Video‐Assisted Thoracoscopic Left Lower Lobectomy and Bronchial Foreign Body Removal for Treating a Rare Occult Bronchial Foreign Body in an Adult

ABSTRACT

Occult bronchial foreign bodies are extremely rare in adults. Affected patients typically lack a clear history of aspiration, exhibit no characteristic clinical signs and present with unremarkable chest imaging, often leading to misdiagnosis or missed diagnosis. This paper reports a case of an adult patient with occult bronchial foreign body aspiration that was initially misdiagnosed as pulmonary sequestration. An enhanced chest computed tomography and bronchial arteriography performed at another hospital failed to detect the foreign body. However, contrast‐enhanced chest CT at the respiratory department of our hospital revealed a suspected foreign body along with left lower lobe atelectasis. Endobronchial ultrasound thereafter confirmed complete occlusion of the left lower lobe bronchus with scar hyperplasia. Multiple retrieval attempts were unsuccessful, necessitating referral to the thoracic surgery department for thoracoscopic left lower lobectomy and bronchial foreign body removal. This case highlights the rarity of surgical intervention for occult bronchial foreign bodies complicated by recurrent pneumonia and bronchopulmonary abnormalities.

We report a case of an adult patient with occult bronchial foreign body aspiration that was initially misdiagnosed as pulmonary sequestration. A retrospective analysis of the patient's clinical course and the surgical approach are presented.

1. Introduction

Tracheobronchial foreign bodies result from the aspiration of external materials and are most common in children aged 1–3 years, with adult cases being less frequent [1]. In adults, clinical presentation is often atypical, and a clear history of aspiration is rarely available, frequently resulting in misdiagnosis as chronic obstructive pulmonary disease, bronchial asthma, or other respiratory conditions [2]. Occult bronchial foreign bodies pose significant risks, as prolonged retention complicates removal, delays treatment and might lead to obstructive pneumonia, bronchiectasis, atelectasis, or irreversible damage necessitating surgical intervention. Less than 2% of tracheobronchial foreign body aspiration cases are unmanageable via bronchoscopy and require further open‐chest surgery for removal [3]. As a result, most studies focus on bronchoscopic extraction, while reports on video‐assisted thoracoscopic left lower lobectomy combined with bronchial foreign body removal for rare adult occult bronchial foreign bodies remain exceptionally rare. This case is particularly noteworthy due to the patient's underlying bronchial and pulmonary abnormalities, which led to an initial misdiagnosis of pulmonary sequestration and subsequent treatment delays. Herein, a retrospective analysis of the patient's clinical course and the surgical approach are presented.

2. Case Report

A 31‐year‐old male presented to our respiratory and critical care department with a history of cough and haemoptysis for over a year, with recurrence over the past 10 days. The patient was previously healthy but developed a mild cough with haemoptysis in mid‐2022. He reported no sputum production, chest tightness, or shortness of breath. Initial non‐contrast and enhanced chest computed tomography (CT) at a provincial hospital (Figure 1A–C) revealed: (1) a soft tissue mass with calcification in the left lower lobe, directly supplied by the descending aorta, consistent with pulmonary sequestration; and (2) mild inflammation in the left lower lobe. Bronchial artery CT angiography (CTA) (Figure 1D,E) showed: (1) bilateral bronchial arteries originating from the descending aorta, with dilation and tortuosity, suggestive of vascular malformations; and (2) a mass‐like lesion adjacent to the spine in the left lower lobe, directly supplied by the descending aorta, with thickened and tortuous vessels, suggesting possible vascular malformations or developmental abnormalities. The patient received anti‐infective therapy and supportive care, leading to symptom resolution. Over the following year, no recurrence was reported. In December 2023, the patient again experienced haemoptysis approximately one mouthful of bright red blood, without a clear precipitating factor. He returned to the same hospital for further evaluation. Repeat chest CT revealed multifocal pneumonia in both lungs, with an elevated C‐reactive protein level of 23.5 mg/L. A diagnosis of pneumonia was considered, and the patient received anti‐infective therapy and mucolytics such as ambroxol for symptomatic relief. Follow‐up chest CT 1 week later (Figure 1F) showed partial resolution of the inflammatory changes in the left lung. However, a mass‐like soft tissue density with high‐density shadow was observed in the left lower lobe at the level of the thoracic vertebrae T8–T11, raising suspicion of a bronchial foreign body with atelectasis. Further evaluation was recommended. The patient subsequently sought treatment at our hospital for further investigation and management.

FIGURE 1.

Chest non‐contrast, enhanced CT and bronchial artery CTA images from an external hospital. (A–C) Initial non‐contrast and enhanced chest CT images; (D, E) bronchial arteriography (CTA) images of the patient; (F) post‐antibiotic therapy follow‐up chest CT images of the patient.

Enhanced chest CT at our hospital (Figure 2A–C) revealed several key findings: a smaller left thoracic cavity; a suspected foreign body at the opening of the left lower lobe bronchus, with associated atelectasis of the left lower lobe; compensatory enlargement of the left upper lobe with mild inflammation; and small nodules in the lingular segment of the left upper lobe; tortuous vessels within the mass. Ultrasound bronchoscopy confirmed complete occlusion of the left lower lobe bronchus due to scar tissue formation, with no evidence of neoplastic growth (Figure 2D–F). Based on these findings, a diagnosis of bronchial foreign body with bronchial occlusion was established. During treatment in the respiratory department, multiple attempts were made to retrieve the foreign body via bronchoscopy, including planned incision of the scar tissue to expose the foreign body. However, these attempts were unsuccessful due to immediate and profuse bleeding upon minimal incision of the scar, which obscured the surgical field. The patient was subsequently referred to thoracic surgery for further management. Following the exclusion of surgical contraindications, the patient underwent video‐assisted thoracoscopic left lower lobectomy and bronchial foreign body removal under general anaesthesia. The procedure proceeded uneventfully (Figure 3A,B), and the extracted bronchial foreign body was ultimately identified as a sunflower seed shell (Figure 3C,D).

FIGURE 2.

Enhanced chest CT scan and endobronchial ultrasound images from our hospital. (A–C) Enhanced chest CT scan images of the patient; (D–F) endobronchial ultrasound (EBUS) images of the patient.

FIGURE 3.

Images from the patient's surgery and the extracted foreign body, along with pre‐ and post‐chest tube removal x‐ray images. (A, B) Operative images of video‐assisted thoracoscopic left lower lobectomy and bronchial foreign body removal; (C, D) extracted bronchial foreign body—sunflower seed shell; (E) pre‐chest tube removal x‐ray images of the patient; (F) post‐chest tube removal x‐ray images of the patient.

Postoperatively, the patient demonstrated an uneventful recovery, with normal body temperature, no respiratory discomfort, clear lung sounds on auscultation and the surgical incision healed well. Comparison of the patient's x‐ray images before and after chest tube removal demonstrated significant recovery (Figure 3E,F), and the patient was subsequently discharged in good condition.

3. Discussion

This case presents a rare instance of an adult patient with occult bronchial foreign body aspiration, where the aspirated material was identified as a plant‐based sunflower seed shell. Although the patient reported a disease course of over a year, the exact timing of aspiration remained uncertain. Initial enhanced chest CT and bronchial arteriography (CTA) suggested bronchial and vascular malformations consistent with the criteria for pulmonary sequestration, suggesting that the foreign body had been aspirated during childhood. Subsequent enhanced chest CT and ultrasound bronchoscopy at our hospital revealed a complete occlusion of the left lower lobe, indirectly supporting the aforementioned hypothesis. A similar case is documented in a study of a 29‐year‐old female who had an 18‐year history of recurrent coughing, choking and respiratory infections following foreign body aspiration, eventually leading to chronic lung abscess [4]. However, unlike the present case, the previous study did not provide detailed information about the bronchial, vascular and pulmonary lesions, despite the history of foreign body aspiration.

Upon retrospective analysis of the images, we discovered that the initial enhanced CT scan and bronchial arteriography (CTA) had already indicated the possibility of a bronchial foreign body. However, it was initially misdiagnosed as a mass‐like soft tissue shadow with calcification. Furthermore, based on the enhanced CT scan performed at our hospital, the vascular abnormalities were not attributable to pulmonary sequestration but rather resulted from occlusion and atrophy of the left lower lobe. These observations underscore the importance for clinicians to remain vigilant when diagnosing atypical airway foreign bodies. Diagnoses should not rely solely on radiological reports but should involve meticulous examination of imaging findings, particularly focusing on high‐density shadows within the airway and masses with calcification, to minimise the risk of missed or incorrect diagnoses.

Typically, segmentectomy or lobectomy is considered a last resort treatment option for patients due to its numerous negative impacts. Kogure et al. [5] reported a case in which rigid bronchoscopy was successfully used to remove a difficult‐to‐remove bronchial foreign body. In this case, during treatment in the respiratory department, attempts were made to incise the scar tissue to expose the foreign body. However, these efforts were unsuccessful due to immediate and profuse bleeding upon minimal incision of the scar, which obscured the surgical field. To prevent life‐threatening haemorrhage, further endoscopic interventions were terminated and rigid bronchoscopy was also not employed. This outcome was consistent with preoperative imaging findings (enhanced CT and bronchial artery CTA) and postoperative pathological results, both of which demonstrated abundant tortuous vessels in the lesion area. Furthermore, it had caused complete dysfunction of the left lower lobe and was associated with bronchial developmental abnormalities, making conservative treatments ineffective. For such cases, we recommend timely surgical consultation and intervention. Previous studies have reported that in cases of delayed treatment of bronchial foreign bodies in children leading to significant pulmonary complications, lobectomy was performed on seven patients and pneumotomy was performed on one patient [6]. In this case, we opted for a video‐assisted thoracoscopic left lower lobectomy combined with bronchial foreign body removal. The final outcome confirmed that this surgical approach was indeed appropriate and effective.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, execution, acquisition of data, analysis, writing and interpretation. All authors have read and agreed to the published version of the manuscript.

Ethics Statement

The authors declare that written informed consent was obtained for the publication of this manuscript and accompanying images using the consent form provided by the Journal.

Conflicts of Interest

The authors declare no conflicts of interest.

Shi Q., Bao J., Li J., and Shu J., “Video‐Assisted Thoracoscopic Left Lower Lobectomy and Bronchial Foreign Body Removal for Treating a Rare Occult Bronchial Foreign Body in an Adult,” Respirology Case Reports 13, no. 6 (2025): e70262, 10.1002/rcr2.70262.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.