Foreign body aspiration (FBA) is a phenomenon commonly seen in infants and young children. Adult aspiration of foreign bodies acutely presents with symptoms of upper airway obstruction. When aspirations into the distal airways are silent they can lead to prolonged entrapment of foreign materials and significant complications. Those complications can lead to misdiagnosis and inadequate treatment.
32 year old African American female admitted to the hospital for worsening shortness of breath and cough for two weeks and left sided pleuritc chest pain. Past medical history was notable for morbid obesity and asthma for 16 years treated with inhaled bronchodilators, inhaled and systemic steroids. Physical exam revealed a heart rate of 127, respiratory rate of 28, and blood pressure of 168/92. Temperature was 98F.She had diffuse expiratory wheezes bilaterally. Laboratory evaluation revealed a WBC of 15,000. Chest radiograph revealed left lingular infiltrate and left hemidiaphragm elevation. Patient was treated for asthma exacerbation and pneumonia and underwent ventilation/perfusion (V/Q) scan (secondary to iodine allergy) to rule out pulmonary embolism (PE). V/Q scan was low probability for PE but remarkable for absence of ventilation to the left lung. As a result, the patient underwent flexible FOB which revealed almost completely occluded left main stem bronchus by an endobronchial mass 4 cms from the carina. Pathology of the mass revealed granulation tissue.Patient was taken to the operating room for FOB after intubation under general anesthesia which revealed a left mainstem bronchial lesion and distal to it a FB, successfully removed by alligator forceps. Pathology confirmed the presence of a 1.1cm long, 0.8 cm wide tip of a plastic drinking straw. Close questioning revealed a history of aspiration while chewing a plastic straw at the age of 16 yrs.
FBA in adults is limited to the larynx or proximal trachea and usually occurs on the right. Common aspirated materials include food, dental prosthesis, and bone, fragments of teeth, tracheostomy tubes and speech devices. The first case of an aspirated drinking straw obstructing an airway was reported in 1990.Common initial symptoms following an acute event include coughing and choking. Severe symptoms can occur including hemoptysis and diffuse wheezing. Silent aspirations can occur after major trauma, drug or alcohol intoxication, or in patients with dysfunction of the oropharynx and neurological disorders. Diagnosis is often delayed because of absence of early specific symptoms. This leads to FBA misdiagnosed as other respiratory diseases including asthma, lung cancer and infectious causes. Aspirated foreign body in the airway usually induces bronchial wall edema and inflammation. Eventually, foreign body is surrounded by granulation tissue leading to airway stenosis. The granulation tissue response can be severe and can mimic endobronchial carcinoma.Diagnosing a FB in the airway can be challenging. The chest radiographic findings are inadequate to exclude the diagnosis and include atelectasis and bronchiectasis. Computed Tomography is more accurate for detecting lung parenchymal manifestations of FBA and should be used as a tool for guiding retrieval of FB using FOB.
Endobronchial FBA should be included in the differential diagnosis for patient’s with atypical onset, adult onset, and difficult to control asthma. Patient’s with FBA can present with diffuse bilateral wheezes as a result of bronchial hyperresponsiveness prompted by the aspirate. Aspiration can be asymptomatic at first if the foreign body is aligned in such a way that it does not obstruct the airway. However, prolonged entrapment can lead to granulation tissue formation and airway obstruction. Pathologic finding of granulation tissue upon biopsy of an airway lesion should lead to the suspicion of FBA. Full recovery after prolonged entrapment of FB of 16 years as in our case is possible.
Rubina Kerawala, None.