INTRODUCTION:A tracheobronchial foreign body (TFB) can be a life-threatening emergency which requires urgent intervention. TFBs occur most commonly in childhood as a result of aspiration. Traumatic TFB is less commonly reported in the literature. We report a case of a TFB resulting from an impaling injury more than 30-years prior to presentation.
CASE PRESENTATION:A 45 year-old Hispanic male fell from a tree at age 13, impaling himself on one of its lower branches. The patient recalls being taken to a local hospital in Mexico where a piece of wood was pulled out of his right posterior chest, and a right-sided chest tube was placed. The chest tube was removed three days later and the patient was discharged from the hospital. The patient reports that he had no further problems until age 39 when he developed a chronic cough with intermittent episodes of hemoptysis. Over the last several years he had also experienced frequent episodes of pneumonia. On physical exam, a 4 cm well-healed scar was noted on the mid aspect of his right posterior hemithorax. Rhonchi were auscultated in the right posterior lower lung fields. A chest CT revealed a foreign body extending from the right lower lobe bronchus up into the bronchus intermedius. On rigid bronchoscopy, the patient was noted to have a large brown foreign body extending from the right lower lobe and causing near-complete obstruction of the right bronchus intermedius. Using rigid forceps, several pieces of yellow-brown splintering material were removed from the right bronchus intermedius. Pathology of this material was consistent with wood. Because the foreign body was firmly impacted into the right lower lobe bronchus, the majority of the body could not be removed. The patient underwent right thoracotomy with right middle lobe and right lower lobe resection. A 5 * 2.3 * 1.5 cm piece of wood was removed with the surgical specimen. The patient’s post-operative course was uncomplicated and he did well following hospital discharge with no further episodes of cough or pneumonia.
DISCUSSIONS:Since its inception in 1897, bronchoscopy has been used to assess and manage tracheobronchial foreign bodies. The overwhelming majority of these occur in children, as a result of aspiration. Although the literature has several reports of traumatic tracheobronchial foreign bodies, these events are exceedingly rare. The clinical presentation of TFB in adults may be insidious, with cough as the most commonly reported complaint. Radiographic changes in adults, if present, more commonly show pneumonic or atelectatic patterns. Our patient exhibited no symptoms attributable to his retained intrathoracic wood fragment for more than 2 decades. Others have reported a clinical presentation more than 60 years after the initial injury causing the TFB. Migration of the TFB is also rare, but has been reported. We postulate that in this patient, the gradual migration of the wood to an intrabronchial location explained the delayed symptom onset. Removal of the TFB may occur bronchoscopically, or may require surgical excision, as with our patient.
CONCLUSION:Adult TFB is a rare event, which may present with a non-specific constellation of insidious symptoms years after the initial injury. Accurate diagnosis often requires a detailed history, early use of CT imaging, and bronchoscopic evaluation. To our knowledge, all of the reported cases in the literature to date have involved an initial projectile injury; gunshot, explosive device, etc. We believe our case is the first report of an impaling injury causing a delayed TFB.
DISCLOSURE:Konrad Davis, None.