Volume 4, Issue 2 , Pages 59-61, March 2009
A frightening bronchial foreign body
Article Outline
Summary
We report our experience, not previously reported in the literature, with a young male Jehovah Witness who aspirated a metal button backing into his right bronchus intermedius. While in the operating room, a size 5, 30
cm Storz rigid ventilating bronchoscope with a 0 degrees rod lens telescope was passed through the larynx to visualize the bronchus intermedius. Then, using the “duckbill” telescopic alligator forceps, the sharp edges of the foreign body were grasped and removed. The patient recovered well and was discharged home hours after without any complications.
Keywords: Bronchial foreign body, Pediatrics, Metal button backing
1. Introduction
Bronchial foreign bodies are common in children [1]. Sharp bronchial foreign bodies however are relatively uncommon, especially in young children [2]. Fortunately, multi-pointed bronchial foreign bodies are rare, since the potential morbidity increases when several sharp points are present. Such foreign bodies increase the need to resort to thoracotomy and bronchotomy for safe removal.
We report our experience, not previously reported in the literature, with a young male Jehovah Witness who aspirated a metal button backing into his bronchus intermedius.
2. Case report
A 5-year-old male Jehovah's Witness, while playing unsupervised in a sewing room, aspirated a metal button backing (with four sharp triangular points) (Fig. 1). Concerned by his coughing fit, his mother brought him to their local Emergency Department. A chest X-ray demonstrated the metal button backing in the bronchus intermedius, with the sharp points facing superiorly (Fig. 2). The patient was transferred to B.C. Children's Hospital in stable condition, with no respiratory distress. His tetanus shots were up-to-date. The patient was consented for rigid bronchoscopy with removal of the foreign body. We explained that if attempted removal of the foreign body resulted in bronchial rupture, that thoracotomy and possibly blood transfusion might be required in rapid sequence in order to save the patient's life. A thoracic surgeon was consulted and cell-saving and cardiac bypass equipment and an ICU bed were made available.
Fig. 1.
Photograph of the aspirated metal button backing.
Fig. 2.
Chest X-ray—AP and lateral of aspirated metal button backing.
Upon our request, the patient's mother asked her friend to bring us a duplicate foreign body, so we could determine, by preoperative in vitro testing, which forceps and removal technique would work best.
The patient was brought to the operative room and administered anesthesia by the anesthesiologist. During induction of anesthesia, the “duplicate” foreign body arrived. An attempt to close two of the points of the “duplicate” foreign body with duckbill forceps (in vitro) caused it to “jump” from the forceps onto the back table with high velocity. Then it was realized that this button backing had five points and was probably larger than the foreign body that the patient had aspirated. The duckbill forceps seemed to provide the best grasp on the individual points of the five-pointed button backing. A hollow object forceps and rotational forceps were not available.
When the patient was anaesthetized but breathing spontaneously, a size 5, 30cm Storz rigid ventilating bronchoscope with a 0° rod lens telescope was carefully introduced and passed through the subglottic larynx. The foreign body was seen in the bronchus intermedius with the points facing to the patient's right (the points had spontaneously rotated laterally after the chest X-ray). A mixture of 0.5cc of 1% xylometazoline and 2% xylocaine was instilled through a catheter to cause vasoconstriction of the local mucosa (which was minimally swollen).
Using the “duckbill” telescopic alligator forceps, the most superior of the sharp points of the foreign body was grasped. The foreign body was gently and incrementally rotated distally and medially, so that all the points were disengaged from the mucosa and faced superiorly. No attempt was made to try and close the points together (based on the in vitro experience). Instead, the bronchoscope was advanced to ensheath all four points (while one point was held with the forceps), then the foreign body was removed while the bronchoscope remained in the trachea.
A regular telescope and a flexible suction were re-inserted through the bronchoscope. Traces of blood were aspirated from a shallow linear mucosal laceration on the right side of the bronchus intermedius. There was no evidence of bronchial rupture. The patient was given decadron (to prevent subglottic edema) and ampicillin (to prevent bronchitis). Post-operatively, the patient did very well and was discharged home within a few hours. He had a full recovery, and agreed not to place non-food items in his mouth. Moreover, his mother agreed to keep her metallic sewing paraphernalia under lock and key.
3. Discussion
Chevalier Jackson developed the standard techniques for rigid bronchoscope removal of pins, based on his belief, “advancing points perforate; retreating points do not” [5]. In order to spare his patients thoractomy, Jackson developed pin-bending forceps and long, thin costophrenic bronchoscopes designed to retrieve foreign bodies lodged within subsegemental bronchi.
Ideally, a true duplicate of the foreign body should be tested before the patient enters the operating room. We realized that the “duplicate” foreign body that we had received was not an exact duplicate after we discovered, in vitro, that the points of a button backing could not be bent together with our strongest bronchial forceps.
Positive action forceps are useful for most removing pediatric foreign bodies since they offer a wide range of blades to extract various types of objects. The blade types include forward-grasping, rotation and globular object [3]. We used a large, duck-billed forward-grasping forceps since it offered the most powerful grip on the pointed metal edges of the button backing. A hollow forceps might have been preferable if it had been available and if the points of the foreign body had still been facing superiorly and could not be forward-grasped because of mucosal edema. We were surprised that the object had spontaneously turned 90° before bronchoscopy. The minimal mucosa edema, plus topical treatment with xylometazoline, allowed rotation of the foreign body back to its initial orientation without significant trauma. Thus we were able to avoid thoractomy and possible blood transfusion in this Jehovah Witness child.
Since 1998, at B.C. Children's Hospital, ten other sharp bronchial foreign bodies have been removed, including several pins and thumbtacks and one blow-dart (but no Arabian scarf-pins) [2]. The most difficult bronchial foreign body removal at our hospital was a 5cm glass mercury thermometer fragment in the distal left main stem bronchus in a 6-year-old girl [4]. This foreign body was eventually removed with the use of an inflated Fogarty catheter without complications, after multiple failed attempts to remove the foreign body with various forceps.
4. Conclusion
Aspiration of sharp metallic objects remains a challenge to otolaryngologists. Treatment of patients with foreign bodies of multiple sharp points must be individualized based on the characteristics of the foreign body, the condition of the surrounding bronchial mucosa, and the equipment and surgical expertise available. In vitro preoperative testing, when possible, is paramount. The need for emergent or urgent thoracotomy, bronchotomy and repair and/or blood transfusion are very real possibilities that must be considered before any attempts at removing a bronchial foreign body with multiple sharp points.
References
- . Pins at the periphery of the lung. Archives of Otolaryngology. 1932;15:860–882
- . Choking on pins, needles, and a blowdart: aspiration of sharp, metallic foreign bodies secondary to careless behavior in 7 adolescents. International Journal of Pediatric Otorhinolaryngology. 2007;71:307–310
- . Management of foreign bodies of the airway. In: Shields TW editors. General Thoracic Surgery. Fifth edition. Philadelphia: Lippincott Williams & Wilkins; 2000;p. 853–862(Chapter 73)
- . Broken glass mercury thermometer: a difficult airway foreign body. Otolaryngology-Head and Neck Surgery. 2002;127:339–341
- . Peroral Endoscopy and Laryngeal Surgery. St. Louis: Laryngoscope Company; 1914;
PII: S1871-4048(08)00047-6
doi:10.1016/j.pedex.2008.06.007
© 2008 Elsevier Ireland Ltd. All rights reserved.
Volume 4, Issue 2 , Pages 59-61, March 2009
