Lung Resection for Delayed Foreign Body Retrieval in Healthy Adult Male

Tracheobronchial foreign body aspiration is most commonly seen in children and the elderly. Presentation varies widely, but cough, dyspnea, chest pain, stridor, wheezing, and hemoptysis are most commonly seen. Rarely observed in healthy adults, it is often overlooked in the differential diagnosis. Delayed diagnosis of a foreign body in the bronchial tree can result in irreversible changes to the bronchi and the lungs, complicating treatment.1 There are no established guidelines on the choice of treatment for this clinical condition. Here, we discuss an adult male patient with recurrent pneumonias of the left upper lobe after a remote episode of severe emesis. A small foreign body was identified radiographically in the bronchus but was unable to be visualized by bronchoscopy. Ultimately, thoracoscopic segmentectomy was undertaken. A 53-year-old black male with a history of gastroesophageal reflux disease and sickle cell trait first presented to our hospital in April of 2015 with pneumonia. During his workup, a 7-mm foreign body was seen on CT in the left upper lobe bronchus. On questioning, it was discovered that he had several episodes of emesis before presentation. He underwent two bronchoscopies, both identifying a partial obstruction of the upper lobe bronchus without any clear foreign body. Removal was attempted with snares unsuccessfully. The patient’s condition ultimately improved, and he was discharged home on oral antibiotics. Repeat imaging several months later, after resolution of his pneumonia, showed a persistent radiolucent object in the lumen of the anterior segment of the left upper lobe, now more distal than prior. Once again, an unsuccessful attempt was made to retrieve the foreign body with bronchoscopy. Despite close follow-up, he required admission to the hospital in December of 2017 for recurrent pneumonia in the identical wedge-shaped distribution as his prior episode (Fig. 1). He was then referred to thoracic surgery for further evaluation. In addition to inpatient admissions, significant time was lost from work because of intermittent, less severe respiratory symptoms, all leading to failure to thrive. For this reason, we elected to intervene definitively. An anterior (S3) segmentectomy, particularly on the left, is an “atypical” segmental resection and rarely performed because of technical complexity. In addition, given the prior pneumonias and inherent inflammatory foreign body reaction around the segmental anatomy, we selected a trisegmentectomy (S1+2+3), sparing the lingular segments (S4+5) of the upper lobe. The operation proceeded uneventfully and apical trisegmentectomy was completed thorascopically. Ex vivo, the specimen was opened, and successful removal of the foreign body, suspected to be an aspirated tooth, was confirmed (Fig. 2). The patient did well postoperatively with no major complications and was discharged home on postoperative day 3. Symptoms suggestive of foreign body aspiration do not typically vary with the age of patients; however, a delay in diagnosis, location of the foreign body, and radiographic identification of an aspirated foreign body have been shown to differ between pediatric and adult populations.2 Diagnosis is often accomplished using CT because studies have shown that there is a statistically significant increase in sensitivity of multidetector CT over plain X-rays when identifying foreign bodies.3 CT can also be useful in distinguishing shape, size, and location of a bronchial foreign body, which is helpful for planning should surgical retrieval or pulmonary resection prove necessary.4 Bronchoscopy is the gold standard for both identification and therapeutic retrieval of foreign bodies, and often multiple attempts at flexible or rigid bronchoscopy are undertaken before escalating to surgery. This is particularly true for late-diagnosed bronchial foreign body aspiration, defined as aspiration diagnosed one week or more after the event occurred. Because of inflammation and granulation tissue hyperplasia within the airway, delayed foreign bodies can be difficult to visualize or retrieve with endoscopic Address correspondence and reprint requests to Jacob Moremen, M.D., Division of Thoracic Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. E-mail: jmoremen@umc.edu.