A memorable patient: A plastic plug resurfaces
Authors: J. Newbury
Journal: BMJ (2000)

In 1984 an 8 year old boy was rushed into our general practice from school with a sudden onset of a violent cough. His teacher had noticed him chewing his ballpoint pen immediately before the coughing spasm. He denied that he had inhaled a piece of the pen. His distress was so marked that she called an ambulance. I initially treated him with nebulised salbutamol which partly relieved his cough. He had no history of asthma and I was perplexed at what had caused this coughing spasm.When he had calmed down considerably I asked if he had inhaled a part of his pen. He said that he had had the plastic plug from the end of the barrel of a biro in his mouth when it suddenly disappeared. I then arranged transfer to a tertiary paediatric hospital for definitive management of a presumed aspirated foreign body.

Aspiration of a foreign body into the lungs is a relatively common occurrence in childhood. The age of peak incidence is less than 3 years and the diagnosis is made more difficult as the “actual event of aspiration is frequently not witnessed.”1 My patient was older at 8 years but similarly had an indefinite history.

His symptoms had resolved in the several hours it took to reach the capital city referral centre. He was investigated with inspiratory and expiratory chest x ray examinations, bronchoscopy, and a lung scan. In 1984 these were the only investigations available. No evidence of an aspirated foreign body was found and he remained symptom free. He was discharged home with a diagnosis of no foreign body in his lungs.

Difficulties in diagnosis still persist despite improvements in imaging techniques and flow charts to guide diagnosis.2 Serious consequences occur with either acute respiratory distress or complications as a consequence of delayed diagnosis. Extraction becomes more difficult with delays in diagnosis. In one series of 94 cases, 30% of admissions for definite treatment occurred three days or more after aspiration and one death resulted.3

I next saw him one month later with a few days of mild cough. Examination showed no chest signs. Four months later he represented with intermittent cough. Repeat inspiratory and expiratory chest x ray examinations were again normal. At this time I prescribed oral theophylline.

Twenty one months later he presented to one of my partners with upper respiratory tract symptoms. He was noted to be wheezy. A viral infection was diagnosed and a salbutamol metered dose inhaler was prescribed.

More than three years after the initial event he fell into a lake while canoeing. He aspirated some water and another coughing spasm started. The following day he expectorated the plastic plug. Three years and three months had passed since the initial presumed aspiration event and he was now aged 12. He and his mother came to my surgery the next day to show me the plastic plug (approximately 5 mm × 5 mm).

General practice provides an opportunity to follow patients for prolonged periods of time. Despite minor symptoms this child remained in good health with an unrecognised pulmonary foreign body for over three years. Subsequently another event precipitated a coughing spasm. I presumed the growth in diameter of his bronchi enabled this violent coughing spasm to dislodge the plastic plug.