Head Scarf Pin in the Airway and Challenges in Rigid Bronchoscopy: A Case Series

Abstract

Accidental Foreign body aspiration, especially sharp metallic objects may lead to life threatening complications. A metallic object is identified readily on a Xray chest or CT chest and helps us in ascertaining its location. A straight pin with blunt head in the shape of pearl is used in wearing a head scarf also known as hijab to hold it in place. The head scarf pin (hijab pin) if accidentally aspirated into the airway may lead to grave complications. Hence timely intervention with suitable instrumentation is essential to prevent any lethal complications. We have reported four different cases of adolescent females who had accidentally aspirated hijab pin and challenges faced by us during removal.

Introduction

A Hijab is a headscarf commonly worn by Muslim female population of Middle East Asia, India, Pakistan, Bangladesh, Indonesia etc. The headscarf is used to cover the hair, neck and ears leaving the face visible. The headscarf is secured in its place using a straight sharp pin, hereby referred to as Hijab Pin. This pin has a pointed sharp end and a blunt head in the shape of a pearl. It is a common practice that the pin is held between the lips or teeth with the blunt end inside the mouth; prior to applying over the headscarf. Accidental aspiration results when the individual suddenly laughs, phonates or if there is any lapse in concentration. (1) Foreign body aspiration is defined as an accidental inhalation of an object into the airway and if not intervened timely may lead to a fatal complication. (2) The symptoms of foreign body aspiration may vary from person to person depending on the site and orientation of lodgment of the foreign body in the airway. Patients most commonly present with recurrent cough, hemoptysis or difficulty breathing while in some cases patient may be completely asymptomatic [1]. (3) Sharp or pointed end foreign bodies are particularly dangerous because of their potential to pierce through the tracheobronchial tree leading to lethal complications. Imaging by means of X ray chest or CT chest is helpful in identifying metallic foreign bodies, their site of impaction and orientation. Early intervention by rigid bronchoscopy is the gold standard to remove the foreign body from tracheobronchial tree. Here we report 4 different cases of hijab pin aspiration and challenges faced during extraction.

Case Report 1

A 13-year-old female patient presented in the emergency room with a history of accidental hijab pin aspiration 3 h back while tying hijab and casually talking to her mother. Following aspiration, the patient developed an excessive cough along with chest pain and was rushed to the hospital. On examination there was tachypnea along with tachycardia. There was no audible stridor, chest retractions or cyanosis. On auscultation there was bilateral equal air entry. Chest X RAY AP View showed a metallic pin lying in the left main bronchus distally. (Fig. 1) Patient was immediately shifted to Operation Theatre. Under Total Intravenous Anesthesia (TIVA), a size 6 ventilating bronchoscope was introduced, and foreign body localized. With the patient breathing spontaneously and aided by intermittent oxygenation via the ventilating port of bronchoscope, a KARL STORZ Optical alligator forceps was introduced, and the visualized foreign body was pulled from left main bronchus. However, owing to its unfavorable orientation within the left bronchus and horizontal angulation of the left main bronchus with carina, the pin was not getting pulled up beyond the level of carina. In order to facilitate extraction, the pin was pulled up to the level of carina and then slightly pushed into the right main bronchus. The pin was then again held by the alligator forceps from the right main bronchus and removed successfully. Check bronchoscopy was normal with no evidence of airway injury. The foreign body was approximately 4 cm in length. (Fig. 2) There were no post operative complications, and the Chest X ray was normal. The patient was kept under observation for the next 12 h and discharged the next day.

Fig. 1.

showing hijab pin lying in left main bronchus

Fig. 2.

showing Hijab Pin removed from Left main bronchus

Case Report 2

A 12-year-old female presented with an alleged history of accidental aspiration of hijab pin while tying hijab followed by violent bouts of cough 15 days back. There was a history of 4 unsuccessful attempted removals (3 rigid bronchoscopies + 1 flexible bronchoscopy) prior to presenting to our center. On examination there was reduced air entry over left lung field along with associated crepitation. A Xray chest done showed the metallic foreign body lying approximately at the level of left lower lobe bronchus. (Fig. 3) During the first attempt undertaken at our Centre, patient was anaesthetized with TIVA;a size 6 ventilating bronchoscope was introduced but pin could not be visualized due to extensive granulation tissue and edema present over left main bronchus. The procedure was abandoned, and the patient was started on IV antibiotics, IV dexamethasone, oral mucolytics and nebulization with a bronchodilator. A HRCT Chest with 3d reconstruction was performed to localize the foreign body. (Fig. 4). On CT chest the metallic foreign body was seen impacted in the left lingula. A second attempt for removal was undertaken after 3 days. A 5 mm rigid ventilating bronchoscope was used this time. In comparison to previous bronchoscopy, the edema over the left main bronchus was found to be reduced significantly and tip of the foreign body could be visualized. But the foreign body could not be extracted due to difficulty in negotiating the optical forceps through the narrow passage. A third attempt with a 3 mm flexible bronchoscope was undertaken on the same day along with the help of a Pulmonologist. A rat tooth forceps was introduced through the working channel and tip of the foreign body grasped with it. Still the pin could not be extracted as it was found to have pierced through and through the bronchus and tightly embedded within the surrounding granulation tissue. The intervention was abandoned as the patient developed bradycardia during the procedure and CPR was initiated for resuscitation. Finally, after taking due consent from the patient’s attendant for an open approach; a thoracotomy was performed by Pediatric surgeon. An intraoperative X ray using C Arm was taken to confirm the Pin’s location. The pin head was palpated, and an incision was given over the lung parenchyma at that point by a monopolar cautery and pin removed (Fig. 5). A chest drain was kept in situ for 1 week and subsequently removed and patient discharged. The patient didn’t develop any complications in the follow up period.

Fig. 3.

shows a metallic pin lying at the level of left lower lobe bronchi

Fig. 4.

HRCT chest showing a metallic foreign body in the left lingula piercing through the bronchus

Fig. 5.

showing the metallic pin removed by thoracotomy

Case Report 3

A 13-year-old female child presented with a history of accidental aspiration of hijab pin and symptoms of recurrent and violent cough for 4 days. Prior to presenting to our Centre, the patient had already undergone a flexible bronchoscopy procedure in which pin was visualized in the left lower bronchus. (Fig. 6) However due to difficulty in instrumentation, the pin couldn’t be extracted by flexible bronchoscopy and referred for rigid bronchoscopy. A rigid bronchoscopy using size 6 ventilating Karl Storz Bronchoscope and using optical forceps under Total Intravenous Anesthesia (TIVA) was attempted. The Pin was partially visualized in the left lower bronchus. It was grasped with alligator optical forceps. However, on attempted removal of the pin with the forceps, it was found to be impacted within the surrounding granulation tissue and couldn’t be extracted. An open approach with thoracotomy was planned thereafter with the help of pediatric surgeon. A preoperative C- ARM Xray was performed to localize the pin. (Fig. 7) A thoracotomy was performed. However, during the intraoperative Xray, the pin was found dislodged from its previous position into the trachea. The was patient was then extubated. A rigid bronchoscopy was performed, and the pin was visualized lying in the lower trachea and subsequently removed with optical grasping alligator forceps. The thoracotomy wound was closed. It was assumed that due to positional changes and lung manipulation during surgery, the pin migrated from the left lower bronchus into the trachea. The post operative period was uneventful, and the patient was discharged after 1 week with no complications.

Fig. 6.

Flexible bronchoscopy showing the location of the pin

Fig. 7.

showing the orientation of the pin in C arm prior to thoracotomy. An artery forceps was placed over the chest wall to aid in surface marking

Case Report 4

A 12-year-old female presented to our hospital with a history of persistent cough following hijab pin aspiration 3 days back. Patient’s vitals were stable with associated reduced air entry over right lung field. A HRCT chest done 3 days back showed a metallic foreign body lodged in left main bronchus. The patient was planned for rigid bronchoscopy. The patient was admitted in ward and administered IV antibiotics, IV Dexamethasone and mucolytic prior to the procedure. A Chest Xray (AP and lateral view) was repeated. There was no evidence of any foreign body in the X ray chest. A HRCT Chest with 3D Reconstruction was then performed, which showed collapse of left upper lobe without any evidence of foreign body. Rigid bronchoscopy was performed under TIVA using size 6 ventilating bronchoscope. A 3 mm Olympus telescope was introduced via the bronchoscope to inspect till the till the secondary bronchi bilaterally. No foreign body was visualized in bronchoscopy. Thick secretions over the left bronchus were suctioned out. The left main bronchus till the secondary bronchi appeared erythematous. The patient was observed for next 48 h. A chest X Ray PA View with abdomen was repeated after 48 h and there was no evidence of any metallic foreign body. There was significant reduction in clinical signs and symptoms as evidenced by a reduction in cough and improved air entry over the left lung field. The patient was discharged on oral antibiotics and mucolytics for the next 5 days. On follow up after 7 days patient was asymptomatic with no fresh complaints. We assumed that the patient probably coughed out and expelled the foreign body prior to presenting to our center unknowingly.

Discussion

Foreign body aspiration contributes to a major proportion of morbidity and mortality worldwide, occurring most commonly in children under the age of 15 years and in the elderly [4, 5]. Foreign body aspiration: specially the sharp ones may lead to potential life-threatening complications viz respiratory distress syndrome, pneumonia, atelectasis, pneumothorax, pneumomediastinum and acquired tracheoesophageal fistula or bronchopleural fistula etc. [6] Foreign body aspiration in pediatric age group is more common due to poor neuromuscular coordination, associated mental health issues and underdeveloped dentition [7]. Aspirated foreign body most commonly gets impacted into the right main bronchus as it is more in line with the trachea and wider than the left. The metallic pin (hijab pin) aspiration as discussed in the cases above is seen predominantly in young Muslim females wearing hijab. Individuals while wearing the hijab(headscarves) with their two hands usually place the pin between their lips or teeth, and actions viz speaking, laughing coughing or a momentary lapse of concentration leads to accidental pin aspiration. These cases have been previously grouped as “turban pin syndrome” or “hijab syndrome” [8]. However unlike other foreign body aspiration, the metallic pins are more likely to get impacted into the left main bronchus owing to Bernoulli’s phenomenon [2]. Laughing, or speaking generates larger negative pressure at the narrower left bronchus than right main bronchus, and this appears to outweigh the anatomic predominance of right bronchus in the case of metallic pin aspiration.1 The design of the hijab pin which consist 3 parts: a head made of round plastic bead,a long narrow body and a tapering pointed end. Due to this design, the head end of the pin owing to its heavy weight tends to point downward during an event of accidental aspiration. There is always a possibility of the sharp end abrading the airway mucosa and piercing through the tracheobronchial tree leading to lethal complications [6]. Diagnosis is simple as these pins can be easily detected on a plain X ray chest. Sometimes in addition an HRCT chest with 3d reconstruction (Virtual Bronchoscopy) can be performed to pinpoint the exact location of impaction. However, it is not always mandatory and depends on the Surgeon’s preference, general condition of patient and time of presentation. Various factors that determine patients’ morbidity include the site of pin lodgment, the time from aspiration to intervention and the surgeon’s experience and skills [9]. Longer the time interval between the accidental aspiration of the pin and intervention, greater are the chances of edema setting in along with increased secretions and foreign body granuloma formation further complicating the foreign body removal process [10]. Various methods to remove tracheobronchial foreign body include flexible fiberoptic bronchoscopy, rigid bronchoscopy and in some case cases thoracotomy may be required if therapeutic endoscopic procedure fails. Thoracotomy rates varied from 1.6 to 7% and were performed in cases after failure of therapeutic bronchoscopy procedure [2, 3]. In some rare instances, magnets have also been utilized to extract metallic foreign body [11]. Performing a rigid bronchoscopy in the left main bronchus can be technically challenging in comparison to right side owing to its horizontal orientation and slightly narrow diameter. Various surgical maneuvers like turning the head to the right side, using a smaller size bronchoscope, or pulling out the foreign body from left main bronchus till carina and slightly pushing it towards right main bronchus and reattempting to remove it can aid in the foreign body removal from left main bronchus easier. Prior to removing a sharp hijab pin, it should be borne in mind that the sharp end should be lying freely and not piercing any part of the tracheobronchial tree or else it may lead to a tear in its wall and pave way for fatal complications. In such an instance thoracotomy can be considered as a safer option [12].

Conclusion

Accidental aspiration of sharp metallic pin can lead to lethal consequences if not intervened timely. Appropriate approach (bronchoscopy or open thoracotomy) is decided based on the location and orientation of the pin in the airway and condition of the patient. We presented 3 different challenging cases of accidental hijab pin aspiration and its subsequent removal utilizing different approaches. Our experience with these cases has taught us that special precautions must be taken prior to attempting sharp foreign body removal. A team approach with Pediatric Surgeons or Cardiothoracic surgeons, Pulmonologists and Pediatric Anesthetist is advisable. Lastly public awareness is also essential to reduce these incidents.

Summary of the cases
Case no	Age & Sex	Time of presentation at our centre since foreign body aspiration	Clinical features	Radiological Findings/Diagnostic bronchoscopy findings	Number of bronchosc-opies attempted at our centre	Final mode of foreign body removal
1	13 Years/F*	After 3 h	Cough,chest pain,tachypnea,tachycardia	Chest X ray showed a metallic foreign body in left main bronchus. Normal appearance of Bilateral lung field	1	Bronchoscopy
2	12 Years/F*	After 15 days	Cough, Reduced air entry over lung field along with crepitations	HRCT chest showed a foreign body impacted at the left lingula	3	Thoracotomy
3	13 Years/F*	After 4 days	Cough	Flexible Bronchoscopy showed a pin in left lower bronchus	2	Thoracotomy with rigid bronchoscopy
4	12 Years/F*	After 3 days	Cough, Reduced air entry over left lung field	HRCT chest showed a metallic foreign body lodged in left main bronchus. Repeat CT scan showed no evidence of foreign body	1	? Spontaneous expulsion in cough

F* = Female.

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures involving human participants were in accordance with the ethical standards of the institution.

Informed Consent

Informed consent was obtained from the individual participant. Informed consent was obtained from legal guardians. The legal guardian of the participant have consented to the submission of case report to the journal.