Asian Cardiovasc Thorac Ann 2008;16:e10-e11
© 2008 Asia Publishing EXchange Ltd
Unforeseen Scenario in Removal of a Tracheobronchial Foreign Body
Hasan Türüt, MD,
Erkmen Gulhan, MD1,
Irfan Tastepe, MD1
Department of Thoracic Surgery, Kahramanmaras Sutcu Imam University Medical School
1 Department of Thoracic Surgery, Atatürk Chest Diseases and Thoracic Surgery Center, Ankara, Turkey
For reprint information contact: Hasan Türüt, MD Tel: 90 344 221 2337 Fax: 90 344 221 2371 Email: drhasanturut{at}yahoo.com, Kahramanmaras Sütcü Imam Universitesi, Tip Fakültesi Hastanesi Gögüs Cerrahisi Anabilim Dali, Kahramanmaras 46050, Turkey.
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ABSTRACT
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Tracheobronchial foreign body aspirations occur most commonly in children but under certain circumstances, are seen in adults. Majority of patients can succesfully be managed via bronchoscopy. However, unexpected complications may develop during the removal procedure. We describe an unusual complication encountered during the removal procedure of an inhaled scarf pin in the trachea of a 23-year old woman. Crucial removal procedure is implicated and awareness of this rare complication is emphasized.
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INTRODUCTION
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Foreign bodies in the tracheobronchial system are rare in adults. They can be successfully removed in majority of patients via either fl exible or rigid bronchoscopy.1,2 In our country, Turkey, the scarf pin (so called türban pin) traditionally used to fasten head scarfs, has a high incidence of being aspirated since it is routinely held in the mouth during the wearing of the türban.
When a patient presents with tracheobronchial foreign body aspiration (FBA), an immediate rigid or fi beroptic bronchoscopy is indicated. Removal rates of aspirated foregn bodies without any complications are quite high.1,3 However, unexpected complications can occur during the removal procedure. We report a case of tracheal scarf pin aspiration that penetrated the membranous wall, and was localised between the superior vena cava (SVC) and the aorta during removal without any damage to the vital mediastinal structures.
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CASE REPORT
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A 23-year-old woman presented to a state hospital with choking and cough due to aspiration of a scarf pin. An urgent bronchoscopy was performed under general anaesthesia. During removal via rigid bronchoscopy the pin was grasped from its bead and pulled out through the bronchoscope. The bead of the pin was extracted succesfully but not the metallic part. The lumen of the bronchoscope and the tracheobronchial tree was examined to extract the residual metallic part, but the pin could not be seen in the airway. At the same time, a lateral chest X-Ray showed the absence of pin from the tracheobronchial system (Figure 1
). Fiberoptic bronchoscopy performed subsequently failed to detect any foreign body either. The patient was referred to our clinic, a tertiary centre in thoracic surgery. On examining the lateral X-Ray, the pin was thought to be displaced from tracheobronchial tree during the procedure. There were no fi ndings consistent with pneumothorax or mediastinal widening. Computed tomography confi rmed its location between the arcus aorta and SVC (Figure 2). Thoracotomy was considered instead of mediastinoscopy because of the potential risk of injury to the vital structures in this region due to the sharp sides of the metallic foreign body. Right minithoracotomy revealed the pin within the deep mediastinal fatty tissue just behind the SVC, and adjacent to the aorta and the membranous part of the trachea 1.5 cm above the carina. It was hard to detect the pin but it was removed succesfully by sharp mediastinal dissections. The patient was discharged on the 5th postoperative day.
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Figure 1. Lateral chest X-Ray showing the position of the metallic foreign body (FB) with respect to the endotracheal tube (ET) indicating that the FB is not in the tracheobronchial system.
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Figure 2. Chest computed tomograph showing the metallic foreign body outside the trachea above its bifurcation, between superior vena cava and arcus aorta.
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DISCUSSION
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Tracheobronchial FBA occurs most commonly in children but under certain circumstances, it can occur in adults and may be associated with various clinical scenarios.1,2,4–6 Upon diagnosis of FBA, early bronchoscopy is indicated for its removal to reduce complications.7 Rigid open tube bronchoscope is the instrument of choice for removal of foreign bodies in the airways in adults, but a fl exible fi breoptic bronchoscope may also provide a valuable option in selected conditions.3 Thoracotomy should be considered as the last option.
The removal procedure is safe and is usually successfully carried out with the right instruments in the hands of experienced physicians in specialized centers.5 However, sometimes unexpected complications may occur during removal of the foreign body even at the level of the trachea, as in our case. We emphasize that every removal procedure of a foreign object, anywhere in the trachebronchial tree should be considered as a serious surgical operation, and a multidisciplinary approach with full equipments should be ready during the procedure. We do not recommend the removal procedure of a trachebronchial FB as an outpatient-procedure but rather in an operating theatre.
Complications during removal of FBs via bronchoscopy from the tracheobronchial tree may be encountered even by experienced hands. The most commonly reported complications include failure in removing the FB, laryngeal edema, pneumothorax, pneumomediastinum, subcutaneous emphysema, tracheotomy or assisted ventilation necessity for laryngeal obstruction or respiratory distress, hypoxic brain events, bradycardia, cardiopulmonary arrest and even death.5,8 In our case, a part of tracheal-located pin was removed but the remaining metallic part penetrated the membranous wall of the trachea. The pin localised within the mediastinal pleura, posterior to SVC and adjacent to the aorta but without causing pneumothorax. To the best of our knowledge, this complication has been encountered in only two cases so far but retrocaval location has never been reported.
We conclude that removal of a tracheobronchial FB should be considered as a serious surgical procedure with potential complications and should always be performed in a well-equipped operating theatre.
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REFERENCES
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ABSTRACT
INTRODUCTION
