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Use of mediastinoscopy for foreign body removal
International Journal of Pediatric Otorhinolaryngology 50 (1999) 225 – 228 www.elsevier.com/locate/ijporl
Case report
Use of mediastinoscopy for foreign body removal Jennifer B. Lynch a, Joseph E. Kerschner a,*, John J. Aiken b, Neil Farber c, Michael Bousamra d a
Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Children’s Hospital of Wisconsin, 9000 West Wisconsin A6enue, Milwaukee, WI 53226, USA b Department of Pediatric Surgery, Medical College of Wisconsin, Children’s Hospital of Wisconsin, 9000 West Wisconsin A6enue, Milwaukee, WI 53226, USA c Department of Anesthesiology, Medical College of Wisconsin, Children’s Hospital of Wisconsin, 9000 West Wisconsin A6enue, Milwaukee, WI 53226, USA d Department of Cardiothoraic Surgery, Medical College of Wisconsin, Children’s Hospital of Wisconsin, 9000 West Wisconsin A6enue, Milwaukee, WI 53226, USA Received 19 February 1999; received in revised form 16 July 1999; accepted 19 July 1999
Abstract Foreign body removal from the aerodigestive tract can be a challenging endeavor despite improvements in technology. Rigid bronchoscopy has been demonstrated to be a safe and effective means of airway foreign body removal with appropriate training and expertise. However, potential complications exist and include extraluminal impaction of a penetrating foreign body during removal. This report details such a complication and the first known use of mediastinoscopy to remove the impacted foreign body to avoid the need for thoracotomy. © 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Foreign body aspiration; Bronchoscopy; Complications; Thoracotomy; Mediastinoscopy
1. Introduction Despite improvements in technology, the management of aspirated foreign bodies remains a challenge. Rigid bronchoscopy has been demonstrated to be a safe, reliable and effective means of * Corresponding author. Tel.: +1-414-266-6476; fax: + 1414-266-6989. E-mail address: [email protected] (J.E. Kerschner)
foreign body removal when performed properly [1,2]. Development of the fiberoptic telescope and the Hopkins rod-lens system has significantly improved instrumentation available for rigid bronchoscopic retrieval of aspirated foreign bodies. A variety of complications from airway foreign bodies have been known to occur including pneumothorax, anoxia, pneumonia, stricture, perforation, granulation formation and death [3,4]. Complications related to bronchoscopic re-
0165-5876/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 5 8 7 6 ( 9 9 ) 0 0 2 3 4 - 7
226
J.B. Lynch et al. / Int. J. Pediatr. Otorhinolaryngol. 50 (1999) 225–228
moval of foreign bodies are possible, especially with sharp and penetrating foreign bodies [1]. These complications include extraluminal impaction of a penetrating object. This report details such a complication and the first published case of mediastinoscopy instead of thoracotomy for foreign body removal.
2. Case report The patient is a ten-year-old boy in otherwise good health who was initially evaluated in the emergency room after suspected aspiration of a stick pin. Vital signs were normal for age and he was in no acute distress. Lungs were clear to auscultation and the remainder of the physical examination was within normal limits. Chest xray revealed a radio-opaque foreign body within the left mainstem bronchus consistent with a stick pin. The foreign body was oriented transversely. The pediatric surgery service was consulted and the patient was taken to the operating room. A 6.5-mm rigid bronchoscope was introduced and the pin was visualized just distal to the carina in
the left mainstem bronchus. Grasping optical forceps were used to secure the head of the pin and the bronchoscope was removed with the grasping forceps. Upon removal it was noted that the head of the pin was separated from the pin itself, and only the head had been removed through the bronchoscope. The bronchoscope was reintroduced but the pin could not be localized. An intraoperative chest film was obtained, demonstrating the pin to be bent and lying outside of the tracheal lumen just above the carina (Fig. 1). The pediatric otolaryngology service was consulted, and attempts to localize the pin with the combination of fluoroscopy and bronchoscopy were made without success. Rigid esophagoscopy was normal and fluoroscopy confirmed that the remaining foreign body was outside both the tracheal and esophageal lumen. The foreign body was presumed to have been embedded into the mediastinum during the initial attempted removal and it was elected to obtain a CT scan. The CT scan showed the pin to be in the right tracheoesophageal groove, extending down to the carina (Fig. 2). The patient was returned to the operating room and mediastinoscopy was per-
Fig. 1. Chest radiograph obtained after initial bronchoscopy demonstrating the new position of the foreign body, bent and apparently outside the tracheal lumen.
J.B. Lynch et al. / Int. J. Pediatr. Otorhinolaryngol. 50 (1999) 225–228
227
Fig. 2. CT obtained after bronchoscopy, with the foreign body lying outside the trachea in the tracheoesophageal groove.
formed by the cardiothoracic service. The stickpin was palpated and a hemostat was used to remove the end of the pin with fluoroscopic guidance. Reinsertion of the mediastinoscope confirmed hemostasis. Surgicel was placed at the previous site of the pin, and the wound was closed. The patient did well postoperatively and was discharged on postoperative day 1.
3. Discussion Rigid bronchoscopy with optical instrumentation has become the standard of care for airway foreign body removal. Experience with bronchoscopes and forceps for the various types of foreign body problems is of fundamental importance. If time allows, obtaining a duplicate foreign body will allow trial on a model to see which instruments work best for the particular mechanical problem. A significant rate of failures in foreign body extraction has been attributed to inadequate familiarity with known, safe techniques [1]. However, even an experienced surgeon can encounter significant difficulty. Sharp and penetrating objects pose a special
problem. This type of foreign body must be approached with complete and thoughtful consideration of the physiologic and mechanical factors involved [1]. When a foreign body is visualized, its orientation and shape are fully assessed. Localizing the point and advancing the bronchoscope to sheath the foreign body is crucial. If the point cannot be sheathed, the foreign body may be rotated with the point allowed to trail, preventing penetration of the mucosa. All manipulation is gentle and precise rather than forced. Additional techniques are sometimes required for more challenging foreign bodies. Fluoroscopy has been shown to be a valuable tool in the retrieval of radio-opaque foreign bodies, especially those located peripherally [5,6]. The C-arm fluoroscope can provide views of radio-opaque foreign bodies from various angles and is not limited by granulation tissue or edema. Ureteral stone baskets, Fogarty catheters and tracheotomy have been used to retrieve distal foreign bodies. Thoracotomy has also been required for removal of distal foreign bodies and for foreign bodies located outside the aerodigestive tract. The need for thoracotomy in aspirated foreign bodies
228
J.B. Lynch et al. / Int. J. Pediatr. Otorhinolaryngol. 50 (1999) 225–228
has been reported as B 1% [7]. Thoracotomy presents a number of potential risks which include trauma and injury to the underlying lung, lung herniation and chest wall muscle atrophy [8 – 10]. Use of mediastinoscopy for removal of foreign bodies has not been previously mentioned in the literature. Compared with thoracotomy, it offers the advantage of reduced recovery time, reduced pain, and improved cosmesis [11]. This report describes a foreign body located within the mediastinum as a complication of its removal. However, retained foreign bodies also occasionally migrate out of the aerodigestive tract and into the mediastinum [12]. Mediastinoscopy may provide an alternative method of removal to thoracotomy in such cases and limit potential complications such as injury to the lung, lung herniation and chest wall atrophy. As with any surgical procedure mediastinoscopy requires appropriate training and experience to be employed effectively and presents potential complications itself such as pneumothorax, pneumomediastinum or vascular injury. In conclusion, this report outlines a novel technique for removal of mediastinal foreign bodies to avoid the morbidity of thoracotomy. It also illustrates a potential complication of rigid bronchoscopic removal of a penetrating foreign body.
[2]
[3]
[4] [5]
[6]
[7]
[8]
[9]
[10]
[11]
References
[12]
[1] L.D. Hollinger, Management of sharp and penetrating
.
.
foreign bodies of the upper aerodigestive tract, Ann. Otol. Rhinol. Laryngol. 99 (1990) 684 – 688. L.D. Hollinger, Foreign bodies of the larynx, trachea and bronchi, in: C.D. Bluestone, S.E. Stool (Eds.), Pediatric Otolaryngology, WB Saunders, Philadelphia, PA, 1990, pp. 1205 – 1214. J Reilly, J Thompson, C MacArthur, S Pransky, D Beste, M Smith, et al., Pediatric aerodigestive foreign body injuries are complications related to timeliness of diagnosis, Laryngoscope 107 (1997) 17 – 20. J.S. Reilly, Airway foreign bodies: update and analysis, Int. Anesthesiol. Clin. 30 (4) (1992) 49 – 55. D.W. Vane, J. Pritchard, C.W. Colville, K.W. West, H. Eigen, J.L. Grosfeld, Bronchoscopy for aspirated foreign bodies in children. Experience in 131 cases, Arch. Surg. 123 (7) (1988) 885 – 888. R.E. Black, K.J. Choi, W.C. Syme, D.G. Johnson, M.E. Matlak, Bronchoscopic removal of aspirated foreign bodies in children, Am. J. Surg. 148 (6) (1984) 778 – 781. R.E. Black, D.G. Johnson, M.E. Matlak, Broncoscopic removal of aspirated foreign bodies in children, J. Pediatr. Surg. 29 (1994) 682 – 684. R.K. Deeik, M.A. Memon, J.T. Sugimoto, Lung herniation secondary to minimally invasive direct coronary artery bypass surgery, Ann. Thorac. Surg. 65 (1998) 1772 – 1774. C. Frola, J. Serrano, S. Cantoni, M. Casiglia, I. Turtulici, F. Loria, CT findings of atrophy of chest wall muscle after thoracotomy: relationship between muscles involved and type of surgery, Am. J. Roentgenol. 164 (3) (1995) 599 – 601. J.P. Hayes, E.A. Williams, P. Goldstraw, T.W. Evans, Lung injury in patients following thoracotomy, Thorax 50 (9) (1995) 990 – 991. R.J. Harris, M.S. Kavuru, T.W. Rice, T.J. Kirby, The diagnostic and therapeutic utility of thoracoscopy, Chest 108 (1995) 828 – 841. D.M. Burton, J.A. Stith, Extraluminal esophageal coin erosion in children, Int. J. Pediatr. Otorhinolaryngol. 23 (1992) 187 – 194.
Case report
Use of mediastinoscopy for foreign body removal Jennifer B. Lynch a, Joseph E. Kerschner a,*, John J. Aiken b, Neil Farber c, Michael Bousamra d a
Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Children’s Hospital of Wisconsin, 9000 West Wisconsin A6enue, Milwaukee, WI 53226, USA b Department of Pediatric Surgery, Medical College of Wisconsin, Children’s Hospital of Wisconsin, 9000 West Wisconsin A6enue, Milwaukee, WI 53226, USA c Department of Anesthesiology, Medical College of Wisconsin, Children’s Hospital of Wisconsin, 9000 West Wisconsin A6enue, Milwaukee, WI 53226, USA d Department of Cardiothoraic Surgery, Medical College of Wisconsin, Children’s Hospital of Wisconsin, 9000 West Wisconsin A6enue, Milwaukee, WI 53226, USA Received 19 February 1999; received in revised form 16 July 1999; accepted 19 July 1999
Abstract Foreign body removal from the aerodigestive tract can be a challenging endeavor despite improvements in technology. Rigid bronchoscopy has been demonstrated to be a safe and effective means of airway foreign body removal with appropriate training and expertise. However, potential complications exist and include extraluminal impaction of a penetrating foreign body during removal. This report details such a complication and the first known use of mediastinoscopy to remove the impacted foreign body to avoid the need for thoracotomy. © 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Foreign body aspiration; Bronchoscopy; Complications; Thoracotomy; Mediastinoscopy
1. Introduction Despite improvements in technology, the management of aspirated foreign bodies remains a challenge. Rigid bronchoscopy has been demonstrated to be a safe, reliable and effective means of * Corresponding author. Tel.: +1-414-266-6476; fax: + 1414-266-6989. E-mail address: [email protected] (J.E. Kerschner)
foreign body removal when performed properly [1,2]. Development of the fiberoptic telescope and the Hopkins rod-lens system has significantly improved instrumentation available for rigid bronchoscopic retrieval of aspirated foreign bodies. A variety of complications from airway foreign bodies have been known to occur including pneumothorax, anoxia, pneumonia, stricture, perforation, granulation formation and death [3,4]. Complications related to bronchoscopic re-
0165-5876/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 5 8 7 6 ( 9 9 ) 0 0 2 3 4 - 7
226
J.B. Lynch et al. / Int. J. Pediatr. Otorhinolaryngol. 50 (1999) 225–228
moval of foreign bodies are possible, especially with sharp and penetrating foreign bodies [1]. These complications include extraluminal impaction of a penetrating object. This report details such a complication and the first published case of mediastinoscopy instead of thoracotomy for foreign body removal.
2. Case report The patient is a ten-year-old boy in otherwise good health who was initially evaluated in the emergency room after suspected aspiration of a stick pin. Vital signs were normal for age and he was in no acute distress. Lungs were clear to auscultation and the remainder of the physical examination was within normal limits. Chest xray revealed a radio-opaque foreign body within the left mainstem bronchus consistent with a stick pin. The foreign body was oriented transversely. The pediatric surgery service was consulted and the patient was taken to the operating room. A 6.5-mm rigid bronchoscope was introduced and the pin was visualized just distal to the carina in
the left mainstem bronchus. Grasping optical forceps were used to secure the head of the pin and the bronchoscope was removed with the grasping forceps. Upon removal it was noted that the head of the pin was separated from the pin itself, and only the head had been removed through the bronchoscope. The bronchoscope was reintroduced but the pin could not be localized. An intraoperative chest film was obtained, demonstrating the pin to be bent and lying outside of the tracheal lumen just above the carina (Fig. 1). The pediatric otolaryngology service was consulted, and attempts to localize the pin with the combination of fluoroscopy and bronchoscopy were made without success. Rigid esophagoscopy was normal and fluoroscopy confirmed that the remaining foreign body was outside both the tracheal and esophageal lumen. The foreign body was presumed to have been embedded into the mediastinum during the initial attempted removal and it was elected to obtain a CT scan. The CT scan showed the pin to be in the right tracheoesophageal groove, extending down to the carina (Fig. 2). The patient was returned to the operating room and mediastinoscopy was per-
Fig. 1. Chest radiograph obtained after initial bronchoscopy demonstrating the new position of the foreign body, bent and apparently outside the tracheal lumen.
J.B. Lynch et al. / Int. J. Pediatr. Otorhinolaryngol. 50 (1999) 225–228
227
Fig. 2. CT obtained after bronchoscopy, with the foreign body lying outside the trachea in the tracheoesophageal groove.
formed by the cardiothoracic service. The stickpin was palpated and a hemostat was used to remove the end of the pin with fluoroscopic guidance. Reinsertion of the mediastinoscope confirmed hemostasis. Surgicel was placed at the previous site of the pin, and the wound was closed. The patient did well postoperatively and was discharged on postoperative day 1.
3. Discussion Rigid bronchoscopy with optical instrumentation has become the standard of care for airway foreign body removal. Experience with bronchoscopes and forceps for the various types of foreign body problems is of fundamental importance. If time allows, obtaining a duplicate foreign body will allow trial on a model to see which instruments work best for the particular mechanical problem. A significant rate of failures in foreign body extraction has been attributed to inadequate familiarity with known, safe techniques [1]. However, even an experienced surgeon can encounter significant difficulty. Sharp and penetrating objects pose a special
problem. This type of foreign body must be approached with complete and thoughtful consideration of the physiologic and mechanical factors involved [1]. When a foreign body is visualized, its orientation and shape are fully assessed. Localizing the point and advancing the bronchoscope to sheath the foreign body is crucial. If the point cannot be sheathed, the foreign body may be rotated with the point allowed to trail, preventing penetration of the mucosa. All manipulation is gentle and precise rather than forced. Additional techniques are sometimes required for more challenging foreign bodies. Fluoroscopy has been shown to be a valuable tool in the retrieval of radio-opaque foreign bodies, especially those located peripherally [5,6]. The C-arm fluoroscope can provide views of radio-opaque foreign bodies from various angles and is not limited by granulation tissue or edema. Ureteral stone baskets, Fogarty catheters and tracheotomy have been used to retrieve distal foreign bodies. Thoracotomy has also been required for removal of distal foreign bodies and for foreign bodies located outside the aerodigestive tract. The need for thoracotomy in aspirated foreign bodies
228
J.B. Lynch et al. / Int. J. Pediatr. Otorhinolaryngol. 50 (1999) 225–228
has been reported as B 1% [7]. Thoracotomy presents a number of potential risks which include trauma and injury to the underlying lung, lung herniation and chest wall muscle atrophy [8 – 10]. Use of mediastinoscopy for removal of foreign bodies has not been previously mentioned in the literature. Compared with thoracotomy, it offers the advantage of reduced recovery time, reduced pain, and improved cosmesis [11]. This report describes a foreign body located within the mediastinum as a complication of its removal. However, retained foreign bodies also occasionally migrate out of the aerodigestive tract and into the mediastinum [12]. Mediastinoscopy may provide an alternative method of removal to thoracotomy in such cases and limit potential complications such as injury to the lung, lung herniation and chest wall atrophy. As with any surgical procedure mediastinoscopy requires appropriate training and experience to be employed effectively and presents potential complications itself such as pneumothorax, pneumomediastinum or vascular injury. In conclusion, this report outlines a novel technique for removal of mediastinal foreign bodies to avoid the morbidity of thoracotomy. It also illustrates a potential complication of rigid bronchoscopic removal of a penetrating foreign body.
[2]
[3]
[4] [5]
[6]
[7]
[8]
[9]
[10]
[11]
References
[12]
[1] L.D. Hollinger, Management of sharp and penetrating
.
.
foreign bodies of the upper aerodigestive tract, Ann. Otol. Rhinol. Laryngol. 99 (1990) 684 – 688. L.D. Hollinger, Foreign bodies of the larynx, trachea and bronchi, in: C.D. Bluestone, S.E. Stool (Eds.), Pediatric Otolaryngology, WB Saunders, Philadelphia, PA, 1990, pp. 1205 – 1214. J Reilly, J Thompson, C MacArthur, S Pransky, D Beste, M Smith, et al., Pediatric aerodigestive foreign body injuries are complications related to timeliness of diagnosis, Laryngoscope 107 (1997) 17 – 20. J.S. Reilly, Airway foreign bodies: update and analysis, Int. Anesthesiol. Clin. 30 (4) (1992) 49 – 55. D.W. Vane, J. Pritchard, C.W. Colville, K.W. West, H. Eigen, J.L. Grosfeld, Bronchoscopy for aspirated foreign bodies in children. Experience in 131 cases, Arch. Surg. 123 (7) (1988) 885 – 888. R.E. Black, K.J. Choi, W.C. Syme, D.G. Johnson, M.E. Matlak, Bronchoscopic removal of aspirated foreign bodies in children, Am. J. Surg. 148 (6) (1984) 778 – 781. R.E. Black, D.G. Johnson, M.E. Matlak, Broncoscopic removal of aspirated foreign bodies in children, J. Pediatr. Surg. 29 (1994) 682 – 684. R.K. Deeik, M.A. Memon, J.T. Sugimoto, Lung herniation secondary to minimally invasive direct coronary artery bypass surgery, Ann. Thorac. Surg. 65 (1998) 1772 – 1774. C. Frola, J. Serrano, S. Cantoni, M. Casiglia, I. Turtulici, F. Loria, CT findings of atrophy of chest wall muscle after thoracotomy: relationship between muscles involved and type of surgery, Am. J. Roentgenol. 164 (3) (1995) 599 – 601. J.P. Hayes, E.A. Williams, P. Goldstraw, T.W. Evans, Lung injury in patients following thoracotomy, Thorax 50 (9) (1995) 990 – 991. R.J. Harris, M.S. Kavuru, T.W. Rice, T.J. Kirby, The diagnostic and therapeutic utility of thoracoscopy, Chest 108 (1995) 828 – 841. D.M. Burton, J.A. Stith, Extraluminal esophageal coin erosion in children, Int. J. Pediatr. Otorhinolaryngol. 23 (1992) 187 – 194.