www.elsevier.com/locate/jpedsurg

Successful bronchoscopic retrieval of Timothy grassfrom the airway

Ahmed Nasra, Vito Forteb, Jacob Friedbergb, Jacob C. Langera,*

aDepartment of Surgery, Hospital for Sick Children, Toronto, Ontario, Canada M5G 1X8bDepartment of Otolaryngology, Hospital for Sick Children, Toronto, Ontario, Canada M5G 1X8

Revised 14 October 2004

1531-5037/05/4004-0046$30.00/0 D 20

doi:10.1016/j.jpedsurg.2005.01.028

T Corresponding author. Tel.: +1 416

E-mail address: jacob.langer@sickk

Index words:Timothy grass;

Foreign body aspiration;

Bronchoscopy

Abstract Aspiration of Timothy grass in the airway is a well-recognized cause of bronchiectasis, and

management often requires pulmonary resection. The authors describe 2 cases of Timothy grass

aspiration with established pulmonary infection that were successfully managed by bronchoscopic

removal with subsequent improvement. Every effort should be made to accomplish this goal, and

pulmonary resection should be considered a last resort in these cases.

D 2005 Elsevier Inc. All rights reserved.

nse) is commonly found in grass aspiration were successfully managed by broncho-

Timothy grass (Phleum prate

North America. This plant is highly allergenic and is also a

common cause of foreign body aspiration in the airway.

Timothy grass occupies a special position among foreign

bodies because the spikelets project off the head at an acute

angle, which acts as a barb, preventing expectoration and

encouraging progression more distally into the airway. The

head of the Timothy grass plant often migrates into the distal

bronchus and has a predilection to burrow deep beyond the

reach of the bronchoscope. There is often not a reliable

witness to supply the clinical history, especially in children,

and the progression of the problem is usually insidious.

When diagnosis is delayed, complications of retained

Timothy grass such as unresolving pneumonia, recurrent

asthmatic attacks, lung abscess, recurrent hemoptysis, and

bronchiectasis may necessitate surgical intervention, usually

requiring pulmonary lobectomy.

We report 2 cases in which a chronic history of

bronchiectasis and pneumonia resulting from Timothy

05 Elsevier Inc. All rights reserved.

813 6405; fax: +1 416 813 7477.

ids.ca (J.C. Langer ).

scopic removal.

1. Case reports

1.1. Case 1

A 1-year-old boy was well until 5 months before

admission when he was hospitalized in another hospital

because of right lower lobe pneumonia. Two days before

admission he developed fever and nasal discharge. Later

that day he vomited blood, passed melena, and presented to

the hospital. Widespread inspiratory and expiratory rhonchi

were heard over the lung fields. He was transfused and over

the next 12 hours his gastrointestinal bleeding stopped.

Chest radiograph showed pneumonia in the right lower lobe.

The possibility of bronchiectasis, possibly because of a

foreign body, was suspected.

Under general anesthesia, a 3.5 � 30 fiberoptic bron-

choscope was passed. There was a thick whitish discharge in

the right lower bronchus and a foreign body was seen

protruding from one of the segmental bronchi. Attempt was

Journal of Pediatric Surgery (2005) 40, E39–E41

Fig. 1 Computerized tomography from case 2 showing bron-

chiectasis involving the anterior segment of the right lower lobe.

ig. 3 Piece of Timothy grass removed from the right lower lobe

case 2.

A. Nasr et al.E40

made to aspirate the foreign body with opened-ended

suction, resulting in several small pieces of what initially

appeared to be a peanut. A foreign body forceps was then

used and a 2-in long piece of Timothy grass was

successfully extracted.

Three days postoperatively, chest x-ray showed consol-

idation in the right lower lobe with a more lined appearance

suggestive of a clearing pneumonia. Six months later he was

asymptomatic and his radiograph showed resolution of the

bronchiectasis. The cause of the initial gastrointestinal

bleeding was never elucidated and did not recur.

1.2. Case 2

An 8-year-old boy was referred with a prolonged history

of right lower lobe pneumonia and chronic cough, which

Fig. 2 Bronchoscopic view of the right lower lobe bronchus

from case 2 showing granulation tissue and fibrin-coated

foreign material.

Fin

started after a fall while running in a farmer’s field 6 months

previously. He was treated with a course of antibiotics, but

symptoms of fever and cough persisted. After giving

another course of antibiotics the fever resolved, leaving an

unresolving dry cough and decrease in energy level. He had

fine crackles over the chest but no respiratory distress.

Blood work was normal. Immunoglobulins G, A, M, and E

were normal. Investigations for tuberculosis, histoplasmosis,

and blastomycosis were all negative. His chest x-ray showed

slightly decreased air entry on the right side. Spirometry

results revealed forced respiratory function in 1 second of

84% predicted and forced vital capacity of 94% predicted

suggesting a mild obstructive pattern. Computed tomogra-

phy scan showed prominent right hilar lymph nodes along

with right lower lobe outer segment consolidation. The

consolidation measured 3 to 4 cm (Fig. 1).

A flexible 5 � 30 bronchoscope was introduced and

revealed only some pus and hyperemia of the right lobe.

Bronchioalveolar lavage showed mixed organisms. The

child was referred for pulmonary resection.

Before planned lobectomy, rigid bronchoscopy was

performed. Granulation tissue was noted in the right postero-

basal segment of the lower lobe (Fig. 2). Sample of secretions

was sent for culture and sensitivity. Microalligator forceps

were used under optical vision with the bronchoscope to

remove a 4-cm piece of Timothy grass (Fig. 3).

Postoperatively, his cough has resolved and he has not

had any recurrent episodes of fever. Follow-up chest

radiograph showed significant improvement in the right

lower lobe consolidation. One year postoperatively he was

asymptomatic and his chest radiograph was normal.

2. Discussion

In children, foreign body aspiration typically occurs in

otherwise healthy individuals. By contrast, adults frequently

have an underlying condition associated with impairment of

airway protection, such as neurologic disorders [1]. Foreign

Successful bronchoscopic retrieval of Timothy grass from the airway E41

body aspiration is most difficult to diagnose in infants and

small children. A history of choking cannot always be

obtained from parents [2]. Despite this, the history is often

the most important method used in making the diagnosis of

foreign body aspiration. After foreign body aspiration the

child may present intense coughing, wheezing, vomiting,

pallor, and even cyanosis or short episode of apnea. After

these initial episodes, the symptoms may eventually dis-

appear completely, leading to the impression that the object

was expelled by coughing or was swallowed. A delay in

diagnosis can lead to significant morbidity, with ongoing

treatment of pneumonia and asthma, which may give tem-

porary relief of symptoms but fail to correct the underlying

problem [3,4]. The diagnosis should be suspected in any

child with pneumonia that is not responding to treatment,

and bronchoscopy should be performed [5].

Investigators have reported inhalation of the flowering

heads of various grasses [6,7]. Some of these grasses, such as

Timothy grass, possess inflorescences with well-developed

terminal spikes that project proximally toward the larger

airways, causing the spike to migrate into the lung periphery.

As a result, early diagnosis is important before the grass

progresses beyond the reach of a bronchoscope and becomes

enveloped in granulation tissue. Sometimes this migration

may be so extensive that the grass spike traverses the pleural

space and is eventually extruded through the skin [8,9]. In

other cases, aspiration of Timothy grass may lead to

irreparable pulmonary damage [6].

There are very few data in the English literature

regarding Timothy grass aspiration. Jewett at al [6] reported

3 cases, 2 of whom underwent lobectomy. In the third case,

bronchoscopy was successful in removing the grass. There

are more data regarding aspiration of other grass inflo-

rescences. Merriam et al [7] reported 4 cases of grass aspi-

ration; Williams and Phlen [10] reported another 8 cases;

and Godfrey [11] reported 2 cases. In all cases, pulmonary

resection was done. Woolley [12] reported 3 cases, of which

2 were retrieved by bronchoscopy and the third case

required pulmonary resection.

Traditionally, rigid bronchoscopy has been the procedure

of choice for the removal of foreign bodies in children [13].

The main advantage of the rigid bronchoscope in children is

the ability to ventilate through it during removal of the

foreign body [14]. A wide range of sizes, improved optical

telescopes, and the large array of ancillary instruments to

retrieve foreign bodies have made rigid bronchoscopy the

preferred technique for retrieval of foreign bodies in

pediatric patients [14,15]. Some authors suggest that if rigid

bronchoscopy does not reveal a foreign body, flexible bron-

choscopy should be performed because it allows inspection

of more distal airways [16]. Others propose using diagnostic

flexible bronchoscopy as a first procedure if there is no

evidence of a foreign body from physical and radiographic

findings [17]. Mehta and Rafanan [18] conducted a

prospective study in 83 children with suspected foreign

body aspiration and recommended rigid bronchoscopy as

the first step if asphyxia, radio-opaque foreign body, or

obstructive emphysema is present, and flexible bronchos-

copy as the first step in all other cases.

Based on our experience, any previously normal child

presenting with acute respiratory tract infection in the

summer months when Timothy and other types of grass

reach fruition should be viewed for foreign body aspiration,

particularly if the infection is accompanied by severe

coughing and wheezing. A careful history should be taken

to elicit the possibility of inhalation of a grass head.

Bronchoscopy should be done to both diagnose the foreign

body aspiration and to remove the piece of grass, even if the

history is chronic and established bronchiectasis and

pneumonia exists. It is unclear whether rigid or flexible

bronchoscopy is better for this purpose, but both should be

tried if the first one is unsuccessful. Pulmonary resection

should be a last resort for the management of this problem.

References

[1] Limper AH, Prakash UB. Tracheobronchial foreign bodies in adults.

Ann Intern Med 1990;112:604-9.

[2] Weissberg D, Schwartz I. Foreign bodies in the tracheobronchial tree.

Chest 1987;91:730 -3.

[3] Mantor PC, Tuggle DW, Tunell WP. An appropriate negative

bronchoscopy rate in suspected foreign body aspiration. Am J Surg

1989;158:622-4.

[4] Fraga JC, Neto AM, Seitz E, et al. Bronchoscopy and tracheotomy

removal of bronchial foreign body. J Pediatr Surg 2002;37:1239-40.

[5] Cataneo AJ, Reibscheid SM, Ruiz Jr RL, et al. Foreign body in the

tracheobronchial tree. Clin Pediatr (Phila) 1997;36:701 -6.

[6] Jewett TC, Butsch WL. Trials with treacherous timothy grass.

J Thorac Cardiovasc Surg 1965;50:124-6.

[7] Merriam JC, Storrs RC, Hoefnagel D. Lung disease caused by

aspirated timothy grass heads. Am Rev Respir Dis 1964;90:947 -52.

[8] Cavens TR, McGee MD, Miller RR, et al. Pneumocutaneous fistula

secondary to aspiration of grass. J Pediatr 1973;82:737-8.

[9] Hilman BC, Kurzweg FT, McCook WW, et al. Foreign body aspiration

of grass inflorescences as a cause of hemoptysis. Chest 1980;78:306-9.

[10] William HE, Phelan PD. The missed inhaled foreign body in children.

Med J Aust 1969;1:625 -38.

[11] Godfrey RC. The behavior of inhaled grass inflorescences. Lancet

1957;2:273-4.

[12] Woolley Jr PV. Grass inflorescences as foreign bodies in the respi-

ratory tract. J Pediatr 1955;46:704-6.

[13] Pasaoglu I, Dogan R, Demircin M, et al. Bronchoscopic removal of

foreign bodies in children: retrospective analysis of 822 cases. Thorac

Cardiovasc Surg 1991;39:95 -8.

[14] Martinot A, Closset M, Marquette CH, et al. Indications for flexible

versus rigid bronchoscopy in children with suspected foreign body

aspiration. Am J Respir Crit Care Med 1997;155:1676 -9.

[15] Swanson KL, Midthun DE, Utz JP, et al. Flexible bronchoscopic

management of airway foreign bodies in children. Chest 2002;121:

1695-700.

[16] Perez CR, Wood RE. Update on pediatric flexible bronchoscopy.

Pediatr Clin North Am 1994;41:385-400.

[17] Wood RE, Gauderer WL. Flexible fiberoptic bronchoscopy in the

management of tracheo bronchial foreign bodies in children: the value

of a combined approach with open tube bronchoscopy. J Pediatr Surg

1984;19:693 -4.

[18] Mehta AC, Rafanan AL. Extraction of airway foreign body in adults.

J Bronchol 2001;8:123 -32.