Airway Foreign Body—Leave Nothing Behind

ABSTRACT

A middle‐aged male presented with chronic cough, shortness of breath and fever. In the presence of wheeze and mild right‐sided opacities on chest x‐ray, he was treated for infective exacerbation of asthma with nebulised bronchodilators, antibiotics and steroids. Due to persistent wheeze, a contrasted computed tomography (CT) scan was done and revealed the presence of two endobronchial linear foreign body (FB) opacities, the second located more distally than the first. A rigid bronchoscopy‐based technique under general anaesthesia was used to remove the first FB, and flexible bronchoscopy via endotracheal tube was used for the second FB in the same session. This case illustrates the tenets of airway FB diagnosis and management. The differential diagnosis of radiolucent airway FB needs to be considered in patients with chronic symptoms. Rigid and flexible bronchoscopy techniques are complementary. Peripheral lesions are more accessible by flexible bronchoscopy. Measures to ensure complete removal of FBs must be consistently incorporated into routine practice.

We present a case of airway FB aspiration radiolucent on chest x‐ray, presented 2 years after occurrence and careful study of CT images revealed 2 FBs. The second FB located more peripherally than the first. Complete removal was achieved by rigid and flexible bronchoscopy techniques.

1. Introduction

Globally, foreign body (FB) airway aspiration has the highest age standardised death rate compared to FB in other body parts [1]. Diagnosis can be challenging, especially in cases with no clear history of choking. Only 25%–38% of adults with airway FB recall choking [2]. Persistent symptoms of cough, shortness of breath (SOB) and wheezing can be mistakenly treated as chronic lung disease before delayed diagnosis. Radiolucent airway FB adds to the diagnostic challenge. In case series, 24.6% of airway FB cases were not visible on chest x‐ray (CXR) [3]. We report a case of FB aspiration, radiolucent on CXR, diagnosed 2 years after occurrence, requiring careful study of CT scan images before complete removal by rigid and flexible bronchoscopy techniques.

2. Case Report

A middle‐aged male presented with fever, chronic cough for 2 years and SOB. His temperature was 39.3°C, heart rate 120 beats per minute, peripheral oxygen saturations of 95% on room air, respiratory rate 20 breaths per minute and blood pressure 136/70 mmHg. On lung auscultation, bilateral wheeze was present. His total white count was elevated at 13.36 × 10⁹/L. CXR (Figure 1) reported mild right lower zone opacities. He was treated for an infective exacerbation of asthma with bronchodilators, antibiotics and oral steroids. His SOB and fever improved with treatment. Persistent cough led to concerns that he may not be able to perform spirometry accurately. As there was a lack of resolution of persistent cough and wheezing, a contrasted CT thorax was obtained (Figure 2A,B). The CT thorax reported a linear intra‐bronchial FB projected over the right lower lobe (RLL) bronchus and a separate linear density seen more distally in the segmental bronchus. As the FB appeared sharp in nature, rigid bronchoscopy (Figure 2C,D) was performed under general anaesthesia (GA) for removal of the FB. The patient was intubated with a rigid bronchoscope (Karl Storz 7.5, Tuttlingen, Germany) under rigid telescope visualisation. A flat‐shaped FB was visualised. A semi‐rigid grasping forcep was inserted into the rigid bronchoscope and, under visualisation via the rigid telescope, the FB was grasped and pulled to the tip of the rigid bronchoscope. The instruments were withdrawn ensemble, and the patient was extubated. The FB was released from the forcep and collected.

FIGURE 1.

Chest x‐ray reported as mild right lower zone opacities indicated by white arrow. FB is not visible.

FIGURE 2.

(A and B) CT thorax coronal cuts visualising two separate linear intra‐bronchial FBs. (C) First FB located proximally visualised on rigid bronchoscopy. (D) First FB securely grasped and pulled to tip of rigid bronchoscope before removal. (E) Second FB visualised on flexible bronchoscopy. (F) Retrieved FBs consistent in appearance to chicken bone fragments.

As CT report mentioned separate linear density seen distally in the RLL segmental bronchus, we used a flexible bronchoscope (BF‐1TH190, Olympus, Tokyo, Japan) to search for the second FB, which was found distally and was smaller in size but similar in shape, colour and appearance (Figure 2E). Due to the peripheral location and sharp nature of the FB, we decided on flexible bronchoscopy removal of the second FB via an endotracheal tube (ETT). After size 8.5 ETT intubation by the anaesthetist, the flexible bronchoscope was manoeuvred to the location of the second FB. A flexible forcep (FB‐211D, Olympus, Tokyo, Japan) was used to grasp the FB and pulled it to the tip of the ETT. The flexible bronchoscope, forcep grasping the FB and ETT were withdrawn en bloc. The second FB was collected upon extubation.

Anaesthetist used laryngeal mask while patient was allowed time to awaken. Flexible bronchoscopy airway inspection was repeated to ensure no FB fragment was left behind. He was transferred on nasal prongs to medical high dependency for observation. The next day, he reported feeling significantly better and his respiratory symptoms had resolved. He recalled that he was eating chicken meat 2 years ago and had an episode of choking and severe coughing. Our postulation was that the two FBs are chicken bone fragments (Figure 2F). He was discharged with no recurrence of symptoms on follow‐up.

3. Discussion

Our case presents an opportunity for reinforcing key tenets of airway FB management. In diagnosis, all that wheezes is not asthma. Restrictive [4] or obstructive [5] deficits can be present in FB aspiration on pulmonary function testing (PFT). The ease of availability and familiarity amongst respiratory physicians are benefits. However, PFT is neither sufficiently sensitive nor specific for the definitive diagnosis of airway FB.

Lack of history of choking and radiolucent FBs not directly visualised on CXR or CT add further challenges to diagnosis [2]. Delayed diagnosis can result in debilitating complications such as non‐resolving pneumonia, post‐obstructive bronchiectasis, haemoptysis and bronchial stenosis [3]. We advocate for continued follow‐up and surveillance with consideration to proceed to CT and bronchoscopy for patients with non‐resolving symptoms despite treatment.

For airway FBs that are radiologically visible, careful study of radiological images is imperative. Anatomical location, characteristics of FB and presence of complications are often gathered from radiological images and used for procedural planning and decision making. Our case had the uncommon finding of two separate FB linear densities on CT scan. It heightened our alertness to search for a second FB after the successful and smooth removal of the first FB. The alternative of fluoroscopy to screen for incomplete FB removal in this case was unhelpful as the FBs were radiolucent on x‐ray. A repeat CT scan on a separate occasion would be less preferred to the proceduralist making deliberate efforts to leave nothing behind during FB removal.

Discussions regarding choice of flexible versus rigid bronchoscopy are ongoing. FB removal via flexible bronchoscopy is successful in 90% of cases [3]. Experts have distilled the factors influencing decision‐making to patient characteristics, nature of FB and operator expertise rather than the inherent efficacy of techniques [6]. In our practice, the availability of flexible and rigid modalities allowed us to use both complementarily. Our patient had no pre‐existing co‐morbidities. FB was assessed to be sharp in nature, and the chronicity of symptoms led to the suspicion that it may be stuck down by impaction, justifying the use of rigid bronchoscopy not just for reducing the risk of damage to the airway and vocal cord during FB removal but also to increase the range of rigid instruments that can be deployed [7]. The distal location of the second FB and comparatively smaller size gave us confidence that flexible bronchoscopy via ETT would be successful.

We conclude that diagnosis, radiological features, complementary modalities of flexible and rigid bronchoscopy and deliberate checks to prevent leaving FB fragment are key to optimal management of airway FB.

Author Contributions

K.C.S. conceptualised and designed the manuscript. J.N. and C.T. drafted and wrote it. Photos and figures were obtained by C.T. All authors reviewed the manuscript.

Consent

The authors declare that written informed consent was obtained for the publication of this manuscript and accompanying images and attest that the form used to obtain consent from the patient complies with the Journal requirements as outlined in the author guidelines.

Conflicts of Interest

K.C.S. is an Editorial Board member of Respirology Case Reports and a co‐author of this article. He was excluded from all editorial decision‐making related to the acceptance of this article for publication. The other authors declare no conflicts of interest.

Ng J., Thong C., and See K. C., “Airway Foreign Body—Leave Nothing Behind,” Respirology Case Reports 13, no. 8 (2025): e70332, 10.1002/rcr2.70332.

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.