Bronchoscopy for Removal of Foreign Body in Lower Airway: A Retrospective Analysis

: Bronchoscopy is performed for diagnostic or therapeutic purpose. Therapeutic bronchoscopy is mainly done for removal of foreign body from lower airway. Both the condition and procedure itself are associated with high mortality and morbidity. The aim of the study was to audit data regarding demography, types and location of foreign body, onset of symptom, admission duration, clinical and investigation findings along with duration of ventilation. We also highlight on the complications pertaining to the condition in our series.


Introduction
Foreign body in aerodigestive tract is a common encounter in otorhinolaryngology practice. Comparing between airway and digestive tracts, the airway foreign body has lesser occurrence, attributed to the protective function of the larynx in preventing foreign body intrusion. For foreign body airway, children are affected more common than adult. Different kind of foreign bodies have been implicated and reported to dislodge into different parts of bronchus and bronchioles. They warrant removal most of the time under general anesthesia, either by flexible or rigid bronchoscopy. As the condition as well as the procedure involve shared airway with the anesthetist, the situation is often associated with high morbidity and mortality. 1 Early diagnosis and treatment has been proven to reduce complications. 2

Objectives
An audit of bronchoscopy for foreign body removal and its complications in lower airway was carried out during the period of 2009 till 2016 at a general hospital in the Negeri Sembilan, Malaysia. We also recorded the demography of affected population, types and location of the foreign body, onset of symptoms, duration of ventilation and admission.

Methodology
Retrospective analysis of patients who underwent rigid bronchoscopy for foreign body in lower airway from 2009 till 2016 was performed at Hospital Tuanku Ja'afar Seremban. All patients who were admitted were divided into early and late diagnosis groups depending on whether they presented to the hospital within 24 hours or later. All rigid bronchoscopy was performed under general anesthesia.

Discussion
Foreign body intrusion into the lower airway occurs commonly following penetrating neck injury or aspiration. Aspiration can occur whenever a patient loss his protective mechanism of the larynx, usually after being unconscious following motor vehicle accident (MVA), or impairment of sensory or motor innervation of the larynx following malignant lesion or iatrogenic complications following surgery. It affects both sexes, however shows preponderance in male and children below 10 years of age. 2 Males are more commonly involved as penetrating laryngotracheal injuries affects male more commonly following MVA, or they are more likely to be involved in warfare 3,4 . Nuts, seeds, tooth and headscarf pins are common foreign bodies found in lower airway. [5][6][7][8] Right bronchus, owing to its anatomical predilection, is more common compared to the left 6,9,10 . Rarely left bronchus is affected. 11 In children, some occurrence was witnessed by the parents or guardians, thus leading to almost accurate history and immediate diagnosis. History of choking during eating, followed by cough and examination showed reduced breath sound on the affected side are almost pathognomonic and diagnostic. 6,9,10,12 Delayed presentations include unilateral decreased breath sounds, ronchi or crepitations. 13 Persistent cough or non-resolving pneumonia can be one of the delayed signs.
Foreign body in the airway often associated with high morbidity and mortality. Studies from the Indian population have reported the complication and mortality rates of 10% and 2%, respectively. 6 Complications more tendency to develop in proportionate to the duration of the foreign body in the tracheobronchial tree. 6,8 The complication may include tracheotomy to relieve the upper airway obstruction, or side effects following bronchoscopy or the need for thoracotomy to remove the deepseated foreign body. 13 It was reported that in an Asian study, 5.3% in whom bronchoscopy was performed need to undergo thoracotomy [14][15] . In our series, one patient required tracheostomy for foreign body removal. No fatality was recorded.
The strength of our study is that we have studied the radiological findings and complications. Multiple studies have reported data regarding foreign body types, but there is limited discussion on radiological findings and complications. The limitations of our study are that it is a retrospective study, small sample size and the complications may be under reported. Long-term follow-up after hospital discharge was not reviewed as well.

Conclusion
Foreign body in lower airway causes considerable morbidity and it should be kept in mind that the outcome can be fatal. It is a frequently missed and misdiagnosed condition. Additional procedure such as tracheostomy or thoracotomy might be required.

Conflict of interest: None declared
Author's contribution: Data collection: SR, SK, SK Interpretation of data: SR, VKA, IM Critical revision and final approval: IM