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Foreign Body
C H A P T E R
13 Foreign Body Amir Hanna and Pierre Baldeyrou Interventional Bronchoscopy Unit, Division of Thoracic Surgery and Lung Transplantation, Marie Lannelongue Hospital, Paris, France
The most commonly inhaled foreign bodies (FBs) in adults are foodrelated particles, teeth, fractured dental equipment, dentistry material, nails and screws, and small pen parts. Teeth are easily broken during difficult, urgent intubations. The discovery of inhaled FBs may be late during infection or pseudotumor clinico-radiological syndrome. We must consider the possibility of FBs in the presence of an obstructive or suppurative pathology, particularly on the right side, and more importantly in the presence of tumor-like granulomatous formations when biopsies are negative for tumors. Granulomatous buds in contact with the FBs may simulate tumor obstruction. In bronchial pathology of transplantation, a fragment of necrotic bronchus forms a sphacelus that behaves like an FB and should thus be removed when it is about to get detached. The discovery of an FB during fiber-optic bronchoscopy always requires an extraction attempt. A few simple guidelines must be followed during these maneuvers. Dormia basket or biopsy forceps are the most useful tool. It is preferred to pass through the oral cavity to avoid impaction of the foreign body in the rhinopharynx during extraction, with the risk that it might fall again. After suction of all secretions distal to the obstruction and reinforcement of local anesthesia, the forceps’ grip would be easy if there is a sharp and anfractuous or irregular edge more difficult if the edge is smooth, unless we manage to move the forceps and turn the FB to have a better view on a better side. It is easy if the FB is impacted in the bronchus intermedius, for example. In case of complete obstruction of the basal segments, the bronchus tends to retain the FB that must be moved gently but firmly and brings
Normal and Pathological Bronchial Semiology DOI: https://doi.org/10.1016/B978-0-12-815795-4.00013-9
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© 2019 Elsevier Inc. All rights reserved.
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13. FOREIGN BODY
it closer to the contact point of the lens of the flexible bronchoscope; during removal, cough as well as the contact of this FB with the mucous membrane and the subglottic arch should be limited by asking the patient to breathe in deeply to minimize the risk of the FB to fall back. In intubated patients or those with tracheotomy, the size of the FB may be larger than that of the tube. In this case, the patient is extubated with the bronchoscope withdrawn with the forceps holding the FB and the patient is then reintubated again. This is easier and safer to be performed in the operating room using a rigid bronchoscope. In such case, various available forceps better adapted to these FBs; they are larger in size with a better grip. A balloon catheter may be used to bypass the FB; when the balloon is inflated, the FB can be brought in contact with the tube and then withdrawn entirely without the risk of the FB to fall back. Bleeding during withdrawal may be an additional difficulty; a rigid bronchoscope with adapted forceps will be the best solution for any extraction without difficulty.
NORMAL AND PATHOLOGICAL BRONCHIAL SEMIOLOGY
CASES
159
CASES
FIGURE 13.1 Irregular, thickened, hyperemic mucosal injury due to traumatic FB aspiration. One week after silver nitrate traumatic injury.
FIGURE 13.2 Reduced middle lobe divisions, healing by stenosis 1 month after silver nitrate traumatic injury.
FIGURE 13.3
Removal of the remaining part of silver nitrate and complete removal
using forceps.
NORMAL AND PATHOLOGICAL BRONCHIAL SEMIOLOGY
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13. FOREIGN BODY
FIGURE 13.4 Middle lobe divisions healing by stenosis, 2 months after traumatic silver nitrate injury.
FIGURE 13.5 Left lower basal segment reactional granuloma formation related to old missed FB inhalation.
FIGURE 13.6 Missed part of a metallic stent after ablation seen embedded in the right side of the tracheal mucosa.
NORMAL AND PATHOLOGICAL BRONCHIAL SEMIOLOGY
CASES
161
FIGURE 13.7 Ulcerating granulomatous obstruction induced by FB inhalation. Source: Reproduced from Baldeyrou P, Pariente R. L’endoscopie laryngo-trache´o-bronchique. Encycl. Me´d. Chir. Paris. 1982. Poumon. 6000 M10-12. Copyright r 1982 Elsevier Masson SAS. All rights reserved.
FIGURE 13.8 FB extraction. Barbed broach. Source: Reproduced from Baldeyrou P, Pariente R. L’endoscopie laryngo-trache´o-bronchique. Encycl. Me´d. Chir. Paris. 1982. Poumon. 6000 M10-12. Copyright r 1982 Elsevier Masson SAS. All rights reserved.
FIGURE 13.9
FB extraction. Dental prosthesis.
NORMAL AND PATHOLOGICAL BRONCHIAL SEMIOLOGY
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13. FOREIGN BODY
FIGURE 13.10 FB extraction. Dental prosthesis.
FIGURE 13.11 FB extraction. Metallic screw.
NORMAL AND PATHOLOGICAL BRONCHIAL SEMIOLOGY
13 Foreign Body Amir Hanna and Pierre Baldeyrou Interventional Bronchoscopy Unit, Division of Thoracic Surgery and Lung Transplantation, Marie Lannelongue Hospital, Paris, France
The most commonly inhaled foreign bodies (FBs) in adults are foodrelated particles, teeth, fractured dental equipment, dentistry material, nails and screws, and small pen parts. Teeth are easily broken during difficult, urgent intubations. The discovery of inhaled FBs may be late during infection or pseudotumor clinico-radiological syndrome. We must consider the possibility of FBs in the presence of an obstructive or suppurative pathology, particularly on the right side, and more importantly in the presence of tumor-like granulomatous formations when biopsies are negative for tumors. Granulomatous buds in contact with the FBs may simulate tumor obstruction. In bronchial pathology of transplantation, a fragment of necrotic bronchus forms a sphacelus that behaves like an FB and should thus be removed when it is about to get detached. The discovery of an FB during fiber-optic bronchoscopy always requires an extraction attempt. A few simple guidelines must be followed during these maneuvers. Dormia basket or biopsy forceps are the most useful tool. It is preferred to pass through the oral cavity to avoid impaction of the foreign body in the rhinopharynx during extraction, with the risk that it might fall again. After suction of all secretions distal to the obstruction and reinforcement of local anesthesia, the forceps’ grip would be easy if there is a sharp and anfractuous or irregular edge more difficult if the edge is smooth, unless we manage to move the forceps and turn the FB to have a better view on a better side. It is easy if the FB is impacted in the bronchus intermedius, for example. In case of complete obstruction of the basal segments, the bronchus tends to retain the FB that must be moved gently but firmly and brings
Normal and Pathological Bronchial Semiology DOI: https://doi.org/10.1016/B978-0-12-815795-4.00013-9
157
© 2019 Elsevier Inc. All rights reserved.
158
13. FOREIGN BODY
it closer to the contact point of the lens of the flexible bronchoscope; during removal, cough as well as the contact of this FB with the mucous membrane and the subglottic arch should be limited by asking the patient to breathe in deeply to minimize the risk of the FB to fall back. In intubated patients or those with tracheotomy, the size of the FB may be larger than that of the tube. In this case, the patient is extubated with the bronchoscope withdrawn with the forceps holding the FB and the patient is then reintubated again. This is easier and safer to be performed in the operating room using a rigid bronchoscope. In such case, various available forceps better adapted to these FBs; they are larger in size with a better grip. A balloon catheter may be used to bypass the FB; when the balloon is inflated, the FB can be brought in contact with the tube and then withdrawn entirely without the risk of the FB to fall back. Bleeding during withdrawal may be an additional difficulty; a rigid bronchoscope with adapted forceps will be the best solution for any extraction without difficulty.
NORMAL AND PATHOLOGICAL BRONCHIAL SEMIOLOGY
CASES
159
CASES
FIGURE 13.1 Irregular, thickened, hyperemic mucosal injury due to traumatic FB aspiration. One week after silver nitrate traumatic injury.
FIGURE 13.2 Reduced middle lobe divisions, healing by stenosis 1 month after silver nitrate traumatic injury.
FIGURE 13.3
Removal of the remaining part of silver nitrate and complete removal
using forceps.
NORMAL AND PATHOLOGICAL BRONCHIAL SEMIOLOGY
160
13. FOREIGN BODY
FIGURE 13.4 Middle lobe divisions healing by stenosis, 2 months after traumatic silver nitrate injury.
FIGURE 13.5 Left lower basal segment reactional granuloma formation related to old missed FB inhalation.
FIGURE 13.6 Missed part of a metallic stent after ablation seen embedded in the right side of the tracheal mucosa.
NORMAL AND PATHOLOGICAL BRONCHIAL SEMIOLOGY
CASES
161
FIGURE 13.7 Ulcerating granulomatous obstruction induced by FB inhalation. Source: Reproduced from Baldeyrou P, Pariente R. L’endoscopie laryngo-trache´o-bronchique. Encycl. Me´d. Chir. Paris. 1982. Poumon. 6000 M10-12. Copyright r 1982 Elsevier Masson SAS. All rights reserved.
FIGURE 13.8 FB extraction. Barbed broach. Source: Reproduced from Baldeyrou P, Pariente R. L’endoscopie laryngo-trache´o-bronchique. Encycl. Me´d. Chir. Paris. 1982. Poumon. 6000 M10-12. Copyright r 1982 Elsevier Masson SAS. All rights reserved.
FIGURE 13.9
FB extraction. Dental prosthesis.
NORMAL AND PATHOLOGICAL BRONCHIAL SEMIOLOGY
162
13. FOREIGN BODY
FIGURE 13.10 FB extraction. Dental prosthesis.
FIGURE 13.11 FB extraction. Metallic screw.
NORMAL AND PATHOLOGICAL BRONCHIAL SEMIOLOGY