Does foreign body inhalation make a health problem in young female muslims?

Patients and methods: A prospective cohort study included 50 females with a history of scarf pin inhalation. This study was conducted in Cardiothoracic Surgery Department, Mansoura University Hospital after approval from the Research and Ethics Committee of Faculty of Medicine, Mansoura University from January 2017 to January 2019. Other forms of foreign body inhalation were excluded from this study. All patients underwent radiological work-up in the form of plain chest X-ray, both Postro-Anterior (PA) and lateral views, to confi rm the presence of the pin within the tracheo-bronchial tree.


Introduction
Foreign body aspiration is a common life threatening emergency and easily preventable problem. Every year thousands of lives are endangered because of foreign body inhalation by children and teenagers. In Muslim nations, a unique group of population has recently been reported. This comprises young girls and women who put headscarf [1].
During the fi xation of the scarf, the neck is extended and the pins are held between the lips. Meanwhile speech or laughter can cause the deep aspiration of the pin into the tracheo-bronchial tree [2].
The majority of inhaled foreign bodies lodge into right main bronchus due to its anatomical position, conversely pins mostly lodge in the left main bronchus. Various writers have endorsed the reason this fi nding to the Bernoulli phenomenon, which manifest that greater negative pressure is produced in the left bronchus than in right bronchus which is wider [3].
The most common presentation in metallic scarf pin inhalation is choking, coughing, pain and rarely respiratory distress. The inhalation of metallic foreign bodies into airway is a serious and life-threatening condition. The inhalation of metallic objects loses many lives every year because they are infrequently coped in due course for intervention [1].
These foreign bodies can easily be diagnosed by x-ray chest as all of these inhaled FBs are radiopaque [4].
Uncommonly pins are spontaneously expectorated, and the defi nitive treatment of foreign body aspiration is removal as soon as possible. Aspirated turban pins can be removed by rigid or fi ber-optic bronchoscopy, if both fl exible and rigid bronchoscopies are unsuccessful, extraction of pin through thoracotomy will be the only solution [5]. This study presented an experience with scarf pin aspiration and discussed the unique clinical characteristics of this problem and challenges in management [6].

Patients and methods
A prospective cohort study included 50 females with a history of scarf pin inhalation. This study was conducted in Cardiothoracic Surgery Department, Mansoura University Hospital after approval from the Research and Ethics Committee of Faculty of Medicine, Mansoura University from January 2017 to January 2019. Other forms of foreign body inhalation were excluded from this study.
The detailed history of onset, duration and time between inhalation and presentation to hospital was taken. Size and shape of pin was asked from the patients. The comprehensive physical examination was carried out in all patients to recognize any cardio respiratory complications. All patients underwent radiological work-up in the form of plain chest X-ray, both Postro-Anterior (PA) and lateral views, to confi rm the presence of the pin within the tracheo-bronchial tree.
The patient was asked to cough forcibly, in a hope for coughing the pin. If the previous trial failed, the patient was prepared for rigid bronchoscopy. Rigid bronchoscopy (Storz, Germany) is done under general anesthesia. After choosing an appropriate sized scope, it is connected to the light source and by aid of the direct laryngoscope the bronchoscope is advanced from the mouth till it passes between the vocal cords. Then the laryngoscope is removed, and bronchoscope is slightly advanced in the trachea and the anesthesia machine is connected to the side port of the bronchoscope. The site of the pin is localized, and if the pin is visualized, a crocodile forceps is advanced through the bronchoscope to retrieve the pin. If pin is not visualized or retrieval is not possible by the rigid bronchoscope, a fi ber-optic bronchoscope is advanced though the rigid bronchoscope and the pin is picked-up. If the above procedure failed to retrieve the pin, the procedure was repeated few days later after taking a written consent from the patient and/or her relatives for thoracotomy and operative intervention in the form of bronchotomy if bronchoscopic retrieval of the pin failed in the second time.
Patients who underwent successful rigid bronchoscopy were hospitalized for 24 h. Those who underwent classic thoracotomy were discharged from the hospital after the total expansion of both lungs and removal of the chest tubes.

Statistical analysis
After data collection, verifi cation and revision. We analyzed tabulated data statistically using SPSS (statistical package for social science for windows statistical package, version 24.0). Data were expressed as number and percentage for qualitative variables and mean + standard deviation for quantitative one. Data were summarized using the arithmetic mean, the stnadard deviation and median.

Results
A total of 50 female patients were identifi ed with a diagnosis of scarf pin inhalation. Their age ranged from 11 to 30 years and the mean was 14.7 years. All patients had the same history, that while holding the pin between teeth or lips for fi xing Hijab, and at that time a sudden episode of deep inspiration due to laughing, crying or hiccup followed by chocking due to pin inhalation. The average duration of reporting to our emergency department was 5 hours with delayed presentation ranging from 24 to 36 hours.
Seventeen patients have no symptoms when arrived to the hospital while 10 complained of dry cough, 4 complained of odynophagia, 1 complained of suffocation, 7 complained of foreign body sensation, 5 complained of chest pain, 6 complained of blood tinged sputum. None of the patients had any specifi c physical fi ndings. No associated neurologic or psychiatric comorbid condition was documented in any of the patient (Table 1) Figure 1. Presentation was early (within the fi rst 24 hours) in 97% of patients. Late presentation occurred in 3% of patients (24 hours to 5 days).
Postero-anterior and lateral chest X-rays documented the presence of FB in all cases and pin location was as follow, in 9 patients was located in trachea, in 16 patients the pin was located in the right main bronchus, in 6 patients the pin was located in the right Intermediate bronchus, in 12 patients was in the left main bronchus and in 7 patients was located in the left Intermediate bronchus (Table 2) Figure 2.
In one patient the pin was successfully removed Spontaneous by coughing, in 36 patients retrieved by rigid bronchoscope, In 6 patients the pin was removed by fl exible bronchoscope in the same sitting. In 7 cases pin could not be retrieved at all because of penetration into lung parenchyma  and hemorrhage due to initial manipulation. These patients managed by thoracotomy (5 cases of bronchotomy, 1 case of right lower lobectomy and 1 case of left lower lobectomy) ( Table  3) Figure 3. The complications noted only in one patients of those managed by thoracotomy and the complication was in the form of prolonged air-leak (more than one week), that spontaneously resolved.

Discussion
Foreign bodies are multidisciplinary emergency. Frequently seen in younger children it is sometimes a life-threatening condition. Foreign Bodies Aspiration (FBA) can largely be prevented by proper education and care. In the children younger than 4 years of age, the major cause of accidental death is asphyxia that is caused by inhaled foreign body [6].
Headscarf pin aspiration is a distinct clinical entity found in countries where headscarves are used because of religious or traditional reasons. In Islamic countries, females begin to wear scarves when secondary sex characteristics appear.The lack of experience in wearing headscarves can predispose young women to pin inhalation [7].
This complex task is usually done by both hands in front of a mirror with one or more pins held between lips or teeth with plastic end inwards during sequential insertion of pins. Any maneuver during the task like talking, coughing, sneezing or laughing predisposes them to inhalation of the pins especially in young teenage group who lack the requisite experience that the task demands. Diagnosis is usually straightforward via a history and the presence of the radio-opaque pin on a chest X-ray. For proximally located pins in the trachea and main bronchi, the treatment is extraction using a rigid bronchoscope and less commonly a fl exible bronchoscopy [8].
All patients included in this study are females, because Muslim females only wear Hijab, this history was the same that reported by Al-Halfawy [9], in a similar study that included 32 patients.
Another study done by Kaptanoglu, et al. [10], included 414 patients for turban pins aspiration, 56% of the patients were females and 44% were males. However, most of patients included in that study were young children.
The age of patients in this study ranged from 11 to 30 years with a mean of 14.7 years and this result is close to that obtained by Ragab, et al. [11] as the mean age of patients included in that study was 14 years.
In our study 34% of patients were asymptomic when arrived to the hospital while 20% complained of dry cough, 8% complained of odynophagia, 2% complained of suffocation, 14% complained of foreign body sensation, 10% complained of chest pain, 12% complained of blood tinged sputum.
Al-Sarraf, et al. [12], in a similar study included 35 patients reported that all patients initially experienced coughing and all had normal physical examination as they were all nonasphyxiating and non-obstructive FB aspiration. Hemoptysis was only observed in four cases (11%).
The study in our hand showed that the pin location was as follow, in 18 % of patients was located in trachea, in 32% of patients the pin was located in the right main bronchus, in 12% of patients the pin was located in the right secondary bronchus, in 24% of patients was in the left main bronchus and in 14% of patients was located in the left secondary bronchus.   Another study by Fenane, et al. [16], showed that 28 patients were operated for surgical removal of a scarf pin inhaled by accident after unsuccessful endoscopy due to very distal migration of pins and/or their embedding in the bronchus wall with penetration of the lung parenchyma There was no mortality as scarf pin is nonasphyxiating, and regarding this point the result of this study was better than that reported by Elmustafa and Osman [17], in a study that included 14 patients they reported 1 (7.1%) mortality due to foreign body inhalation and its complications.

Conclusion
The use of the scarf pin is a sociocultural practice that