International Journal of Pediatric Otorhinolaryngology 100 (2017) 232e237

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International Journal of Pediatric Otorhinolaryngology

journal homepage: http://www.ijporlonline.com/

The multivariate analysis of indications of rigid bronchoscopy in

suspected foreign body aspiration
E. Divarci*, B. Toker, Z. Dokumcu, A. Musayev, C. Ozcan, A. Erdener
Ege University Faculty of Medicine, Department of Pediatric Surgery, Izmir, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Objective: Foreign body aspiration (FBA) could be a serious life-threatening condition in children. Pa-
Received 14 April 2017 tients usually underwent bronchoscopy with suspicious of FBA alone. In this study, we aimed to
Received in revised form determine which patients need to go to bronchoscopy based on pre-operative findings.
11 July 2017
Methods: Retrospective analysis of patients underwent bronchoscopy between 1999 and 2015 was
Accepted 12 July 2017
performed. Clinical symptoms, witnessed aspiration event (WAE), physical examination findings (PEFs)
Available online 14 July 2017
and radiological findings (RFs) were analyzed by multivariate analysis to evaluate the indications of
bronchoscopy.
Keywords:
Foreign body aspiration
Results: 431 patients (266M, 165F) underwent bronchoscopy with a median age of 2 years (7 months-16
Bronchoscopy years). A foreign body was detected in 68% of the patients. Univariate analysis demonstrated that wheeze
Rigid bronchoscopy was the sole distinctive clinical symptom for detection of FBA (p<0.001). The rates of positive WAE, PEFs
Children and RFs were 83%, 71.7% and 36.9%, respectively. All of them were identified as independent predictive
parameters in the detection of FBA by univariate analysis (p ¼ 0.003&p<0.001&p ¼ 0.015). Multivariate
analysis was performed with considering the association between them. The rate of positive bron-
choscopy was 91.3% in patients with positive WAE, PEFs and RFs together(84/92). In patients with a
positive WAE alone who had not got PEFs and RFs, the rate of positive bronchoscopy was 34.2% (25/73). A
foreign body was detected in 84% of the patients who had not got a WAE but positive PEFs and RFs
together(21/25). Bronchial laceration was occurred in one patient during bronchoscopy. Pneumothorax
was not seen in any of the other patients. The rate of mortality was 0.4% in the overall group (2 patients).
Conclusion: The indications of bronchoscopy in suspected FBA are usually based on clinical suspicious.
The definition of “ suspicous” could be a WAE or positive PEFs and RFs. The association of these factors
increase the rate of positive bronchoscopies. In the light of our study, the classical indication for sus-
pected FBA is still valid as “suspicious requires bronchoscopy”.
© 2017 Published by Elsevier Ireland Ltd.

1. Introduction could be seen as a result of late diagnosis of FBA, and occasionally

Foreign body aspiration (FBA) is a serious and common health
problem in childhood which could cause significant morbidities
and even mortality [1e5]. The types of aspirated foreign bodies
could be varied according to the social and cultural characteristics
and feeding habits of the parents and children [6]. Recurrent res-
piratory disorders such as atelectasis, pneumonia or bronchiectasis
* Corresponding author. Ege University Faculty of Medicine, Department of Pe-
diatric Surgery, 35100 Bornova, Izmir, Turkey.
E-mail addresses: emre.divarci@ege.edu.tr, e.divarci@gmail.com (E. Divarci),
badetoker@gmail.com (B. Toker), z.dokumcu@gmail.com (Z. Dokumcu),
allahverdi79@gmail.com (A. Musayev), coskunozcan11@gmail.com (C. Ozcan), ata.
erdener@ege.edu.tr (A. Erdener).
requires surgical procedures like segmentectomy or lobectomy [7].
Therefore, an aggressive diagnostic approach which comprised
rigid bronchoscopy under general anesthesia is usually advised to
avoid overlooking the definite diagnosis of FBA [8,9].
The extended indications for rigid bronchoscopy result with a
high percentage of negative bronchoscopies in children [10]. Pa-
tients underwent bronchoscopy usually with a witnessed aspira-
tion event for FBA alone. Is it really sufficient to perform a surgical
procedure in a suspected child who has not got any clinical and/or
radiological problems? Also, another substantial dilemma is in
suspected patients without a witnessed aspiration event but have
positive physical or radiological findings for FBA. Is it necessary to
perform bronchoscopy in such cases without any aspiration his-
tory? In this study, we aimed to present our surgical experience in

http://dx.doi.org/10.1016/j.ijporl.2017.07.012
0165-5876/© 2017 Published by Elsevier Ireland Ltd.
 E. Divarci et al. / International Journal of Pediatric Otorhinolaryngology 100 (2017) 232e237
suspected foreign body aspiration in more than four hundred cases
to answer these substantial questions by univariate and multivar-
iate analysis to review and if necessary to revise the indications for
rigid bronchoscopy in children.
2. Material and methods
Retrospective analysis of patients who underwent rigid bron-
choscopy due to a suspected foreign body aspiration (FBA) between
1999 and 2015 was performed. Data regarding age, sex, aspiration
period before admission, witnessed aspiration event (WAE), clinical
symptoms including cough, wheezing, dyspnea and cyanosis,
physical examination findings (PEFs) including unilateral decreased
breath sounds, dyspnea, wheezing and stridor, radiological findings
(RFs) including hyperaeration, pulmonary infiltration and atelec-
tasis, operative findings and complications were reviewed. Postero-
anterior chest radiograph was achieved in all of the patients before
and after bronchoscopy.
Patients underwent rigid bronchoscopy under general anes-
thesia by using ventilation type rigid bronchoscopes (Karl Storz Co.,
Tuttlingen, Germany). A 0 lens (103424AA Karl Storz) and a video
system was used to demonstrate the tracheobronchial tree. An
optical forceps (10378KF Karl Storz) was used to grasp and extract
the foreign bodies. A thin catheter with a balloon at its tip was
occasionally necessary to extract small particles which localized at
distal segmenter bronchia. Second bronchoscopy procedure could
be necessary if bleeding or granulation tissue did not permit to
extract distally localized small foreign bodies. Control bronchos-
copy was carried out in patients who had an excessive granulation
tissue at main bronchi in the first bronchoscopy to control the final
status of granulation tissue at airways.
We used four parameters to perform statistical analysis as wit-
nessed aspiration event (WAE), clinical symptoms, radiological
findings (RFs) and physical examination findings (PEFs). Univariate
and multivariate analysis was performed in these parameters as
alone or together to determine the sensitivity, specificity, positive
and negative predictive values.
All of the parents and adolescents gave their informed consent
prior to their inclusion in the study. An approval was obtained from
our institutional review board. The statistical analysis was per-
formed by SPSS for Windows 20.0. The data underwent Pearson
Chi-square test analysis, and p value as lower than 0.05 was
considered to be statistically significant.
3. Results
3.1. Patient demographics
A total of 431 children (266 M, 165 F) underwent rigid bron-
choscopy for suspected foreign body aspiration in the study period.
Mean age of the patients was 3 ± 3.3 years, and the median age was
2 years (range, 7 months to 16 years). Most of the patients were
lower than 3 years old (3 years old: 352 patients, 81%). The age of
patients was lower than 1 year old in 127 patients (29%), and
higher than  12 years in 24 patients (5%).
A foreign body was detected in 68% of the patients and named as
positive bronchoscopies (295 patients). Foreign body was not
detected in 32% of the patients and named as negative bronchos-
copies (136 patients). The mean age of the patients was 3.2 ± 3.6
years in positive bronchoscopies (7 monthse16 years), and 2.6 ± 2.5
years in negative bronchoscopies (1 yearse16 years). The age of the
patients in positive bronchoscopies was slightly higher than
negative bronchoscopies (p ¼ 0.046) (Table 1).
Most of the patients were male with a 1.6 male to female ratio
(266 M, 165F). The rate of foreign body detection on bronchoscopy
233
was 67.7% and 69.7% in male and female patients, respectively.
There was not seen any statistically significant difference between
the genders in the detection rate of foreign body on bronchoscopy
(p ¼ 0.660).
The elapsed time from the beginning of the clinical history to
admission was divided into three groups. They were grouped as
early admission before than 7 days in 306 patients, moderate
admission between 8 and 29 days in 45 patients and late admission
after than 30 days in 80 patients. The rate of foreign body
detection on bronchoscopy was 68% in early admissions, 78% in
moderate admissions and 65% in late admissions. There was not
seen any statistically significant difference between early, moderate
or late admissions in the rate of foreign body detection on bron-
choscopy (p ¼ 0.319).
3.2. Clinical symptoms
Most of the patients had clinical symptoms before or during
clinical admission (427 patients, 99%). Only four patients did not
have any clinical symptoms. The admission symptoms were cough
(96.8%), cyanosis (46.4%), wheeze (37.6%) and dyspnea (13.2%). The
sensitivity, specificity, positive and negative predictive values of
clinical symptoms were evaluated by univariate analysis and pre-
sented in Table 2. Only wheeze had a statistically significant cor-
relation with the detection of foreign body on bronchoscopy
(p<0.001). The other clinical symptoms such as cough, cyanosis or
dyspnea did not have a significant predictive value in the detection
of foreign body on bronchoscopy (p>0.05).
3.3. Types of foreign bodies
Extracted foreign bodies were grouped as organic or inorganic
types. Foreign bodies were organic in 249 patients (84%). Most
common organic bodies were peanuts, hazelnuts and sunflower
seeds. Inorganic foreign bodies were detected in 46 patients (16%).
Most common types were pins and pen caps. The list of extracted
foreign bodies was presented in Table 3.
3.4. Operative findings
A foreign body was detected in 68% of the patients (295 pa-
tients). The localization of foreign bodies were left bronchus in 130
patients (44%), right bronchus in 124 patients (42%), trachea in 29
patients (10%) and bilateral in 12 patients (4%). Granulation tissue
was detected in 28 patients during bronchoscopy. 16 of them who
had excessive tissue underwent control bronchoscopy 3 weeks
later to evaluate the final status of granulation tissue and airways.
There was not seen any major stenosis or irregularity at the airways
on control bronchoscopy. Foreign bodies were extracted at the first
bronchoscopy in the majority of patients (98%). Only six patients
required second bronchoscopy to extract the residual foreign body.
The major causes for unsuccessful extraction were bleeding and
distant localization at peripheral segmental bronchioles. Bleeding
precluded apparent visualization of the foreign body during bron-
choscopy. Bronchoscopy was terminated in these patients. Second
bronchoscopy was performed 2 or 3 days later. All of the foreign
bodies were extracted finally. Lung infection was deteriorated or
started firstly after bronchoscopy in 31 patients (7%). Two patients
with late clinical admission for foreign body aspiration required
subsequent lobectomy due to chronic problems as bronchiectasis
and atelectasis. Bronchial laceration was occured in one patient
with a hooked needle at left main bronchus. Patient underwent
urgent thoracotomy due to tension pneumothorax and hemody-
namic unstability. Bronchus was repaired primarily, and post-
operative period was uneventful in this patient. Pneumothorax was
234 E. Divarci et al. / International Journal of Pediatric Otorhinolaryngology 100 (2017) 232e237

Table 1
The comparison of patient demographics in positive and negative bronchoscopies.

Positive Bronchoscopy (n ¼ 295, 68%) Negative Bronchoscopy (n ¼ 136, 32%) P value

Mean age, y (range) 3.2 (0.6e16) 2.6 (1e16) 0.046

Gender, n (%) 0.660

Male (n ¼ 266) 180 (67.7) 81 (32.3)
Female (n ¼ 165) 115 (69.7) 50 (30.3)

The timing of clinical admission, n (%) 0.319

Early admission (7 days) (n ¼ 306) 208 (68) 98 (32)
Moderate admission (8e29 days) (n ¼ 45) 35 (78) 10 (22)
Late admission (30 days) (n ¼ 80) 52 (65) 28 (35)

Table 2
The statistical analysis of clinical symptoms in the detection of foreign body on bronchoscopy.

Clinical Symptoms n Sensitivity Specificity Positive Predictive Value Negative Predictive Value p value

Cough 417 97.6% 5.1% 69.1% 50% 0.131

Cyanosis 200 43.7% 47.8% 64.5% 28.1% 0.101
Wheeze 162 46.4% 81.6% 84.6% 41.3% <0.001
Dyspnea 57 13.9% 88.2% 71.9% 32.1% 0.543

Table 3 predictive value of three parameters individually as witnessed

The types of extracted foreign bodies. aspiration event (WAE), physical examination findings (PEFs) and
Types of foreign bodies n (296) % radiological findings (RFs). These parameters were analyzed inde-
Organic foreign bodies
pendently without considering the association between them.
Peanut 65 22
Sunflower seed 43 14
Hazelnut 43 14
3.6. Witnessed aspiration event (WAE)
Walnut 16 5
Roasted chickpea 15 5 Two different clinical admission types could be seen in sus-
Chestnut 9 3 pected foreign body aspiration. First clinical scenario was after a
Almond 7 3
witnessed aspiration event as caregivers explained the event like
Popcorn 6 2
Carrot 6 2 choking, coughing or cyanosis with acute respiratory distress. The
Leaf 5 2 second scenario was a high clinical suspicion for foreign body
Meatball/chicken 5 2 aspiration with positive radiological and/or physical examination
Bean 4 1
findings who had not got a WAE.
Watermellon seed 3 1
Various food particles 27 9
The sensitivity, specificity, positive and predictive values of a
WAE as an independent parameter from other parameters were
Total 249 84
presented in Table 4. A witnessed aspiration event was seen in 360
Inorganic foreign bodies
patients (83%). The rate of foreign body detection was 71.4% of these
Pin 18 6 patients with a WAE (257/360). Also, a foreign body was detected in
Pen cap 11 4 53.5% of the patients without a WAE (38/71). WAE was a significant
Other plastic materials 7 3 independent parameter in the detection of foreign body on bron-
Other metal materials 4 1
choscopy (p ¼ 0.003).
Tooth 1 0.5
Earring 1 0.5
Other inorganic bodies 4 1
3.7. Physical examination findings (PEFs)
Total 47 16
The existence of only one parameter from unilateral decreased
breath sounds, dyspnea, localized wheezing and stridor was
not seen in any other patients during or after bronchoscopy pro- accepted as positive PEFs. The sensitivity, specificity, positive and
cedure. Cardiac arrest was occured in 8 patients due to hypoxemia predictive values of PEFs as an independent parameter from other
before or during bronchoscopy (1.8%). Most of the foreign bodies parameters were presented in Table 4. Positive PEFs was detected in
were located in trachea (3 patients) or bilaterally (3 patients) in 309 patients (71.7%). The rate of positive bronchoscopy was 80.9%
these patients. Mortality was seen in two patients during post- in patients with positive PEFs (250/309). In patients without PEFs,
operative period due to major cerebral ischemia. The rate of mor- the rate of foreign body detection was decreased to 36.9% (45/122).
tality was 0.4% in the overall group. There was not seen any Positive PEFs was a significant independent parameter in the
neurological sequela in the postoperative period in the other sur- detection of foreign body on bronchoscopy (p<0.001).
vived patients. Physical examination findings were analyzed separately in the
detection of FBA. The positive predictive values of these findings
was 80.4% in unilateral decreased breath sounds (218/271), 85.7% in
3.5. Univariate statistical analysis for the detection of FBA dyspnea (30/35), 88.2% in wheezing (67/76) and 92.7% in stridor
(38/41). These independent individual findings were statistically
Univariate statistical analysis was performed to determine the significant in the prediction of FBA(Table 4).
 E. Divarci et al. / International Journal of Pediatric Otorhinolaryngology 100 (2017) 232e237 235

Table 4
The univariate statistical analysis in the detection of foreign body on bronchoscopy.

n % Sensitivity Specificity Positive Predictive Value Negative Predictive Value P value

Witnessed Aspiration Event 360 83 87.1% 24.3% 71.4% 46.5% 0.003

Physical Examination Findings 309 71.7 84.7% 56.6% 80.9% 63.1% <0.001
Decreased Breath Sounds 271 62.9 73.9% 61% 80.4% 51.9% <0.001
Wheezing 76 17.6 22.7% 93.4% 88.2% 35.8% <0.001
Stridor 41 9.5 12.9% 97.8% 92.7% 34.1% <0.001
Dyspnea 35 8.1 10.2% 96.3% 85.7% 33.1% 0.022

Radiological Findings 166 38.5 42.4% 69.9% 75.3% 35.8% 0.015

Hyperaeration 124 28.8 34.9% 84.6% 83.1% 37.5% <0.001
Infiltration 32 7.4 8.1% 94.1% 75% 32.1% 0.407
Atelectasis 29 6.7 4.7% 89% 48.3% 30.1% 0.016

3.8. Radiological findings (RFs) These patients were divided into four groups considering the as-
sociation between PEFs and/or RFs. The positive predictive values
The existence of only one parameter from unilateral hyperaer- (PPV) were analyzed in these groups (Table 5).
ation, atelectasis and parenchymal infiltration was accepted as The highest PPV was 91.3% in patients with positive PEFs and
positive RFs. The sensitivity, specificity, positive and predictive positive RFs together (84/92). PPV was observed as 81.9% in patients
values of RFs as an independent parameter from other parameters with positive PEFs and negative RFs (131/160). This decrease was
were presented in Table 4. RFs was positive in 166 patients (38.5%). significant in the absence of PEFs with positive RFs (48.6%) (17/35).
The rate of positive bronchoscopy was 75.3% in patients with pos- A foreign body was detected in 34.2% of the patients who had not
itive RFs (125/166). In patients without RFs, the rate of foreign body got PEFs and RFs together (25/73).
detection was 64.2% (170/265). Positive RFs had a significant pre-
dictive value in the detection of foreign body on bronchoscopy 3.11. Patients without a witnessed aspiration event (WAE)
(p ¼ 0.015).
Radiological findings were analyzed separately in the detection A witnessed aspiration event was not seen in 71 patients (17%).
of FBA. The positive predictive values of these findings was 83.1% in These patients were divided into three groups considering the as-
unilateral hyperaeration (103/124), 48.3% in atelectasis (14/29) and sociation between PEFs and/or RFs. The positive predictive values
75% in parenchymal infiltration (24/32). Hyperaeration and atel- (PPV) were analyzed in these groups (Table 5).
ectasis were statistically specific in the prediction of FBA (Table 4). The highest PPV was 84% in patients with positive PEFs and
positive RFs together (21/25). PPV was decreased to 43.8% in pa-
3.9. Multivariate statistical analysis for the detection of FBA tients with positive PEFs and negative RFs (14/32). PPV was 21.4% in
patients with positive RFs and negative PEFs (3/14).
Multivariate statistical analysis was performed to determine the
predictive value of the association of three parameters as witnessed 4. Discussion
aspiration event (WAE), physical examination findings (PEFs) and
radiological findings (RFs). These parameters were analyzed Rigid bronchoscopy to extract a foreign body from pediatric
together with considering the association between them. There airways could be a big challenge for clinicians. However, the first
were seven types of clinical admissions (Table 5). WAE was challenge begins with the diagnosis of FBA [9,11]. An aspirated
accepted as major parameter, and statistical analysis was per- foreign body usually could not be seen on radiological studies
formed according to the existence of WAE or not. directly. Indirect findings as radiological or physical examination
findings alert the clinicians for further interventions. The diagnosis
3.10. Patients with a witnessed aspiration event (WAE) of FBA usually starts with a suspicious which could be a witnessed
aspiration event or recurrent respiratory symptoms resistant to
A witnessed aspiration event was seen in 360 patients (83%). long-term medical therapy. Bronchoscopy is an endoscopic surgical
procedure which requires general anaesthesia in children. It could
cause severe intraoperative complications as airway injury and
Table 5
The multivariate statistical analysis in the detection of foreign body on pneumothorax [12]. In addition, an underlying pulmonary infection
bronchoscopy. could be deteriorated in patients without an aspirated foreign body.
n % Positive Predictive Value
The data in our study including patient demographics and
operative findings such as age, gender, elapsed time after aspira-
Positive WAE
tion, types and localization of aspirated foreign bodies were similar
PEFs (þ), RFs (þ) 92 21.3 91.3%
PEFs (þ), RFs () 160 37.1 81.9% to the previous studies [13e16]. The rate of positive bronchoscopies
PEFs (), RFs (þ) 35 8.1 48.6% was consistent to the literature (68%).
PEFs (), RFs () 73 16.9 34.2% In this study we aimed to discuss the indications of rigid bron-
choscopy in suspected foreign body aspiration. We have two main
Negative WAE
questions as mentioned in the introduction part of this study. The
PEFs (þ), RFs () 32 7.4 43.8%
PEFs(), RFs (þ) 14 3.2 21.4% answers of these questions were based on three parameters as
EFs(þ), RFs (þ) 25 5.8 84% witnessed aspiration event (WAE), physical examination findings
WAE: Witnessed aspiration event.
(PEFs) and radiological findings (RFs). Most of the studies in the
PEFs: Physical examination findings. literature performed univariate statistical analysis to investigate
RFs: Radiological findings. the sensitivity, specificity, positive and negative predictive values of
236 E. Divarci et al. / International Journal of Pediatric Otorhinolaryngology 100 (2017) 232e237
these parameters separately [16e18]. They concluded with similar
comments about the importance of diagnostic bronchoscopy in
suspected foreign body aspiration. In our study, we performed
univariate analysis and found consistent results to the previous
studies. Kiyan et al. reported the importance of wheezing as a
specific predictive clinical symptom with a 75% positive predictive
value (PPV) in suspected FBA (p ¼ 0.016) [16]. In our study, wheeze
is the only specific predictive clinical symptom in the detection of
FBA on bronchoscopy (PPV ¼ 84.6%, p<0.001). The other clinical
symptoms such as cough, dyspnea or cyanosis did not have any
statistical significant specific predictive value in the detection of
foreign body on bronchoscopy (Table 3). Witnessed aspiration
event is the main indication for diagnostic bronchoscopy in sus-
pected FBA. Ciftci et al. reported aspiration history was present in
85% of their series (19). They reported the sensitivity and specificity
of aspiration history as 91% and 46%, respectively. In our study, we
found that the sensitivity and specificity of WAE was 87% and 24%,
respectively. The positive predictive value of a WAE as an inde-
pendent factor from other parameters was 71.5% (p ¼ 0.003).
Physical examination findings (PEFs) were the other major in-
dications for rigid bronchoscopy in suspected FBA. Midulla et al.
reported the localized wheezing was the most significant PEF in
detection of FBA [17]. They found that the other findings such as
localized decreased breath sounds, dyspnea, cyanosis or stridor
were not significant predictive PEFs in the detection of FBA
(p>0.05). In our study, decreased breath sounds and wheezing
were highly statistically significant predictive PEFs (p<0.001). At
least one of the PEFs was present in 71.7% of our cases, and the
positive predictive value of PEFs was 80.9% (p<0.001). Lea et al.
reported the sensitivity and specificity of chest x-ray as 67.9% and
71.4%, respectively [20]. We determined the sensitivity and speci-
ficity of radiological findings (RFs) as 41.4% and 69.9%, respectively.
At least one of the RFs was present in 38.5% of our cases, and the
positive predictive value of RFs was 75.3% in our series (p ¼ 0.015).
Most of the previous studies reported univariate analysis of the
stated parameters to evaluate the indications of rigid bronchoscopy
in suspected FBA (16e18). Univariate analysis could give us data
about these parameters as separately which are accepted as inde-
pendent from the other parameters. However, these parameters are
not independent from the others, and the association between
them results with various combinations of different clinical
admission types. In our study, there were seven types of clinical
admissions. In the pediatric literature, there were very few studies
with multivariate analysis in suspected FBA [19,21]. Multivariate
analysis could be more useful in the decision of indications for
bronchoscopy in different clinical admission types. Sink et al. re-
ported the predictors of FBA with multivariate analysis in 102
children [21]. In their study, the sensitivity and specificity of having
a positive WAE, PEFs and RFs together as 46% and 79%, respectively.
The sensitivity and specificity decreased to 43% and 58% with a
positive WAE and PEFs and negative RFs. A positive WAE and RFs
with a negative PEFs resulted with 7% and 100% sensitivity and
specificity, respectively. The sensitivity and specificity of having a
positive WAE with a negative PEFs and RFs were 3% and 67%,
respectively. In the conclusion, they commented the limitation of
their study was evaluating relatively small sample size in the
negative bronchoscopies [21]. They advised to compare the find-
ings in future studies at major tertiary referral centers.
In our study, we performed multivariate analysis with a larger
patient group as more than 400 children. The clinical admissions
could be in seven different types according to three parameters as
WAE; PEFs and RFs. We divided these clinical admissions into two
main groups as with or without WAE. The collaboration of positive
WAE, positive PEFs and positive RFs increased the positive predic-
tive value (PPV) as higher than 90%. This type of clinical admission
usually has obvious respiratory distress and requires urgent rigid
bronchoscopy. The indication for rigid bronchoscopy is relatively
clear in these patients.
In the introduction part of this study, the first question is the
necessity of rigid bronchoscopy in patients with a WAE alone who
have not got any clinical and/or radiological problems. In our study,
a foreign body was detected in one third of the patients with a
positive WAE alone (34.2%). This rate could be seen lower than the
other clinical admission types. However, if you regard the possible
irreversable clinical problems in an overlooked FBA, the risk of
positive bronchoscopy is not acceptable. Also, any of one parameter
from PEFs or RFs added to WAE, the risk of detection of FBA in-
creases to 48.6%e81.9%. In the light of these findings, we advocate
diagnostic bronchoscopy in a patient with a WAE alone. The risk of
deterioration of underlying pulmonary infection must be consid-
ered in patients with a suspicious history of WAE. The rigid bron-
choscopy should be postponed in these types of clinical admissions.
However, in a patient with a definite history of WAE, diagnostic
bronchoscopy should be performed immediately.
The second question is in suspected patients without a wit-
nessed aspiration event but have positive physical and radiological
findings for FBA. In our patients, the rate of positive bronchoscopy
was 84% who admitted with positive PEFs and RFs and negative
WAE. This rate is an extremely high risk in such cases. We thought
that the indication of diagnostic bronchoscopy is clear in patients
with positive PEFs and RFs and negative WAE history.
5. Conclusions
The indications of bronchoscopy should be based on three pa-
rameters as WAE, RFs, and PEFs. The collaboration of these three
factors generate high index of suspicion leading to bronchoscopy. A
foreign body could be detected in one third of the patients with a
WAE alone. Bronchoscopy is not necessary in two third of these
patients. In the other side, it avoids an overlooked foreign body
aspiration which could cause irreversable severe pulmonary
problems. Therefore, a diagnostic bronchoscopy should be keep in
mind in these patients with regarding higher rates of negative
bronchoscopies.
In the light of multivariate analysis of our study, suspicious for
FBA requires diagnostic bronchoscopy. The definition of “ suspi-
cous” could be a witnessed aspiration event or positive physical
examination findings and radiological findings. The association of
these factors increase the rate of detection of FBA on bronchoscopy.
We thought that, the classical indication for suspected FBA is still
valid in children as “suspicious requires bronchoscopy”.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Contributors
All authors were involved in the conception or the design of the
review; participated in the analysis and interpretation of the data,
and the development of this manuscript.
Conflict of interest
None of the authors had any financial, consulting and personal
relationships with other people or organizations that could influ-
ence (bias) the author's work.
 E. Divarci et al. / International Journal of Pediatric Otorhinolaryngology 100 (2017) 232e237
Acknowledgement
The statistical analysis was performed by Professor Mehmet N
Orman (Ege University Faculty of Medicine, Department of Biosta-
tistics; mehmet.orman@ege.edu.tr).
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