Volume 4, Issue 2 , Pages 62-65, March 2009
A new method to solve an old problem: Extraction of a sharp foreign body from the lateral basal part of the bronchial tree of a child
Article Outline
- Summary
- 1. Introduction
- 2. Case report
- 3. Considerations
- 4. Technique
- 5. Discussion
- Acknowledgements
- References
- Copyright
Summary
This paper describes a novel method for the removal of a needle aspirated into the basal part of the right bronchial tree of a 14-year-old girl, where due to the distal location, earlier attempts at extraction had been unsuccessful.
With careful advanced planning creative modelling, and the assistance of our medical engineer, a modified method was developed that allowed successful extraction in cooperation with the pulmonary physician, thereby obviating the need for a possible thoracotomy and lobectomy.
Keywords: Foreign body, Aspiration, Needle, Extraction, Child
1. Introduction
Tracheobronchial foreign body aspiration is a worldwide health problem, which can result in life-threatening complications. Several articles describe methods for the removal of sharp foreign bodies, aspirated into the peripheral bronchi [1], [2], [3]. The use of a rigid or flexible bronchoscope with different instruments such as a grasping forceps or a magnet is commonly described in literature. In this article we present a case in which conventional methods were unsuccessful in extracting a sharp, ball pointed needle from the right peripheral bronchial tree of a 14-year-old girl. With careful creative planning and modelling it was eventually removed, obviating the need for possible thoracotomy and lobectomy.
2. Case report
A 14-year-old girl of Middle Eastern origin was transferred to the Sophia Children's Hospital in Rotterdam from another regional children's hospital, after a failed attempt to extract a sharp, ball pointed needle from the right lateral basal part of the bronchial tree.
The girl accidentally aspirated the needle while she was removing her headscarf that was fixed to her hair with several of these needles. This presentation is a widespread cultural hazard where the wearing of headscarves is common, though the pins are more often swallowed than aspirated.
The experienced lung physician who performed the initial bronchoscopy identified the needle's bronchial position. Because of the very smooth surface of the needle and because the sharp point of the needle was facing upwards into the bronchial mucosa, he was not able to properly fix the needle into several types of bronchoscopy grasping forceps available to him. The distal ball of the needle was trapped in the middle segment subdivision of the right lower lobe bronchus. A proper extraction failed and the girl was transferred to our hospital.
On arrival, the girl had no pulmonary complaints. She had good oxygen saturations, normal respiratory frequencies, no fever or dyspnoea and no pain during inspiration and expiration. There was a mild incidental cough. She was otherwise in a good condition and did not use any medication.
Figs. 1 and 2 are the chest X-rays that were made shortly after admittance.
Figs. 1 and 2.
Chest X-ray in two directions, showing the needle to be positioned deep in the right lower lobe.
3. Considerations
The main goal was a successful endoscopic extraction of the needle, for failure would have required a thoracotomy and possibly a lobectomy. An intervention was planned for the following morning to prevent complications from migration of the needle, or atelectasis due to obstruction of the tertiary bronchial division. It was highly unlikely that the conventional extraction methods performed in the referring hospital, would work in our hospital. A different approach was necessary.
4. Technique
The patient's mother was asked to supply several similar needles, and the girl could positively identify a copy of the aspirated needle. This gave us the length, diameter, material type and smoothness of the foreign body.
With a duplicate of the needle at hand, it was possible to practice extraction with different grasping forceps on an improvised model—the pin beings stuck into a card to simulate forces required for the distraction. It became clear that the conventional bronchoscopy forceps would not be able to apply sufficient grip and pressure to successfully extract the needle from the bronchial tree.
In the hospital database for surgical instruments, our hospital medical engineer found a different forceps, used in adult bronchoscopy for tangential biopsy (type 52C-1). It was brought from the nearby affiliated Erasmus Medical Centre. The difference between this 2-mm forceps and the other forceps at hand, was that it had alligator serrations with interlocking rat teeth and most important, a hole in both swing jaws.
With the point of the needle positioned through the hole in the upper swing jaw and both jaws firmly interlocked, a strong fixation of the needle in the forceps could be realised. The only disadvantage of this method was that in this position, the needle formed a small “fish hook” and could potentially catch on the bronchial mucosa, making the extraction more difficult and possibly causing some mucosal damage.
The procedure was then performed under general anaesthesia. Initially an attempt was made to locate the foreign body using a rigid bronchoscope, but it proved impossible to pass the bronchoscope far enough into the distal part of the lower lobe. A 5-mm flexible bronchoscope was inserted via laryngeal mask so that ventilation could be maintained even during a lengthy procedure. Since precise manipulation and navigation of the bronchoscope, forceps and needle was anticipated, the lung physician was asked to join the team, for his experience with deep flexible bronchoscopy. The medical engineer was standby during the whole procedure.
Eventually the flexible bronchoscope was used to identify the aspirated needle with some difficulty. It was still positioned into the right lateral basal segment of the bronchial tree, as was seen on the chest X-rays. With the forceps it was possible to manipulate the point of the needle out of the mucosal wall. Now that the point was visible, it was manoeuvred through the hole in the upper swing jaw. Both jaws were locked quickly and firmly. Due to the small “fish hook” the needle had to be carefully rotated several times during the procedure, to keep the sharp point in the centre of the bronchial and tracheal lumen, and again to complete the extraction through the vocal cords. Otherwise extraction went smoothly, without damaging the bronchial mucosa (Figs. 3–6). The whole procedure took about 8
min. The girl was kept in overnight for observation and could be discharged in a good condition the following morning.
Figs. 3–6
Upper left: ball pointed needle and forceps. Upper right: point of needle placed into forceps. Lower left: “fish hook”. Lower right: traction and extraction.
5. Discussion
In the Sophia Children's hospital, the otolaryngologist is primary responsible for the diagnosis and treatment of foreign body aspiration in both upper and lower respiratory tract. Therefore this case was not initially presented to a lung physician. The lung physician was however asked to join the team, for his expertise with deep flexible bronchoscopy. Failure to remove this foreign body would have resulted in increasing morbidity for this child, possibly requiring a thoracotomy with a lobectomy.
For inspection of the upper airway and bronchial trees, for suspected foreign bodies, we generally prefer a rigid bronchoscope for several reasons: It is our experience that with use of the rigid bronchoscopes, the view is usually clearer and less deformed than in flexible bronchoscopes, instrument can be easily applied through the rigid scope and more importantly, the rigid scope helps creating a stable, linear route through the bronchial tree. Moreover, it is possible to ventilate the patient through the scope. In this case, however, there was no rigid bronchoscope or optical grasping forceps available with sufficient length and small diameter to reach the location of the foreign body. A flexible scope proved very useful. It is our opinion that in case a rigid bronchoscope is unable to reach the site of the foreign body, conversion to a flexible bronchoscope and associated instruments is the right choice to make.
The effective use of a laryngeal mask for ventilation of a patient with a bronchial foreign body has been described [4], [5], [6]. A laryngeal mask offers easy access to the airway, safe respiratory management, direct visualization of the airway during bronchoscopic procedures and the possibility of using larger bronchoscopes than would be possible through an endotracheal tube.
It is important to realise that even with the use of the above-mentioned instruments and an extended experience and routine of the physician, it is not always possible to successfully perform the planned procedure. We consider the multi-disciplinal approach, the availability of a duplicate of the aspirated foreign body and the possibility to practice extraction of the foreign body on a model, key elements in a successful extraction.
Acknowledgements
We would like to thank Johan Sweep, medical engineer, for his enthusiastic and creative assistance with this case and Harm Tiddens, lung physician, for his experience and his assistance with deep flexible bronchoscopy.
References
- . Extraction of pins from the airway with flexible bronchoscopy. Respiration. 2007;74:674–679
- . Scarf pins sharp metallic tracheobronchial foreign bodies: presentation and management. Int. J. Pediatr. Otorhinolaryngol. 2007;71:769–773
- . Sharp foreign bodies in the tracheobronchial tree. Am. J. Otolaryngol. 2001;22:154–156
- . Bronchoscopic removal of bronchial foreign bodies through the laryngeal mask airway in pediatric patients. Jpn. J. Thorax Cardiovasc. Surg. 1999;47:190–192
- . Pediatric flexible fiberoptic bronchoscopy through the laryngeal mask airway. Arch. Otolaryngol. Head Neck Surg. 1996;122:1364–1367
- . Removal of a straight needle from a subsegmental bronchus using a flexible bronchoscope through a laryngeal mask airway under controlled ventilation. Anaesth. Intensive Care. 2004;32:593–594
PII: S1871-4048(08)00049-X
doi:10.1016/j.pedex.2008.06.006
Crown Copyright © 2008. Published by Elsevier Inc. All rights reserved.
Volume 4, Issue 2 , Pages 62-65, March 2009
