INTRODUCTION: Aspirated foreign bodies (FB) are a common problem and their retrieval can be difficult. Novel technologies are providing unique ways in which these objects can be removed. We present a case of an aspirated metallic FB removed with the assistance of a flexible cryoprobe.
CASE PRESENTATION: A 57-year-old female presented with dyspnea initially attributed to worsening of her chronic obstructive pulmonary disease. A chest x-ray showed a metallic FB in the left lower lobe (LLL). The patient could not recall how the FB was aspirated. She denied chest pain or hemoptysis. Her vital signs and oxygen saturation were normal. Physical exam was unremarkable except for diminished breath sounds bilaterally without wheezing. A CT scan showed a 2cm linear, metallic FB in the bronchus of the LLL without erosion through the bronchial wall or parenchymal changes. The patient underwent flexible bronchoscopy in an attempt to remove the object using endobronchial forceps and snares, but was unsuccessful. The FB appeared to be sharp and was barely pushing into the bronchial mucosa. The position and smooth, metallic material made grabbing the object difficult. Given the lack of urgency and significant sedation required, the procedure was aborted. She was admitted and given several days of antibiotics and inhaled bronchodilators including inhaled steroids. Another bronchoscopy was performed under general anesthesia and endobronchial cryotherapy employed. The cryoprobe was positioned so the tip contacted the FB. The cryoprobe was used to pull the tip of the FB away from the mucosa and lift it out of position, forceps were then used to extract it. She was extubated in the operating room and discharged the same day. When shown the object post-recovery she remembered a week prior she held push pins in her mouth, but did not recall choking.
DISCUSSION: FB aspiration accounted for 3200 deaths in the United States in 1998. The clinical presentation depends on where the FB lodges. In the larynx, aspiration causes acute choking, coughing, and gagging while in the subglottic/tracheal region inspiratory stridor and coughing is observed. If the FB lodges in the lower airways symptoms may be minimal. Aspiration is usually acute in children as the mainstem bronchi are often involved. In adults, aspiration is less acute and may go unnoticed as the FB usually wedges more distally. FB can be organic (blood, mucous) or inorganic (dental work, pins) in nature. These varied objects require different techniques for removal and the selection is influenced by the surrounding tissue reaction and location. The first FB was removed via rigid bronchoscope (RB) by Gustav Killan in 1897. The RB was used for extraction exclusively until the development of the flexible bronchoscope by Shigeto Ikeda in 1968. Forceps, balloons, baskets, magnets, and cryotherapy may be deployed through a flexible bronchoscope. In cryotherapy a coolant is delivered under pressure to the tip of a probe that passes through the working channel of a flexible bronchoscope. When placed in contact with the FB, the cryoprobe can be iced and adhered to the FB. Additional advantages include vasoconstriction, analgesia, and hemostasis due to cellular crystallization and microthrombi formation as well as favorable operator and patient safety. In organic objects cryotherapy also causes shrinkage, facilitating separation from the mucosa. This technique is helpful in removing organic material but only recently has found use when extracting inorganic objects.
CONCLUSIONS: Only one other case was found in the literature using cryotherapy to extract a metallic FB. Due to the slippery nature of smooth-surfaced metallic objects, conventional means can fail in retrieval. This case shows that cryotherapy may be employed when dealing with these objects to facilitate removal.
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Reference #3 Schumann C, Kropf C, et. al. Removal of an aspirated foreign body with a flexible cryoprobe. Resp Care 2010;55(8):1097-1099.
DISCLOSURE: The following authors have nothing to disclose: Adam Wellikoff, Sonia Tindel, Amaraja Kanitker, Robert Holladay
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