The risk of foreign body aspiration is significantly higher in patients with permanent tracheostomy due to bypassing the larynx and natural barriers. We present the case of a 60-year- old patient with a larynx tumor surgically removed in 2013 and permanent tracheostoma, who refused to wear a cannula. He addressed the emergency room for symptoms of arterial hypertension, and presenting dyspnea, headaches and cough.
During the examination, a chest X-ray was indicated and two irregular right supraclavicular opacities were discovered. He was redirected to our pulmonology clinic for specialized investigations under the suspicion of pulmonary metastasis. The fibro-bronchoscopy showed a soft process on the internal wall of the left main bronchus (LMB), bleeding easily on touch. Biopsy showed inflammatory tissue with no tumoral aspects. The CT examination showed a metallic foreign body (approximately 4 cm long) enclaved in the LMB wall, piercing it and missing the left pulmonary vein by millimeters. Under general anesthesia, an attempt of extraction via fibro -bronchoscopy was successful. It amazed us to learn that the foreign body was a green syringe needle (gauge 21) probably aspirated 3 years ago during a post operatory routine tracheostoma cleansing.
Always an emergency, the foreign body aspiration into respiratory airways is a life-threatening condition that has to be managed by skilled medical professionals and followed-up in order to insure that no immediate or short-term complications can endanger the patient’s life.
Intrabronchial foreign bodies can be successfully extracted in the bronchoscopy compartment, using rigid but also flexible endoscopy(1), the latter gaining more ground as a variety of tools have been developed and used but not always as efficient as rigid bronchoscopy.
The most susceptible population group to foreign body aspiration are children, followed by elderly patients and debilitated ones, and the diagnostic is often missed due to the patient’s impossibility to verbalize or the symptoms being misinterpreted(2).
The aspiration of foreign bodies through the trache-ostomy inlet is uncommon, but the risk is significantly higher since the natural barrier of the larynx is
bypassed. The removal of a foreign body through the tracheostomy orifice is difficult because it cannot be performed by rigid bronchoscopy and the only option available is the flexible bronchoscopy. Usually, these patients must be referred to the surgery department and the foreign body must be removed by thoracoscopy(3).
We present the case of a 60-year-old man, with a history of smoking (40 Pack Years), alcohol usage, recently retired, who suffered a laryngectomy roughly three years prior to presentation because of a larynx tumor removal in 2013. He was instructed to wear a tracheostomy cannula (which the patient refused, invok-ing personal reasons) and to perform the daily toilet of the tracheostomy orifice with NaCl 0.09% serum.
He was initially addressed to the Emergency Room (ER) for symptoms of arterial hypertension (headaches and drowsiness, dizziness and dyspnea). At presenta-tion, he had a blood pressure (BP) of 210/110 mmHg, a heart rate (HR) of 112 beats per minute (bpm) and a periferic O2 saturation of 97% in the ambient air. A chest X-ray was recommended in the ER, as he also declared sporadic episodes of hemoptysis. Two irregular right supraclavicular opacities were detected, so he was redirected to the pulmonology clinic for specialized investigations with the suspicion of pulmonary malig-nant disease.
In the Pneumology Department he was admitted with the suspicion diagnostic of pulmonary metastasis from larynx cancer (his recent history of hemoptysis sustained this diagnostic), and a complete set of blood investigations were conducted, with normal laboratory values. The chest X-ray was repeated and besides the opacities already described in the ER we were able to detect the presence of a linear oblique trajectory opacity, overlapping the aorta, in immediate vicinity of the left hilum. Also, from the anamnesis we found out that our patient had a history of tuberculosis in the early ‘90s, leading to a differential diagnostic of the right apical opacities with TB sequelae.
A thoracic CT scan was indicated and, surprisingly, the linear opacity detected by chest X-ray turned out to be a foreign body. The object appeared to be metallic, approximately 4 cm in length, enclaved in the left main bronchus (LMB) wall, piercing it and missing the left pulmonary vein by millimeters (Figure 2). The apical opacities were described as tuberculosis sequelae. A flex-ible bronchoscopy through the tracheostomy inlet was performed with the inspection of the left main bronchus LMB. We discovered a metallic needle, with foreign body granuloma surrounding it and partial bleeding while attempting to mobilize it. In order to facilitate the extraction, the patient was sedated and monitored by the Intensive Care Unit (ICU) personnel.
After multiple attempts of mobilization and traction, we extracted a syringe needle (gauge 21) probably aspirated 3 years ago during a postoperative routine tracheostoma cleansing. The patient was monitored in the ICU for two more days and received aerosols with hyaluronic acid and natrium chloride, intravenous antibiotics (cefuroxime) and dexamethasone. An otorhinolaryngology examination was also conducted and showed no signs of larynx tumor relapse, but re-stated the importance of wearing a cannula for the tracheostomy orifice. He was discharged after 5 days with no signs of hemoptysis or any respiratory symptoms. After one month, the patient was recalled for reexamina-tion and the flexible bronchoscopy conducted showed no signs of sequelae lesions at the extraction site.
The consequences of sharp foreign body aspiration could have been fatal for this patient in both short-term and long-term. The proximity to the main blood vessels and the risk of puncturing during a cough episode was extremely high and with no predictable positive evolu-tion. Although the risk of foreign body aspiration is considerably high in patients not wearing a tracheos-tomy cannula and performing the tracheostomy orifice toilet on their own, the literature presentation of similar cases is scarce. It appears that accidental aspiration occurs while trying to perform the cleansing of the can-nula, meaning that doctors must focus more on explain-ing the risks and assuring the correct cleansing technique while instructing the patients on discharge.
Every foreign body aspiration, regardless of its nature, is an emergency and needs immediate treat-ment. This case particularity consists in the origin of the foreign-body – a syringe needle (most probably aspi-rated during a routine tracheostoma cleansing) and the fact that, given its aspect, the endobronchial granuloma, and the fact that our patient had no memory of an aspi-ration episode and no respiratory symptoms for 3 years, it had been probably aspirated long before its discovery. The position in the immediate vicinity of the left pul-monary vein made it susceptible of a dramatic puncture that, most probably, would have led to massive internal bleeding and death.
As showed in other cases, the patients and their rela-tives need to be more careful and should receive better training for the tracheostomy inlets care, as a foreign body aspiration can be fatal or have unwanted conse-quences that can impair the patient even more(4).
Disclosure: The authors take full responsibility in the information presented in this article and acknowl-edge they have the written consent of the patient to publish the medical data in this paperwork.
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- FigueiredoI RR, MachadoII WS. Foreign body aspiration through tracheotomy: a case report. Rev. Bras. Otorrinolaringol. 2005; 71: 234-6.
- Durukan P, Duman A, Ozkan S, et al. Foreign Body Aspiration from Tracheostomy Inlet. Eurasian J Emerg Med 2015; 14:142-4.