Turban Pin Aspiration Syndrome: Turban Pin Self-Ejected by Coughing: Case Report

Abstract

Turkish Abstract

Introduction

Foreign body aspiration (FBA) is a common problem among children or infants ¹ and important causes of death ². In adults, most of FBAs are seen in the 6th or 7th decade of life when the airway protection mechanism is impaired¹. Turban pin aspiration syndrome is a new clinical entity afflicting young Islamic girls wearing a turban ^3,4. Turban pins are used for attaching the layers of turban to each other in order to keep it in a steady position around the head ⁴. The aspiration history of the turban pins is frequently same in all cases. They hold the pin between teeth while dressing in a turban and aspirating the pin during laughing or talking ⁵. Here, we report a young girl who  aspirated turban pin and self-ejected by coughing. 

Case Report

A previously healthy 19 year old girl admitted to emergency department with turban pin aspiration. She aspirated a turban pin when she tried to talk with the pin in her mouth while fixing the headscarf. She was coughing on admission. Her physical examination revealed no significant abnormality. Radioopaque foreign material was visualized with posteroanterior and lateral chest x-rays (Figure 1). The turban pin was self-ejected by coughing.  Repeat chest x-ray (Figure 2) appeared normal and the patient was discharged after 24 hours of observation. There was no complaint and complication during the folow-up. 

Figure 1 Posteroanterior and right lateral chest X-ray

Figure 2 Repeat posteroanterior and right lateral chest X-ray

Discussion

Foreign body aspiration in adults is very rare ^1,5,6. In adults most of the FBA?s  are seen in the 6th or 7th decade of the life ^1,5 when the airway protection mechanism is impared ¹. It is a common problem among children or infants ^1,5,7-9, emergency room personal ⁸, physchiatric and prison population ⁹. Turban pin aspiration is a new syndrome in Islamic girls wearing turban ^3,4.  In this case, we reported a turban pin aspiration syndrome in whom the turban pin was located in the left lower lobe bronchus and  self-ejected by coughing. Repeat chest x-ray appeared normal. There was no complaint and complication during the follow-up.

To realize the ingestion of a turban pin is as important as aspirating a turban pin. Karaman et al ⁸ reported an 8-year old child who presented with an acute abdomen caused by perforation of the appendix because of an ingestion of safetypin after two days of the ingestion. Mehran et al ⁹ reported a 25-year old girl who presented with a 10 day history of right upper quadrant abdominal pain caused by perforation of the gastric because of an ingestion of metallic pin.

After aspiration, turban pins can go trachea or esophagus. Often goes to the gastrointestinal tract, and exit from the gastrointestinal tract without causing problems ^7-9. Exit must be followed up ⁸. Aspiration of turban pin, leads to complications according to the localization. Gastrointestinal perforation due to turban pin can cause appendicitis, intestinal perforation, intestinal obstruction ⁷, fistula ^7,8, bleeding ^7,8, peritonitis, abscess ⁸. If you are aware of the ingestion, we provide early diagnosis and intervention. Radioopaque inorganic materials like turban pin aspirations are easily diagnosed and localized with posteroanterior and lateral chest x-rays ^1,6.

The most common localization is trachea (42%) in Ilan et al ³ report, right bronchial system (62 %) in Uçan et al ⁵ report and intermediate bronchus (62 %) in El-Khushman et al ¹⁰ report. Varies methods of treatment are: rigid bronchoscopy, flexible bronchoscopy, laryngoscopy, thoracotomy ¹. Ilan et al ³, reported 26 turban pin aspiration syndrome, treated by rigid bronchoscopy, fluoroscopy-assisted rigid bronchoscopy, thoracotomy. One patient self-ejected the turban pin by coughing before bronchoscopy. Hasdıraz et al ⁶, reported 105 turban pin aspiration syndrome, treated by laryngoscopy, flexible fiberoptic bronchoscopy, rigid bronchoscopy, thoracotomy. One patient spontaneously expectorated the turban pin. This case is the third patient in the literature who self-ejected the turban pin by coughing. Çobanoğlu et al ² reported 21 turban pin aspirations in female children aged below 18 years. They used rigid bronchoscopy in 15 (71.4%) cases, thoracotomy in three (14.3%) cases, laryngoscopy in one (4.8%) case and fiber-optic bronchoscopy in two (9.6%) case for the removal of the needles. Turban pins were located in the right bronchial tree in 12 (57.1%), in the left bronchial tree in three (14.3%), in the trachea in five (23.8%) cases and in the larynx in one (4.8%) case. Eight (38.1%) cases lived in a rural area and 13 (61.9%) were urban.

Conclusion

With the increasing use of Islamic headscarves in the country, especially in young girls the frequency of turban pin aspiration occurrence has increased. We recommend safer methods such as the use of adhesive tapes and snap fasteners and to avoid holding the needles with the lips. Clinicians should be aware of this new aspiration syndrome, its method of diagnosis and extraction techniques.

References

1. H Gonullu, et al. Turban pin: an unusual cause of foreign body aspiration in young Islamic adults. Iranian Red Crescent Medical Journal. 2014; 16(3): e2975.
2. Cobanoglu U, Can M, Melek M. Turban pin aspirations in children in eastern anatolia. Indian Journal of Thoracic and Cardiovascular Surgery. 2010; 26(1):20-23.
3. Ilan O, et al. Turban pin aspiration syndrome: new fashion, new syndrome. Laryngoscope. 2012;122(4):916.
4. Kaptanoglu M, et al. Turban pin aspiration; a potential risk for young Islamic girls. Int J Pediatr Otorhinolaryngol. 1999;48(2):131-5.
5. Uçan ES, et al. Turban pin aspiration syndrome: a new form of foreign body aspiration. Respir Med. 1996;90(7):427-8.
6. Hasdiraz L,  et al. Turban pin aspiration: non-asphyxiating tracheobronchial foreign body in young islamic women. Thorac Cardiovasc Surg. 2006;54(4):273-5.
7. Ozgüner IF,  et al. Appendicitis occurring 3 years after ingestion of metallic pin. Turk J Gastroenterol. 2012;23(2):187-8.
8. Karaman A,  et al. Perforation of the appendix caused by a pin. Turkish J Pediatr Dis 2009;3(3):51-53.
9. Mehran A,  et al. Gastric perforation secondary to ingestion of a sharp foreign body. SJSLS. 2005;9(1):91-3.
10. El-Khushman HM, Sharara AM, Sa Ada MA, Hijazi MA. Tracheobronchial straight metallic pin aspiration in young Jordanian females. Saudi Med J. 2007;28(6):913-6

Information Presentation

This case report was  presented as a poster at the 1st Intercontinental Emergency Medicine Congress, 15-18 May, 2014,  Antalya, Turkey.