A previously healthy 18-month-old girl presented to a local hospital with a 2-day history of dry cough, hoarse voice and difficulty breathing. There was no history of aspiration. Despite therapy with nebulized budesonide (4 mg/d, twice daily) and oral dextromethorphan syrup (1 mg/kg/d, twice daily) for 2 days for presumed croup, the patient’s respiratory status did not improve and she was referred to our institution. Stable vital signs, biphasic stridor, increased work of breathing and intercostal retractions (for a video, see Appendix 1 at www.cmaj.ca/lookup/doi/10.1503/cmaj.220544/tab-related-content) prompted further investigations for a foreign body. Computed tomography of her neck and chest showed normal findings. On day 2, a flexible bronchoscopy examination found a thin, sharp shell of a sunflower seed embedded in the patient’s subglottic airway, which was removed with a grasping basket (Figure 1A and 1B). We discharged her on day 6 with complete, uneventful recovery.
Foreign body aspiration accounts for 7% of accidental deaths in children aged 4 years and younger.1 Upper airway foreign body aspiration often manifests with stridor that can mimic croup. This patient presented with biphasic stridor owing to a fixed airflow obstruction from a shell of a sunflower seed. Nuts and seeds are the most commonly aspirated foreign bodies and should be avoided for children aged 4 years and younger. Oral dexamethasone is recommended for children with croup, although inhaled budesonide was chosen in this case.2,3 The antitussive dextromethorphan, available in many over-the-counter cough and cold preparations, is not suggested for use in children aged 6 years and younger in Canada.4 Computed tomography has been used to identify airway foreign bodies, but has notable radiation exposure and may not identify small radiolucent objects; bronchoscopy is the definitive test and facilitates removal.5
Upper airway obstruction from inhaled foreign bodies should be considered in children presenting with fixed or biphasic stridor, or stridor unresponsive to typical therapy for croup.
Footnotes
Competing interests: None declared.
This article has been peer reviewed.
The authors have obtained parental consent.
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