emergent bronchoscopy in which the metallic foreign body was encountered in the left bronchus (Fig 1A). Upon removal, thick cotton strands were noted attached to the distal end of the metallic foreign body as a part of the typical construc-tion (Fig 1B). The foreign body was inspected, and there was no evidence of any missing portions of the cotton strands. After removal, a second bronchoscopy showed no evidence of

retained foreign bodies. The patient was subsequently discharged with-out complication.

Within the subsequent 3 months, 2 ad-ditional male adolescents (aged 14 and 15) presented with nearly identical clinical pictures, admitting to identify-ing instructions for the construction of blowgun darts using household mate-rials on the Internet. These patients also underwent bronchoscopic removal of the dart without complication.

DISCUSSION

Blowgun dart aspiration, although rel-atively uncommon, can have serious

FIGURE 1

A, Rigid bronchoscopic view of blowgun dart in left bronchus; B, blowgun dart post-removal.

FIGURE 2

Anterior-posterior (A) and lateral (B) radiographs demonstrating tracheal radiopaque foreign body (arrow).

e520 WALZ et al

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consequences. Although the patients discussed here had uniformly good outcomes with endoscopic removal alone, previous reports of pin aspira-tions have identiﬁed the need for tho-racotomy for distally located pins.1,10_As

in the case presented here, blowgun dart aspiration may present in a delayed manner because of patient re-luctance to provide complete history. Certainly, a high index of suspicion for aspiration is necessary in the adoles-cent male population presenting with vague respiratory complaints. A low threshold for chest radiography in this

population can assist in diagnosis (Fig 2A and 2B). Blowgun darts, pro-pelled through a tube after maximal inspiratory effort, when vocal cords are fully abducted, can be easily aspirated if a child fails to keep the device out of his mouth until immediately before exhala-tion. This case report highlights an op-portunity for education of not only the adolescent population but also the pe-diatric medical community. With the accessibility of the Internet and large number of instructional websites avail-able, this clinical entity may continue to become more common in the future.

Unfortunately, we identiﬁed at least 20 websites with instructions on creating these and only a minority provides adequate safety warnings. As such, preventative measures emphasizing education targeted to adolescents re-garding the risks of foreign body aspi-ration may help to decrease these risks. Certainly, a high degree of suspicion among clinicians and prompt treatment can result in good outcomes. Foreign body aspiration must be considered in the differential diagnosis of cough in pediatric patients because life-threatening complications can occur.

REFERENCES

1. Black RE, Johnson DG, Matlak ME. Bron-choscopic removal of aspirated foreign bodies in children.J Pediatr Surg. 1994;29 (5):682–684

2. Ludemann JP, Riding KH. Choking on pins, needles and a blowdart: aspiration of sharp, metallic foreign bodies secondary to careless behavior in seven adolescents. Int J Pediatr Otorhinolaryngol. 2007;71(2): 307–310

3. Ragab A, Ebied OM, Zalat S. Scarf pins sharp metallic tracheobronchial foreign bodies: presentation and management.Int J Pediatr Otorhinolaryngol. 2007;71(5):769– 773

4. Murthy PSN, Ingle VS, George E, Ramakrishna S, Shah FA. Sharp foreign bodies in the

tracheobronchial tree.Am J Otolaryngol. 2001;22(2):154–156

5. Hamad AM, Elmistekawy EM, Ragab SM. Headscarf pin, a sharp foreign body aspi-ration with particular clinical character-istics.Eur Arch Otorhinolaryngol. 2010;267 (12):1957–1962

6. Hasdiraz L, Bicer C, Bilgin M, Oguzkaya F. Turban pin aspiration: non-asphyxiating tracheobronchial foreign body in young Islamic women. Thorac Cardiovasc Surg. 2006;54(4):273–275

7. Gencer M, Ceylan E, Koksal N. Extraction of pins from the airway with ﬂexible bron-choscopy.Respiration. 2007;74(6):674–679 8. Al-Sarraf N, Jamal-Eddine H, Khaja F, Ayed

AK. Headscarf pin tracheobronchial

aspiration: a distinct clinical entity. In-teract Cardiovasc Thorac Surg. 2009;9(2): 187–190

9. Al-Ali MAK, Khassawneh B, Alzoubi F. Utility ofﬁberoptic bronchoscopy for retrieval of aspirated headscarf pins.Respiration. 2007; 74(3):309–313

10. Ilan O, Eliashar R, Hirshoren N, Hamdan K, Gross M. Turban pin aspiration: new fash-ion, new syndrome.Laryngoscope. 2012;122 (4):916–919

11. Rehm SR, Donohue PA. Blowgun dart aspi-ration—a historical perspective.J Thorac Cardiovasc Surg. 1988;95(6):1084 12. Vander Salm TJ, Ellis N. Blowgun dart

as-piration.J Thorac Cardiovasc Surg. 1986;91 (6):930–932

CASE REPORT

PEDIATRICS Volume 132, Number 2, August 2013 e521

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DOI: 10.1542/peds.2012-3340 originally published online July 22, 2013;

2013;132;e519

Pediatrics

Kris R. Jatana

Patrick C. Walz, Melissa A. Scholes, Meredith N. Merz, Charles A. Elmaraghy and

Foreign Body Aspiration

The Internet, Adolescent Males, and Homemade Blowgun Darts: A Recipe for

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