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