Discussion
In 1897, Gustav Killian achieved a historic milestone by successfully extracting a tracheo-bronchial foreign body using an esophagoscope, removing a chicken bone lodged in the right main bronchus (7). This groundbreaking procedure led to the development of the rigid bronchoscope, which revolutionized medical practices by significantly reducing mortality and morbidity associated with foreign body aspiration (FBA). The advent of the rigid bronchoscope allowed for more precise and less invasive removal of foreign bodies from the airways, paving the way for safer and more effective treatments. Subsequently, in 1970, the discovery of the flexible bronchoscope further advanced FBA management, becoming the primary tool for extracting foreign bodies in adult airways and those lodged in distal airways (6). The flexible bronchoscope’s versatility and ease of maneuverability made it a valuable addition to the arsenal of medical tools for airway management.
Despite these advancements, the rigid bronchoscope continues to play a crucial role, particularly in treating children and dealing with foreign bodies located in proximal airways (8). Flexible bronchoscopy typically involves conscious sedation, making it less invasive and more comfortable for patients, while rigid bronchoscopy often requires general anesthesia due to its more invasive nature. This distinction is important in clinical decision-making, as the choice of instrument can depend on the patient’s condition, the location of the foreign body, and the patient’s age.
Elderly patients often do not provide a history of FBA, complicating diagnosis. FBA is slightly more common in males, with the average age of occurrence typically ranging from 50 to 60 years (9). Iatrogenic procedures such as tooth extraction and tracheostomy, as well as traumatic airway events, are also associated with FBA (10). Foreign bodies tend to lodge in the right bronchial tree, particularly favoring the bronchus intermedius and basal segments (5). However, as observed in our case, foreign bodies can also be found in the left bronchial tree. Foreign bodies in the left upper lobe are relatively uncommon, possibly explained by the patient’s recumbent position during feeding and left-sided hemiparesis.
Chest X-ray (postero-anterior and lateral) is often the initial investigation in suspected FBA, although its sensitivity is limited. However, it can accurately locate metallic and other dense foreign bodies in proximal airways. High-resolution CT (HRCT) of the chest is the preferred imaging modality for organic and radiolucent foreign bodies (5). Both chest X-ray and CT demonstrate secondary changes associated with FBA, such as collapse, consolidation, hyperinflation, bronchial stenosis, and bronchiectasis. Radiolucent foreign bodies, especially those chronically impacted, can be challenging to detect, even with CT imaging (7). Therefore, secondary signs like obstructive pneumonia, focal bronchiectasis, and segmental atelectasis should provide hints to the possibility of a chronically impacted foreign body (9). Early detection and appropriate management are crucial to preventing complications and ensuring successful removal of the foreign body.
Funding: None