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Retained Endobronchial Foreign Body Removal Facilitated by Steroid Therapy of an Obstructing, Inflammatory Polyp
Retained Endobronchial Foreign Body Removal Facilitated by Steroid Therapy of an Obstructing, Inflammatory Polyp· Terrence C. ." oi.wln M.D ., EC.C .P.t
Oral and topical steroids were used to induce regression in an inRammatory, obstructing endobronchial polyp caused by a retained foreign body. The FB (a peanut half), which had been present for over six month s, was then able to be easily and bloodlessly retrieved with fiberoptic bronchos(Chest 1991; 100:270) copy.
I FB =foreign bod y
FICUIlE I. ttc nualed e ndobronchial polyp after ste roid therapy and immed iately post FB extraction.
E
ndobronchial polyps mav lollow foreign body aspiration," smoke inhalation' and other inflammatory processes. ' .5 TIll' lise of steroid s in a foreign body-induced inflammatory polypoid lesion to facilitate successful endoscopic extraction is presented and d iscussed . CAS E REPORT
A 40-year-old woman develop ed a choking sen sation , cough, and transi ent dyspn ea while t>ating peanuts. Because of possible aspiration , she was seen in an e me rge ncy room, but no abnormalities wer e detected at the time . Ove r the next few weeks, symptoms of increasing cough, whee zing, and purulent sputum production were treat ed by various physicians with antibiotics and bronchodilators, and a diagnosis of asthma was made . Six month s late r, she was referred to the author. Endo scopy was performed after both a che st cr and chest x-ray film were interpreted as normal. At endoscopy, an obstructing polypoid lesion was noted in the posterobasal segment of the right lower lobe . Only a small , irregular lumen remained which allowed limited visualization of a partially incorporated FB . Pronounced vascularity of the polypo id lesion and the small residual lumen precluded attempts at extraction of the FB with the fiber scope . An inhaled steroid (triamcinolone) was started and oral prednisone at 20 mwday was initiated . The prednisone was reduced to 10 mg/day after three weeks and then stopped after tapering for three more weeks. Repeat end oscopic evaluation revealed a dramatic regression in the size of the polypoid lesion (Fig I), and a peanut half (Fig 2) was readily extr acted without bleeding using the fiberoptic endoscope and forcep s. Ectasia of the obstructed segment is visible in Figure 1. Follow-up bronchoscopy five months postextraction revealed no visible evidence of an endobronchial proce ss and all symptoms were resolved .
FIGURE 2. Foreign body (peanut half).
only repeated treatment for reactive airways disease may provide a clue as to the diagnosis.· In this case , the history and physical findings made a retained FB highly likely as endoscopy ultimately demonstrated. Since steroids have been previously shown to reduce inRammatory polyp size ," their use seemed logical in this case in an attempt to reduce the polyps size and vascularity (presumably a function of the persistent irritating nature of the FB). Additionally, Berman et al' described the use of steroids in the treatment of a FB-induced polyp, though this was after the FB was extracted. In view of the chronicity of the process in this patient, the addition of the short course of steroids, in addition to continuing antibiotics and bronchodilators, seemed to pose little short-term risk. The steroid-induced regression of the obstructing polyp was clearly the intervention which allowed fiberscopic removal rather than resorting to more aggressive measures. Further regression of the polyp occurred after FB removal without the need for continued steroids. Though perhaps only warranted in an occasional patient under similar circumstances, the use of steroids to reduce the inflammatory mucosal response should be kept in mind as a therapeutic option .
DISCUSSIO:-J
Endobronchial polypoid lesions appear to be a sequela of a variety of imRammatory insult s including that produced by FB. I.' Immediate extraction after aspiration would obviously preclude this development; however, as in this case , we are occasionally faced with a patient where a long standing, retained FB has caused symptoms of hyperactive airways, wheezing, or recurrent bronchial infections . In children, where the histor y of aspiration may be missed , ·From the Department of Medicin e and Preventive Medicine, Loyola University-Stritch School of Medicine, Maywood, and the Midwest Center for Env ironm ental Medicine, Orland Park, II. tClinica( Associate Professor of Medicine. Reprint requests: Dr. Moisan, Midwest Center fur Environmental Medicine , 15.'100 West Avenu e, Orland Iurk, II. 60462
270
REFERENCES
2
3
4 5 6
Greene JG , Lassin L, Saberi A. Endobronchial epithelial papilloma associated with a foreign body. Chest 1990: 97:229-30 Berman DE, Wright ES , Edstrom H'N. Endobronchial inflammatory polyp associated with a foreign body. Chest 1984; 86:3:48384 Adams C, Moisan T, Chandrasekhar AJ. Warpeha R. Endobronchial polyposis secondary to thermal inhalational injury. Chest 1979; 75:5:643-45 Saini VK, Waki PL . Inflammatory polyp on the bronchus. Ann Thoracic Surg 1968: 5:2:141-45 Arguelles M, Blanco I. Inflammatory bronchial polyps associated with asthma. Arch Intern Med 1983; 143:570-71 Caglayan S, Erkin S, Coteli I, Oniz H. Bronchial foreign body vs asthma. Chest 1989; 96:3:509-11 RetainedEndobronchial ForeignBody Removal (Terrence C. Moisan)
Oral and topical steroids were used to induce regression in an inRammatory, obstructing endobronchial polyp caused by a retained foreign body. The FB (a peanut half), which had been present for over six month s, was then able to be easily and bloodlessly retrieved with fiberoptic bronchos(Chest 1991; 100:270) copy.
I FB =foreign bod y
FICUIlE I. ttc nualed e ndobronchial polyp after ste roid therapy and immed iately post FB extraction.
E
ndobronchial polyps mav lollow foreign body aspiration," smoke inhalation' and other inflammatory processes. ' .5 TIll' lise of steroid s in a foreign body-induced inflammatory polypoid lesion to facilitate successful endoscopic extraction is presented and d iscussed . CAS E REPORT
A 40-year-old woman develop ed a choking sen sation , cough, and transi ent dyspn ea while t>ating peanuts. Because of possible aspiration , she was seen in an e me rge ncy room, but no abnormalities wer e detected at the time . Ove r the next few weeks, symptoms of increasing cough, whee zing, and purulent sputum production were treat ed by various physicians with antibiotics and bronchodilators, and a diagnosis of asthma was made . Six month s late r, she was referred to the author. Endo scopy was performed after both a che st cr and chest x-ray film were interpreted as normal. At endoscopy, an obstructing polypoid lesion was noted in the posterobasal segment of the right lower lobe . Only a small , irregular lumen remained which allowed limited visualization of a partially incorporated FB . Pronounced vascularity of the polypo id lesion and the small residual lumen precluded attempts at extraction of the FB with the fiber scope . An inhaled steroid (triamcinolone) was started and oral prednisone at 20 mwday was initiated . The prednisone was reduced to 10 mg/day after three weeks and then stopped after tapering for three more weeks. Repeat end oscopic evaluation revealed a dramatic regression in the size of the polypoid lesion (Fig I), and a peanut half (Fig 2) was readily extr acted without bleeding using the fiberoptic endoscope and forcep s. Ectasia of the obstructed segment is visible in Figure 1. Follow-up bronchoscopy five months postextraction revealed no visible evidence of an endobronchial proce ss and all symptoms were resolved .
FIGURE 2. Foreign body (peanut half).
only repeated treatment for reactive airways disease may provide a clue as to the diagnosis.· In this case , the history and physical findings made a retained FB highly likely as endoscopy ultimately demonstrated. Since steroids have been previously shown to reduce inRammatory polyp size ," their use seemed logical in this case in an attempt to reduce the polyps size and vascularity (presumably a function of the persistent irritating nature of the FB). Additionally, Berman et al' described the use of steroids in the treatment of a FB-induced polyp, though this was after the FB was extracted. In view of the chronicity of the process in this patient, the addition of the short course of steroids, in addition to continuing antibiotics and bronchodilators, seemed to pose little short-term risk. The steroid-induced regression of the obstructing polyp was clearly the intervention which allowed fiberscopic removal rather than resorting to more aggressive measures. Further regression of the polyp occurred after FB removal without the need for continued steroids. Though perhaps only warranted in an occasional patient under similar circumstances, the use of steroids to reduce the inflammatory mucosal response should be kept in mind as a therapeutic option .
DISCUSSIO:-J
Endobronchial polypoid lesions appear to be a sequela of a variety of imRammatory insult s including that produced by FB. I.' Immediate extraction after aspiration would obviously preclude this development; however, as in this case , we are occasionally faced with a patient where a long standing, retained FB has caused symptoms of hyperactive airways, wheezing, or recurrent bronchial infections . In children, where the histor y of aspiration may be missed , ·From the Department of Medicin e and Preventive Medicine, Loyola University-Stritch School of Medicine, Maywood, and the Midwest Center for Env ironm ental Medicine, Orland Park, II. tClinica( Associate Professor of Medicine. Reprint requests: Dr. Moisan, Midwest Center fur Environmental Medicine , 15.'100 West Avenu e, Orland Iurk, II. 60462
270
REFERENCES
2
3
4 5 6
Greene JG , Lassin L, Saberi A. Endobronchial epithelial papilloma associated with a foreign body. Chest 1990: 97:229-30 Berman DE, Wright ES , Edstrom H'N. Endobronchial inflammatory polyp associated with a foreign body. Chest 1984; 86:3:48384 Adams C, Moisan T, Chandrasekhar AJ. Warpeha R. Endobronchial polyposis secondary to thermal inhalational injury. Chest 1979; 75:5:643-45 Saini VK, Waki PL . Inflammatory polyp on the bronchus. Ann Thoracic Surg 1968: 5:2:141-45 Arguelles M, Blanco I. Inflammatory bronchial polyps associated with asthma. Arch Intern Med 1983; 143:570-71 Caglayan S, Erkin S, Coteli I, Oniz H. Bronchial foreign body vs asthma. Chest 1989; 96:3:509-11 RetainedEndobronchial ForeignBody Removal (Terrence C. Moisan)