ABSTRACT
Foreign body aspiration (FBA) is a common pediatric emergency. Sharp objects, such as pins, pose a unique risk of perforation and migration. Differentiating aspiration from ingestion can be challenging when symptoms and radiological findings overlap, particularly for objects lodged in the mediastinum—a “mediastinal dilemma.” We present two cases of sharp FBA in school‐aged children. Case 1: A 10‐year‐old girl presented with acute chest pain after inhaling a headscarf pin. Chest X‐ray showed a mediastinal radio‐opaque shadow, creating a diagnostic dilemma. Sequential endoscopy (negative esophagoscopy followed by rigid bronchoscopy) confirmed and removed the pin from the left main bronchus. Case 2: A 14‐year‐old boy presented with delayed hemoptysis 2 months after aspirating a sewing needle. Initial rigid bronchoscopy was unsuccessful, necessitating flexible bronchoscopy for retrieval from the peripheral left upper lobe. These cases highlight that sharp FBA can occur in older children and may present with atypical, delayed symptoms. The mediastinal location on radiography often blurs the line between aspiration and ingestion. A high index of suspicion is paramount. The choice of endoscopic technique (rigid vs. flexible) must be tailored to the foreign body's location and nature. This series underscores the need for heightened awareness of this preventable hazard, particularly regarding the risk of holding objects between the lips.
Keywords: diagnostic dilemma, flexible bronchoscopy, foreign body aspiration, hemoptysis, pediatric emergency, rigid bronchoscopy
Key Clinical Message
Consider sharp foreign body aspiration in children with unexplained respiratory symptoms. Mediastinal objects pose a diagnostic challenge. A high index of suspicion and a tailored endoscopic approach are crucial for safe removal.
Abbreviations
- FBA
foreign body aspiration
- SFB
sharp foreign bodies
1. Introduction
Foreign body aspiration (FBA) remains a leading cause of accidental injury and mortality in children, with the highest incidence in those under 3 years of age [1]. While most aspirated objects are organic materials like nuts and seeds [2], inorganic sharp foreign bodies (SFBs)—including pins, needles, and nails—are associated with a significantly higher risk of complications such as pneumothorax, bronchial perforation, and vascular erosion [3, 4].
The clinical presentation of SFB aspiration can be variable. Acute choking is classic, but cases with smaller or peripherally located objects may have a subtle or delayed onset, mimicking conditions like asthma [5]. A key diagnostic challenge arises when a radio‐opaque SFB appears in the mediastinum on chest radiograph. In this location, it is radiologically difficult to distinguish definitively between an esophageal and a tracheobronchial object, as both can cause symptoms like odynophagia and chest pain [6]. This “mediastinal dilemma” can delay management.
We present a two‐case series of sewing pin aspiration in school‐aged children that illustrates this diagnostic challenge and the spectrum of clinical presentation—from an acute event to a delayed complication. These cases, occurring in an older pediatric demographic often considered lower risk, underscore the importance of a meticulous history and the strategic selection of endoscopic technique.
2. Case History/Examination
2.1. Case 1
A previously healthy 10‐year‐old girl presented to the emergency department with acute‐onset cough and subsequent sharp, retrosternal chest pain exacerbated by deep inspiration and swallowing. The history revealed she had been holding a metallic headscarf pin between her lips while adjusting her headscarf and inadvertently inhaled it. Examination revealed stable vital signs and unremarkable cardiorespiratory auscultation.
2.2. Case 2
A 14‐year‐old boy presented to the outpatient clinic with a four‐day history of cough and intermittent hemoptysis (blood‐streaked sputum). He was afebrile and reported no dyspnea. Upon direct questioning, he recalled an aspiration event 2 months prior: while holding three blunt‐tip sewing needles between his lips during a craft activity, he inhaled suddenly. A transient cough resolved, and as two needles fell from his mouth, he assumed all three had been expelled or swallowed, leading him not to seek care until hemoptysis occurred. Examination revealed localized wheezing over the left hemithorax.
3. Differential Diagnosis, Investigations, and Treatment
3.1. Case 1
Chest radiography (posterior–anterior and lateral views) showed a linear, radio‐opaque foreign body projected over the mediastinum, with no pneumothorax (Figure 1). Given the symptoms and radiographic location, both esophageal and bronchial impaction were considered.
FIGURE 1.
(Case 1) Pre‐operative chest radiograph (posterior–anterior view) demonstrating a linear, radio‐opaque foreign body (headscarf pin) projected over the mediastinum.
3.2. Case 2
Chest X‐ray localized a radio‐opaque needle within the left upper lobe bronchus (Figure 2).
FIGURE 2.
(Case 2) Pre‐operative chest radiographs. (A) Posterior–anterior view showing a linear, radio‐opaque foreign body (sewing needle) within the left lung field (white arrow). (B) Lateral view confirming the needle's location in the region of the left upper lobe bronchus.
4. Conclusion and Results (Outcome and Follow‐Up)
4.1. Case 1
Under general anesthesia, a systematic endoscopic approach was employed. Initial esophagoscopy was negative. Subsequent rigid bronchoscopy identified the pin lodged in the left main bronchus, with its sharp tip embedded in the mucosa. The pin was successfully disimpacted and removed in its entirety using grasping forceps (Figure 3). The patient received standard post‐procedure monitoring and was discharged after 24 h of uneventful observation.
FIGURE 3.
(Case 1) Intraoperative view during rigid bronchoscopy. The metallic headscarf pin is visualized lodged in the left main bronchus and is being grasped by forceps for removal.
4.2. Case 2
The patient underwent endoscopic retrieval. Initial rigid bronchoscopy failed to access the peripheral segmental bronchus. The procedure was converted to flexible bronchoscopy, which visualized the needle in the left upper lobe bronchus, surrounded by inflamed and ulcerated mucosa (Figure 4). It was successfully retrieved with flexible forceps. A thorough radiographic evaluation confirmed the absence of the other two needles. A post‐procedure ultrasound ruled out complications. He was discharged after 48 h following symptom resolution, having received analgesia as needed; antibiotics were not administered in the absence of signs of active infection.
FIGURE 4.
(Case 2) Intraoperative view during flexible bronchoscopy. The blunt‐tip sewing needle is seen embedded within the inflamed mucosa of a segmental bronchus in the left upper lobe, immediately prior to retrieval.
5. Discussion
This series highlights the diagnostic and therapeutic nuances of sharp FBA in children, emphasizing the “mediastinal dilemma” and the need for tailored intervention. Our cases, involving similar objects but differing in presentation (acute vs. delayed) and location (central vs. peripheral), offer practical insights.
The central challenge, exemplified in Case 1, is differentiating aspiration from ingestion when a radio‐opaque object projects over the mediastinum. Symptoms like odynophagia and retrosternal pain are nonspecific [6]. In such scenarios, a structured diagnostic algorithm is valuable. While some advocate for preoperative CT for precise localization [7], we employed a sequential endoscopic approach: beginning with lower‐risk esophagoscopy. A negative result promptly directed us to rigid bronchoscopy, the gold standard for central airway FB removal due to its superior airway control and instrumental versatility [4, 8].
Case 2 underscores the risks of delayed presentation, often due to patient or family misinterpretation of the event. The assumption that an aspirated object was “swallowed” is common and dangerous. Delayed diagnosis can lead to complications like bronchiectasis, abscess, or mucosal erosion and hemoptysis [5, 9]. This case also illustrates the technical pivot required based on FB location. While rigid bronchoscopy is optimal for proximal FBs, its utility diminishes in segmental bronchi. Flexible bronchoscopy becomes indispensable for navigating peripheral airways, as demonstrated [10]. The finding of contralateral secretions highlights the chronic, localized inflammatory response even a unilateral FB can provoke.
A critical, under‐recognized commonality is the behavioral context: both children used their lips as a temporary holder during a focused activity. This specific risk behavior in school‐aged children and adolescents—a group often perceived as beyond the typical age for FBA [1]—represents a key gap in preventive education. Public health messaging must expand to warn older children and parents about the dangers of holding any object in the mouth.
5.1. Suggested Diagnostic Approach
Based on our experience and the literature, we propose a simplified algorithm for suspected sharp FB aspiration/ingestion: (1) Detailed history and physical exam; (2) PA/lateral chest X‐ray; and (3) If mediastinal and symptomatic, proceed to endoscopic evaluation under general anesthesia. The choice of initial endoscopy (esophageal vs. bronchial) may be guided by predominant symptoms (e.g., odynophagia favors starting with esophagoscopy), with a low threshold to proceed to the other modality if the first is negative. For peripherally located FBs on imaging, flexible bronchoscopy should be the primary or readily available backup option.
This series demonstrates that sharp foreign body aspiration must be considered in children of all ages with acute or persistent respiratory symptoms, even without a clear initial history. The mediastinal localization of such objects creates a significant diagnostic overlap with ingestion. A high index of suspicion, a meticulous history focusing on risk behaviors, and a flexible, two‐pronged endoscopic strategy are crucial for timely and safe management. These cases serve as a critical reminder for enhanced preventive counseling against the habit of holding objects in the mouth.
Author Contributions
Seyed Javad Seyedi: conceptualization, investigation, resources, writing – original draft, writing – review and editing. Ahmad Mohammadipour: resources, visualization, writing – original draft, writing – review and editing. Amin Saeidinia: formal analysis, resources, writing – original draft, writing – review and editing.
Funding
The authors have nothing to report.
Ethics Statement
This case presentation is performed according to ethical guidelines of Mashhad University of Medical Sciences.
Consent
Patient was evaluated for her problem and her parents fulfilled informed consent for participation. Written informed consent for the publication of this case report and any accompanying images was obtained from the patient's legal guardian (parents). The consent form included permission to publish clinical data and imaging details in accordance with the journal's policies on patient confidentiality and privacy.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
The authors have nothing to report.
Seyedi S. J., Mohammadipour A., and Saeidinia A., “The Diagnostic Challenge of Sharp Foreign Body Aspiration in Children: A Two‐Case Series Highlighting Ingestion vs. Aspiration,” Clinical Case Reports 14, no. 2 (2026): e71844, 10.1002/ccr3.71844.
Data Availability Statement
The data that support the findings of this study are available from Ghaem Hospital, Mashhad University of Medical Sciences, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the corresponding author.
References
- 1. Fidkowski C. W., Zheng H., and Firth P. G., “The Anesthetic Considerations of Tracheobronchial Foreign Bodies in Children: A Literature Review of 12,979 Cases,” Anesthesia & Analgesia 111, no. 4 (2010): 1016–1025. [DOI] [PubMed] [Google Scholar]
- 2. Tan H. K., Brown K., McGill T., Kenna M. A., Lund D. P., and Healy G. B., “Airway Foreign Bodies (FB): A 10‐Year Review,” International Journal of Pediatric Otorhinolaryngology 56, no. 2 (2000): 91–99. [DOI] [PubMed] [Google Scholar]
- 3. Dikensoy O., Usalan C., and Filiz A., “Foreign Body Aspiration: Clinical Utility of Flexible Bronchoscopy,” Postgraduate Medical Journal 78, no. 921 (2002): 399–403. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Zaytoun G. M., Rouadi P. W., and Baki D. H. A., “Endoscopic Management of Foreign Bodies in the Tracheobronchial Tree: Predictive Factors for Complications,” Otolaryngology and Head and Neck Surgery 123, no. 3 (2000): 311–316. [DOI] [PubMed] [Google Scholar]
- 5. Rance A., Mittaine M., Michelet M., Blondel A. M., and Labouret G., “Delayed Diagnosis of Foreign Body Aspiration in Children,” Archives de Pédiatrie 29, no. 6 (2022): 424–428. [DOI] [PubMed] [Google Scholar]
- 6. Gang W., Zhengxia P., Hongbo L., et al., “Diagnosis and Treatment of Tracheobronchial Foreign Bodies in 1024 Children,” Journal of Pediatric Surgery 47, no. 11 (2012): 2004–2010. [DOI] [PubMed] [Google Scholar]
- 7. Shen J., Huang L., and Hao C., “Value of Multi‐Slice Spiral Computed Tomography for Diagnosis of Tracheobronchial Foreign Body Aspiration in Children: 5‐Year Retrospective Study,” Pediatrics International 62, no. 10 (2020): 1184–1188. [DOI] [PubMed] [Google Scholar]
- 8. Swanson K. L. and Edell E. S., “Tracheobronchial Foreign Bodies,” Chest Surgery Clinics of North America 11, no. 4 (2001): 861–872. [PubMed] [Google Scholar]
- 9. Karatzanis A., Vardouniotis A., Moschandreas J., et al., “The Risk of Foreign Body Aspiration in Children Can Be Reduced With Proper Education of the General Population,” International Journal of Pediatric Otorhinolaryngology 71, no. 2 (2007): 311–315. [DOI] [PubMed] [Google Scholar]
- 10. Hewlett J. C., Rickman O. B., Lentz R. J., Prakash U. B., and Maldonado F., “Foreign Body Aspiration in Adult Airways: Therapeutic Approach,” Journal of Thoracic Disease 9, no. 9 (2017): 3398–3409. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from Ghaem Hospital, Mashhad University of Medical Sciences, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the corresponding author.