Imaging Foreign Bodies: Ingested, Aspirated, and Inserted

Adenomatous hyperplasia induced by chronic cherry pit retention mimicking an endobronchial tumor-case series and systematic review of literature

Introduction

Endobronchial foreign body aspiration is not common in adults, but it is a life-threatening event. Recurrent pneumonias by chronic retention of foreign body often lead to initial medical presentation of the patient. However, lymphoplasmacellular bronchitis with adenomatous hyperplasia and squamous epithelium metaplasia with complete or partial blockage of lobar bronchus mimicking lung tumor is rare in literature, and this particular condition is often misdiagnosed.

Case presentation

we report our experience in the diagnostic and management of two elderly patients with recurrent pneumonia, admitted in hospital for further examination. In both patients, with no history of aspiration, the cherry pit was detected during bronchoscopy and recanalization with flexible cryoprobe, surrounded by purulent secretion, occluding completely the right upper lobe in the first case, and partially the left lower lobe associated with persistent actinomycosis in the second case, with signs of local inflammation, bronchial adenomatous hyperplasia mimicking lung tumor at initial bronchoscopic examination. Histology showed a lymphoplasmacellullar bronchitis with adenomatous hyperplasia and squamous epithelium metaplasia because of chronic retention of foreign body.

Conclusion

Bronchoscopy examination should be considered in cases where there is an unresolved chronic cough with recurrent pneumonia or persistent actinomycosis in patients with high risk. Cryoprobe is a safe and feasible approach for treatment of airway obstructions due to chronic foreign body retention. Furthermore, relevant findings are discussed here, along with a review of the pathologic alterations and treatment modalities seen in chronic retention of foreign body and airway injury.

CT Characteristics and Clinical Findings of Bronchopneumonia Caused by Pepper Aspiration

Purpose

To explore the computed tomography (CT) features of bronchopneumonia caused by pepper aspiration to improve the diagnosis.

Materials and Methods

28 adult patients diagnosed with obstructive pneumonia caused by pepper aspiration from January 2016 to September 2022 were enrolled. The CT characteristics of bronchial changes and pulmonary lesions caused by pepper were analyzed and summarized.

Results

Among 28 patients, the most common symptom was cough (26, 92.9%), followed by expectoration (23, 82.1%). Bronchoscopy revealed that peppers were mainly found in the bronchus of the right lower lobe (n = 18, 64.3%), followed by the bronchus of the left lower lobe (n = 5, 17.9%). In combination with bronchoscopy results, the pepper in the bronchus manifested as circular or V/U-shaped high-density, localized soft tissue, and flocculent opacification in 8 (28.6%), 16 (57.1%), and 3 (10.7%) cases on CT images, respectively. The bronchial wall around the pepper was thickened with localized occlusion (n = 19, 67.9%) and stenosis (n = 9, 32.1%). Regarding adjacent bronchi without peppers, extensive wall thickening with stenosis and/or occlusion was found in 23 (82.1%) cases. Distal pulmonary lesions frequently involved two or three segments (21, 75.0%) and mainly presented as patchy consolidation or atelectasis (24, 85.7%).

Conclusion

In combination to a history of eating peppers and clinical symptoms, bronchopneumonia caused by pepper should be highly suspected if U/V-shaped and annular high-density or localized soft tissue density is detected in the bronchi of the lower lobes, accompanied by extensive bronchial wall thickening, stenosis, or occlusion, and consolidation or atelectasis in multiple distal lung segments.

Artificial intelligence in the detection of non-biological materials

Artificial Intelligence (AI) has emerged as a transformative force within medical imaging, making significant strides within emergency radiology. Presently, there is a strong reliance on radiologists to accurately diagnose and characterize foreign bodies in a timely fashion, a task that can be readily augmented with AI tools. This article will first explore the most common clinical scenarios involving foreign bodies, such as retained surgical instruments, open and penetrating injuries, catheter and tube malposition, and foreign body ingestion and aspiration. By initially exploring the existing imaging techniques employed for diagnosing these conditions, the potential role of AI in detecting non-biological materials can be better elucidated. Yet, the heterogeneous nature of foreign bodies and limited data availability complicates the development of computer-aided detection models. Despite these challenges, integrating AI can potentially decrease radiologist workload, enhance diagnostic accuracy, and improve patient outcomes.

Laryngeal Foreign Body Aspiration in Infancy: A Diagnostic Challenge

Foreign body aspiration (FBA) is a significant cause of accidental death among children, with laryngeal FBA being relatively rare but potentially fatal due to airway obstruction. This report highlights a case of laryngeal FBA in an 11-month-old child, initially misdiagnosed as viral croup. Otolaryngological evaluation, particularly in the case of laryngeal FBA, may facilitate management. An 11-month-old male was brought to the emergency department, presenting with inspiratory stridor following a choking episode. A chest radiograph and CT scan of the chest were read as normal. He was suspected of having croup and treated with dexamethasone and racemic nebulized epinephrine, which led to temporary clinical improvement.  The child returned with persistent stridor to the emergency department eight days after his initial visit, prompting an otolaryngological consultation. Flexible laryngoscopy ultimately identified a star-shaped sequin lodged in the glottis. The foreign body was successfully removed via direct laryngoscopy and bronchoscopy (DLB). Following the removal, the patient demonstrated significant improvement and eventually made a full recovery. This case emphasizes the difficulty in diagnosing laryngeal FBA due to its non-specific symptoms and the limitations of imaging techniques. The importance of a thorough clinical history, physical examination, and proper imaging combined with a high index of suspicion is crucial for early diagnosis and treatment. Additionally, the report discusses the potential for severe complications if diagnosis and treatment are delayed, highlighting the need for awareness and prompt intervention in suspected laryngeal FBA cases.

Foreign Body in the Tracheobronchial Tree as a Cause of Hemoptysis in an Adult Without Risk Factors for Aspiration: A Case Report

Although aspiration of a foreign body into the trachea and bronchi can occur in all age groups, it is more common in infants and young children. Foreign bodies in the tracheobronchial tree are uncommon in adults and mainly present in patients with dysphagia and an altered level of consciousness. The identification of foreign bodies in the tracheobronchial tree is frequently overlooked or delayed, leading patients to present later with chronic symptoms and potential complications. These complications may include persistent coughing, wheezing, obstructive pneumonitis, bronchiectasis, and abscess formation secondary to recurrent pulmonary infections. This article aims to present the case of a 27-year-old patient without risk factors for aspiration who has experienced recurrent self-limiting hemoptysis episodes for five years. Bronchoscopy revealed a foreign body at the entrance to the middle lobe bronchus. The presence of a foreign body in the tracheobronchial tree should be considered in any patient with recurrent hemoptysis. Bronchoscopy leads to accurate diagnosis, treatment, and prevention of complications.

Glass in the Airways: A Bronchoscopic Challenge

Foreign body aspiration (FBA) in adults is indeed a significant medical concern, albeit less common than in children. The increase in incidence with advancing age can be attributed to factors such as a decline in mental status and impairment of the swallowing reflex, which is more prevalent in the elderly population. The symptoms of FBA are highly variable, ranging from severe, acute asphyxiation, which may or may not involve complete airway obstruction, to more subtle signs like coughing, shortness of breath (dyspnea), choking, or fever. These varied presentations, coupled with the fact that many other medical conditions can mimic the respiratory symptoms seen in FBA, make diagnosis challenging. A high index of suspicion is often required, especially in cases where the patient's history does not clearly point toward aspiration. Immediate management focuses on supporting the airway, which is crucial given the potential for severe obstruction. Radiographic imaging plays a key role in localizing the foreign body, which is vital for planning its removal. Bronchoscopy, particularly flexible bronchoscopy, is the cornerstone of both diagnosis and treatment. This technique allows for direct visualization of the airways, localization of the foreign body, and its subsequent removal. This is crucial to avoid long-term complications, which can arise if the foreign body is not promptly and effectively removed. In this case report, we present a 64-year-old female patient who was found to have a foreign object positioned in the right lower lobe of the lungs that was removed via flexible bronchoscopy.

Facilitating the removal of a foreign body in the tongue by intraoperative ultrasound guidance: A case report

The presence of soft tissue foreign bodies (FBs) presents a substantial concern due to their potential to induce both acute and chronic pain as well as tissue irritation. This case report documents the admission of a 25-year-old female with a history of bur fractures during endodontic treatment, accompanied by signs of infection. The clinical examination and radiographic assessment revealed an embedded foreign body within her tongue. The surgical procedure was informed by repeated ultrasound scans through the incision, facilitating precise targeting. Intraoperative ultrasound enables the accurate detection of submucosal foreign bodies in dynamic tissues like the tongue and facilitates focused and image-guided dissection, thereby decreasing surgical trauma to the delicate soft tissues.

[Difficult case of differential diagnosis of partial lung atelectasis. Case report]

In December 2018 the patient over 60 years old sought medical help with complaints of persistent cough. Based on computed tomography data there were identified the sings (symptoms) of right lung lower lobe atelectasis. To run this patient diagnostics there were performed 6 bronchoscopies narrowed down by bronchi checks up only and described the right lung central cancer picture. At the same time the biopsy taken during one of the bronchoscopies appeared non informative. Fine needle biopsy of mediastinal lymph nodes and bronchial wall was performed twice: at Tomsk Cancer Research Institute (it was suspected B-cell lymphoma based on biopsy examination) and at The Loginov Moscow Clinical Scientific Center (signs of inflammation based on biopsy examination). The video-assisted thoracoscopy with lymph node dissection of the right lung root was performed in January 2020. As a surgical material analysis result reactive adenopathy was determined. Therefore, during more than 1 year of diagnostic research the genesis of right lung lower lobe atelectasis was not established. The patient was directed to Central Tuberculosis Research Institute for diagnosis verification. Based on clinical and radiological picture Central Tuberculosis Research Institute colleagues suspected a foreign body in the intermediate bronchus. During an endoscopic examination it was revealed stenosis, biopsies were performed, but the foreign body could not be identified. In the pathomorphological laboratory of Central Tuberculosis Research Institute there were conducted histological examination of the material after endobronchial cryobiopsy and rigid needle biopsy. Both gave an unexpected result: invasive mycosis of the bronchial wall. As a conclusion the decision was taken to apply antimycotic therapy on an outpatient basis. As a result, clear clinical and radiological positive dynamics was obtained. In these favorable conditions for endoscopic examination, it was performed vitally essential cryoextraction of foreign body. The foreign body turned out to be a fragment of a spongy bone of a centimeter size. These actions have let to unlock the right lung lower lobe.

Evaluation and Management of Airway Foreign Bodies in the Emergency Department Setting

BACKGROUND

Airway foreign body can be a life-threatening issue in pediatric and adult patients, and the majority of these patients will first present to the emergency department.

OBJECTIVE

This article provides a narrative review of the diagnosis and management of airway foreign bodies for the emergency clinician.

DISCUSSION

Foreign bodies in the upper and lower airways are potentially life threatening. This affects all age groups but is more common in pediatric patients. A history of a witnessed ingestion or aspiration event should raise the clinical suspicion for an aspirated foreign body. Patients with upper-airway foreign bodies are more likely to present in respiratory distress when compared with lower-airway foreign bodies, which often present with more subtle signs. Stridor, drooling, and wheezing suggest respiratory distress, but the presenting clinical picture is often unclear and may only include a cough. Immediate intervention is required in the patient with hemodynamic instability or respiratory distress. Airway management including laryngoscopy, fiberoptic bronchoscopy, and cricothyrotomy may be needed in these patients, with the emphasis on removing the obstructing foreign body and securing the airway. Specialist consultation can assist in retrieving the foreign body and managing the airway. If the patient is stable, imaging and specialist consultation for potential operating room intervention should be considered.

CONCLUSIONS

An understanding of the presentation, evaluation, and management of the patient with an airway foreign body is essential for emergency clinicians.

Consultations for Foreign Bodies in Aerodigestive Tract: Assessment of Diagnostic Modalities

OBJECTIVE

To evaluate test characteristics of various diagnostic modalities in the workup of foreign body (FB) sensation in the aerodigestive tract.

METHODS

Database containing all inpatient otolaryngology consultations between 2008 and 2020 was used. Cases of FB sensation were identified by documented encounter diagnosis or hospital problem of FB or globus sensation. Variables including basic patient demographics, clinical presentations, diagnostic imaging modalities, procedures, and outpatient follow-up were collected.

RESULTS

One hundred and six patients were included in the study. A FB was visualized in 55 patients (52%) and removed in 52 patients (49%); 3 patients had a FB that was visualized initially but not found in the operating room. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were found to be 41%, 50%, 58%, and 33%, respectively, for X-ray (XR); 91%, 61%, 70%, and 87%, respectively, for computed tomography (CT). Sensitivity and NPV were 25% and 57%, respectively, for flexible fiberoptic laryngoscopy (FFL). Seventy-one of 106 patients (67%) underwent invasive interventions during their workup for FBs. Ten out of 11 (91%) chicken bones were found in the digestive tract compared to 7 out of 19 (37%) fishbones (p = 0.0046).

CONCLUSION

In patients with history of FB ingestion, CT may be more beneficial than XR as a screening tool for locating foreign bodies and guiding further management. FFL alone is inadequate for ruling out a FB in the aerodigestive tract given FB's high likelihood of being in the esophagus or buried in soft tissue or mucosa.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:1361-1366, 2023.

Sonographic features of various dental materials and foreign bodies

OBJECTIVE

To reveal the sonographic characteristics of various foreign bodies and dental materials to aid diagnosis.

METHODS AND MATERIALS

24 objects consisting of various dental materials and foreign bodies were included in the study. Objects were embedded in bovine gelatin. Images of the objects were obtained by conventional radiography and ultrasonography (USG). Opacities were evaluated by conventional radiography. Their visibility and posterior acoustic behaviors were examined by USG. In addition, the actual sizes of the objects and their dimensions measured by USG were compared.

RESULTS

All objects included in the study, including non-opaque ones, could be visualized by USG. When the posterior acoustic behavior of objects was examined, 15 of the objects (62.5%) caused posterior acoustic shadowing on USG. While 6 of the objects (25%) did not have any USG artifacts, 2 of them (8,3%) had comet tail artifact and 1 of them (4,2%) had reverberation artifact. There was no statistically significant difference between the actual dimensions of the objects and their dimensions measured by USG (p > 0,05).

CONCLUSION

USG is a very useful technique for imaging foreign bodies and dental materials, it can even show objects that cannot be seen in X-rays on in-vitro environment.

Nearly missed laryngeal foreign body

Foreign body ingestion and aspiration can present as a life-threatening emergency in children. These foreign bodies are diagnosed based on history, physical exam, and focused radiography to reduce the risk of excessive radiation. We describe a case of a 3-year-old child who ingested magnetic beads and presented to the emergency department with no symptoms. On a single view x-ray of chest and abdomen, the magnetic beads were identified in the abdomen but a closer look at these single view x-rays raised a suspicion of additional foreign bodies in the larynx. A dedicated x-ray of the neck identified 2 more magnetic beads locked with each other on either side of the epiglottis. These laryngeal magnetic beads were nearly missed on initial x-rays, especially because the child had no symptoms of upper airway obstruction. This case report provides further evidence that in the evaluation of radiopaque foreign bodies in children we should strongly consider "nose to rectum" x-rays.

Management of a misidentified and misnumbered intraocular glass foreign body with an endoscope in a case of endophthalmitis

An endoscope is a useful adjunct for the retinal surgeon to overcome haze of a compromised anterior segment. It allows early surgery in trauma and infections which translates to better results. Intraocular glass foreign body is a challenging condition, demanding highly skilled surgical expertise. We present endoscopic removal of an intraocular foreign glass body in a badly traumatised and infected eye. The surgical challenge was accentuated by an imaging misdiagnosis of 'twin metallic foreign bodies'.

Approach to Abdominal Imaging in 2022

Abdominal pain represents 5% to 7% of all emergency department presentations. Many patients require imaging for diagnosis, and choosing the appropriate imaging modality is a crucial decision point. Modern medicine offers a fantastic array of options including abdominal radiograph, computed tomography, MRI, and ultrasonography, but the plethora of alternatives can be paralyzing. This article introduces the commonly available modalities, discusses the advantages and disadvantages, and presents current recommendations for commonly diagnosed conditions.

Ultrasonography in soft-tissue foreign-body detection: a phantom study

Purpose

Foreign body implantation into the soft tissues, either in the early period or late period, is a common cause of emergency department admissions. Direct X-rays are preferred in the diagnosis of soft-tissue foreign-bodies. Herein, we aimed to analyse the detection rates of foreign bodies of various sizes placed in phantoms implanted into soft tissue by ultrasonography.

Material and methods

A total of 740 pieces of chicken fillet were prepared as phantoms. No objects were implanted into 100 phantoms. We inserted glass, porcelain, plastic, wood, pencil tip, chicken bone, iron, walnut shell, and fishbone with a length of < 1 cm, 1-3 cm, and 3-5 cm into 20 pieces of chicken phantom in each size of foreign body (FB). In addition, 1-3 cm long peanut shell, < 1 cm rose spikes, < 1 cm cactus thorns, < 1 cm pellets, and < 1 cm staples were inserted into 20 pieces of chicken for each object. Each of the chicken pieces was placed inside a latex glove and examined by ultrasonography.

Results

The sensitivity of ultrasonography in the detection of the cactus thorn was 5%, whereas it ranged between 82.5 and 100% for other objects. For glass, plastic, wood, iron, and fishbone, we found that when the size exceeded 1 cm, the sensitivity increased.

Conclusions

In the evaluation of soft tissue FBs, as the size of the FBs increases, the diagnostic value of ultrasonography increases.

Foreign body aspiration

The clinical manifestations of foreign body (FB) aspiration can range from an asymptomatic presentation to a life-threatening emergency. Patients may present with acute onset cough, chest pain, breathlessness or sub-acutely with unexplained hemoptysis, non-resolving pneumonia and at times, as an incidental finding on imaging. Patients with iatrogenic FB such as an aspirated broken tooth during difficult intubation or a broken instrument are more common scenarios in the intensive care unit (ICU). Patients with post-obstructive pneumonia with or without sepsis, or variable degree of hemoptysis often require ICU level of care and bronchoscopic interventions. Rigid bronchoscopy has traditionally been the modality of choice; however, with the innovation in instrumentation and wider availability of flexible bronchoscopes, most of the FB removal is now successfully performed using flexible bronchoscopy. Proceduralists choose instruments in accordance with their training and expertise. We describe the use of most common instruments including forceps, balloon catheters, and baskets. Role of cryoprobe and LASER in FB removal is reviewed as well. In general, larger working channel bronchoscopes are preferred; however, smaller working channel bronchoscopes may be used in situations when the patients are intubated with a smaller diameter endotracheal or tracheostomy tubes. Large size FB are removed en bloc with the grasping tool, bronchoscope, and endotracheal or tracheostomy tube, requiring preparation to safely re-establish the airway. After FB removal, bronchoscopy is re-performed to identify any residual FB, assess any injury to the airway, suction post-obstructive secretions or pus, control any active bleeding and remove granulation tissue that may be obstructing the airway. Additional interventions like balloon dilatation may be required to dislodge an impacted FB or to maintain patency of bronchial lumen. If bronchoscopic methods fail, surgery may be required for retrieval of FB in symptomatic patients or to resect suppurative or necrotizing lung process. Multidisciplinary approach involving intensivists, surgeons, and anesthesiologists is the key to optimal patient outcomes.

Anorectal emergencies: WSES-AAST guidelines

Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

Multimodality Imaging of Foreign Bodies: New Insights into Old Challenges

Traumatic wounds and lacerations are a common reason for patients to present to emergency departments, with retained foreign bodies (FBs) accounting for 7%-15% of cases, particularly those involving the extremities. These retained materials result in a granulomatous tissue response known as an FB reaction, a pathologic attempt to isolate the FB from the host. The most common FB materials are glass, metal, and wood, but other compositions can also be found, such as plastic and animal-derived materials. Clinical history, physical examination, and wound exploration are essential in investigation of retained material but are not sufficient to exclude an FB, and additional investigation is required. Imaging evaluation is a useful tool to help depict and locate an FB, assess possible complications, and guide removal. Conventional radiography, the first-line method in this scenario, is a widely available low-cost depiction method that has good sensitivity for depicting FBs. If the retained material is not depicted at conventional radiography, US can be performed. US is highly sensitive in depicting both radiolucent and radiopaque FBs in superficial locations. For deeper objects, CT may be necessary. MRI is the best imaging modality to delineate local soft-tissue and osseous complications. Retained FBs can result in early and delayed complications, with infection being the most frequent complication. To avoid preventable morbidities related to FBs, radiologists should be familiar with imaging findings and provide essential information to help the attending physician treat each patient. Online supplemental material is available for this article. ^©RSNA, 2020.

CT evaluation of self-induced and retained foreign bodies in the abdomen and pelvis

Computed tomography (CT) can both locate and identify foreign bodies as well as pinpoint complications to help direct treatment. Retained foreign bodies in the abdomen and pelvis can lead to perforation, obstruction, intussusception, fistula formation, and abdominal abscess formation. This article reviews the imaging appearance of incidentally found common foreign bodies and the role of CT in identifying unsuspected foreign bodies.

Small bowel obstruction from hollow foreign body ingestion: A case report and brief review of literature

While ingestion of a foreign body by children is common, diagnosis is often challenging, especially when the consumption by a young child is unwitnessed and presenting symptoms mimic other medical conditions. If the foreign body does not pass spontaneously, radiological imaging studies are typically performed, but visualization and identification of the ingested foreign object can be inconclusive, especially when an unidentified mass is radio translucent. Under this circumstance, physicians often have to go on a "fishing expedition", using exploratory endoscopy and/or surgery to identify and extract the object that became lodged. In this report we discuss a case of a 3 year-old boy who presented with abdominal pain and signs of bowel obstruction. Imaging revealed an ingested "radiolucent" foreign body, masqueraded as soft-tissue mass and enteric duplication cyst, delaying the diagnosis. Systematic shape and density reanalysis of CT and US imaging suggested a hollow object lodged at the terminal ileum. The patient underwent exploratory laparotomy with extraction of a hollow toy "fish". There is a dearth of literature regarding hollow ingested objects. This case report highlights the importance of systematic density and shape imaging analyses in order to identify and locate hollow ingested objects.

Evaluation and management of urethral foreign bodies and description of a novel ultrasound-guided catheter-based extraction technique

There are numerous reports in the medical literature documenting urethral foreign bodies with nearly all cases found in men and often associated with underlying psychiatric disorders, autoerotic stimulation, and/or intoxication. Patients most commonly presented with localized penile pain, hematuria, dysuria, and occasionally obstruction. Although endoscopic removal by a urologist is often the first-line treatment, this report describes evaluation and management considerations and presents a novel extraction technique that may allow emergency physicians in consultation with urology to perform removal of some unusual urethral foreign bodies in the emergency department. We report a novel extraction technique using a pediatric foley catheter under ultrasound guidance that has been applied during multiple encounters with 2 individuals who have each presented multiple times at a single emergency department (ED) for evaluation because of urethral foreign body insertion. The foreign body materials have ranged from small pieces of rubber to cellophane to styrofoam and most commonly plastic utensils. Urologic extraction may be required in some cases, but ED removal can be considered. A final discussion of the creation of a multidisciplinary care plan to address resource use concerns also is described.

Unexpected Fatal Tension Pneumothorax: A Case Report Regarding a Patient With Multiple Traumas on Air Medical Transportation

A 45-year-old male driver was assessed by the road rescue team after a car crash. He was in shock and had a deep second-degree burn, multiple bone fractures, and chest wounds. After stabilization, he was delivered to the nearest local clinic by an ambulance. The doctor decided to refer him via air transportation due to the lack of sufficient facilities and the urgent need for an intensive care unit after coordination with the nearest hospital and air medical team. A Bell 214C medical helicopter was called, and transfer was initiated after patient preparation by the air medical team. A few minutes later, his clinical condition deteriorated, and because of the suspicion of a tension pneumothorax, needle thoracostomy was performed. Crosswind and frequent helicopter movements interfered with tube thoracostomy, leading the air medical crew's decision to land. After completion of tube thoracostomy and during endotracheal intubation, his heart rhythm converted to bradycardia and then asystole. Unfortunately, despite 30 minutes of cardiopulmonary resuscitation, the patient died. The forensic report stated that a glassy foreign body led to penetrating chest wall injury and left lung perforation, possibly causing the tension pneumothorax, cardiopulmonary arrest, and death.

Esophageal Obstruction and Death in a Nonverbal Patient

BACKGROUND

There are more than 100,000 cases of esophageal foreign body in the United States each year. Most cases resolve spontaneously; however, complete esophageal obstruction is a medical emergency. Patients with developmental disabilities are at high risk, because a large percentage of this population is effected by dysphagia, pica, tooth loss, or impulsive swallowing. In some cases, the diagnosis of esophageal foreign body can be made clinically, with the typical presentation including coughing, inability to tolerate secretions, drooling, vomiting, and dysphagia. In other instances, imaging is needed to confirm the diagnosis.

CASE REPORT

A nonverbal adult patient with history of mental retardation and dysphagia presented to the emergency department (ED) after a choking episode with persistent coughing. An x-ray study of the chest showed mild opacity at the left lung base and she was discharged with antibiotics. She returned to the ED that day with worsening symptoms suggestive of aspiration pneumonia. A computed tomography scan of the chest revealed numerous cylindrical objects in the esophagus, later identified as crayons. At least 28 crayons were removed via 3 endoscopies. During this time, the patient developed aspiration pneumonia, respiratory distress, and septic shock. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Delayed recognition of foreign body puts patients at risk for esophageal perforation, aspiration, airway compromise, infection, sepsis, and death. In nonverbal patients presenting with upper respiratory symptoms, it is especially important to consider esophageal foreign body in the differential diagnosis, because this group is high risk for missed diagnosis and complications secondary to the foreign body.

Food bolus and oesophageal foreign body: a summary of the evidence and proposed management process

PURPOSE

Food bolus and oesophageal foreign bodies are a common presentation that may be managed by otolaryngologists, gastroenterologists, acute medicine physicians and accident and emergency. The condition is highly variable with presentations ranging from well patients whose obstruction spontaneously passes to peri-arrest with severe aspiration or impending airway compromise. Management of this condition is heterogeneous and often depends on the specialty the patient is originally admitted under. There exist European and American guidelines from the perspective of gastroenterology, but there are no UK-based guidelines and limited consideration of the role of the otolaryngologists and rigid oesophagoscopy.

METHODS

An extensive literature search was carried out to generate conclusions on key management questions for food bolus and oesophageal foreign bodies. This was then summarised into both a written summary of the evidence and a graphical decision tree.

RESULTS

This paper is a review article and presents conclusions regarding management options for food bolus and oesophageal foreign bodies.

CONCLUSION

This article considers the current evidence surrounding investigation and management of oesophageal food bolus and foreign body. It draws conclusions regarding presentation, investigation and subsequent operative treatment. As part of this process, we propose a graphical decision tree to assist in management decisions.

Airway Foreign Body Mimicking an Endobronchial Tumor Presenting with Pneumothorax in an Adult: A Case Report

Foreign body (FB) aspiration occurs less frequently in adults than in children. Among the complications related to FB aspiration, pneumothorax is rarely reported in adults. Although the majority of FB aspiration cases can be diagnosed easily and accurately by using radiographs and bronchoscopy, some patients are misdiagnosed with endobronchial tumors. We describe a case of airway FB that mimicked an endobronchial tumor presenting with pneumothorax in an adult. A 77-year-old man was referred to our hospital due to pneumothorax and atelectasis of the right upper lobe caused by an endobronchial nodule. A chest tube was immediately inserted to decompress the pneumothorax. Chest computed tomography with contrast revealed an endobronchial nodule that was seen as contrast-enhanced. Flexible bronchoscopy was performed to biopsy the nodule. The bronchoscopy showed a yellow spherical nodule in the right upper lobar bronchus. Rat tooth forceps were used, because the lesion was too slippery to grasp with ellipsoid cup biopsy forceps. The whole nodule was extracted and was confirmed to be a FB, which was determined to be a green pea vegetable. After the procedure, the chest tube was removed, and the patient was discharged without any complications. This case highlights the importance of suspecting a FB as a cause of pneumothorax and presents the possibility of misdiagnosing an aspirated FB as an endobronchial tumor and selecting the appropriate instrument for removing an endobronchial FB.

Elevated carcinoembryonic antigen and bronchial obstruction caused by a rotten vegetable leaf mimic lung cancer: A case report

BACKGROUND

Tracheobronchial foreign body aspiration is a potentially risky medical event, while the condition often requires early detection and rapid intervention to improve respiratory symptoms and prevent major morbidity. Notably, foreign bodies may not be identified and they are likely to be mistaken for neoplastic lesions. However, CEA, as one of tumor markers, presents to be available for assisting in lung cancer diagnosis, especially for non-small-cell lung cancer, while the specificity of CEA is not high.

METHODS

Here, we described a case of bronchial opening obstruction with elevated carcinoembryonic antigen (CEA) that was firstly misdiagnosed as lung cancer and proved as foreign body aspiration in the upper lobe bronchus of right lung by bronchoscopy.

RESULTS

Carcinoembryonic antigen level increased. CT scan demonstrated a cavitation accompanied by multiple small nodular shadows appeared in the right upper lobe field. Bronchoscopy suggested right upper lobe bronchus was blocked by a brown smooth organism with plenty of purulent materials, which was proved as a rotten vegetable leaf.

CONCLUSIONS

Elevated CEA and bronchial obstruction are not typical manifestations of lung cancer. Bronchoscopy is crucial for making a reliable diagnosis.

Intraluminal hyperdense appearance of the small bowel on high resolution computed tomography of the abdomen and pelvis secondary to use of Calcium Carbonate tablets (Tums) mimicking a small bowel fistula

Hyperdensity within the small bowel is most commonly seen with positive oral contrast agents, intraluminal hemorrhage and less likely an abnormal fistulous connection with the colon containing rectally administered contrast. We present the case of a 57-year-old female with a complex history of breast cancer and multiple abdominal surgeries presenting with intraluminal hyperdense small bowel on computed tomography (CT) performed with rectal contrast. Postsurgical CT with rectal contrast, and no oral contrast, showed multifocal regions of intraluminal hyperdensity with the small bowel anterior to and close to the surgical anastomosis. This raised concerns for a fistula between the colon and small bowel; however, surgical exploration demonstrated an intact anastomosis without a coloenteric fistula. Additional history notes that the patient consumed an increased dose of calcium carbonate tablets for a few days prior to obtaining the scan and this intraluminal hyperdense appearance of the small bowel was then attributed to this. We conclude that ingested over the counter medications can pose an imaging dilemma for radiologists as their appearance on CT could falsely mimic pathology. It is imperative to obtain a thorough clinical history in such cases to provide accurate diagnoses and decrease unwanted imaging and clinical intervention. It is also important for radiologists to be aware of the appearances of commonly consumed over the counter medications that can mimic pathology as demonstrated by this case.

Unusual foreign bodies visualized by postmortem computed tomography in a deceased with borderline personality disorder

The objective of this case report is the visualization and assessment of ingested or inserted foreign bodies by postmortem computed tomography and autopsy. The presence of foreign objects in the gastrointestinal tract involves, among many other medical subdisciplines, the fields of forensic medicine and psychiatry. We present a case of an 18-year-old female Caucasian with borderline personality disorder who was found unconscious in a closed psychiatric ward with suspected ingested foreign bodies. Cardiopulmonary resuscitation was unsuccessful. Postmortem computed tomography revealed several sharp foreign bodies in the intestine varying in radiodensity and shape but not perforating any anatomic structures. The autopsy showed well-preserved tablets in the intestine, a few inserted glass fragments and one metal fragment. Ultimately, fatal intoxication involving a mixture of opioids, benzodiazepines, neuroleptics and antidepressants resulted. This case illustrates the potential contribution of postmortem computed tomography in diagnosing, localizing and defining ingested and inserted foreign bodies in deceased as well as living individuals. Thus, diagnostic imaging might increase safety not only for the affected individuals but also for medical staff.

A melting, encapsulated, calcified pulmonary nodule in a healthy 51-year-old woman: a case report

Background

Foreign body aspiration is less common in healthy adults, which makes diagnosis difficult. Early detection of smaller/sharp foreign bodies in the distal airway is more difficult because patients might have no symptoms and imaging studies could appear normal.

Here we describe the course of a small, sharp foreign body (chicken bone) lodged in the distal airway of a healthy middle-aged woman. The chicken bone was initially thought to be an old calcified tuberculoma. However, it was encased in a dilated bronchus without obvious surrounding lymphadenitis or parenchymal infiltration, and it melted with time. Two years later, histopathological examination revealed that the calcified lesion was an aspirated chicken bone with a concomitant tuberculoma.

Case presentation

A 51-year-old woman showed an old calcified tuberculoma in the upper right lung lobe during routine examinations. It was “encased” in a dilated bronchus, although it was not raised from the surrounding lung parenchyma. The size of the calcified part decreased (“melted”) with time, and the surrounding inflammation progressed 2 years later, a phenomenon never described in association with tuberculosis. Bronchoscopy revealed a fragment of chicken bone lodged in the next two branches of the upper right posterior bronchus. Surgical segmentectomy was performed, and histopathological examination revealed that the calcified lesion was formed by a fragment of chicken bone as well as a tuberculoma. Eventually, the patient recalled an episode of choking on a chicken bone 5 years ago; she believed that she had coughed it out completely at that time.

Conclusions

The “melting” and “encased” phenomena observed in the present case could be useful imaging findings for early detection of small foreign body aspiration in the distal airway.

Magnetic Apposition across the Epiglottis: Radiographic and Operative Correlation of a Rare Hypopharyngeal Foreign Body

Background and Aim. Rare-earth magnet ingestions are a subset of foreign body ingestions and can result in significant morbidity secondary to pressure necrosis. These magnets are best visualized radiographically, typically located in the gastrointestinal tract. However, unusual locations of magnetic adherence may include the hypopharynx along the epiglottis, where only 2 previous cases have been reported. Clinicians should be aware of the potential dangers of rare-earth magnet ingestion and consider atypical locations of attachment in the appropriate clinical setting. Case Presentation. We present an interesting case of a fourteen-year-old female patient who presents with witnessed ingestion of multiple rare-earth magnets. Soft-tissue neck radiographs demonstrate two adjacent rounded radiopaque densities in the hypopharynx. Intraoperative images confirmed the radiographic findings and identified two magnetic balls stuck along the dorsal and ventral aspect of the epiglottis without evidence of pressure necrosis.

Management of Sharp-Pointed Esophageal Foreign-Body Impaction With Rigid Endoscopy: A Retrospective Study of 130 Adult Patients

OBJECTIVES

To propose a management algorithm for adult patients with sharp-pointed esophageal foreign-body impaction (EFBI) who have rigid endoscopy (RE) indications and to conduct a retrospective analysis of their data.

METHODS

All adult patients who received RE at the Department of Otorhinolaryngology in Beijing Shijitan Hospital between January 2017 and May 2019 were enrolled. The demographics, clinical characteristics, and management data were collected and analyzed.

RESULTS

A total of 130 patients were identified, 56.9% were female with median age 60 years. More than half (56.9%) of patients had foreign-body (FB) ingestion on holidays. The most frequent FBs were jujube pits (66.9%) and bones (23.8%). There is a significant female predominance in ingestion of jujube pits (65.5%, P = .005). The most common symptoms were odynophagia (49.2%) and sore throat (47.7%). The majority (96.8%) of FB founded were lodged at upper esophagus. In all, 74 patients were categorized as having mild complications and 54 having significant complications. Time interval from ingestion to presentation longer than 15 hours was an independent risk factor for significant complications, while esophagogram with barium as a protective factor.

CONCLUSIONS

Long-time interval from ingestion to presentation will lead to high risk of significant complications. Computed tomography should be a prioritized imaging method for all patients suspected with EFBI, and multidisciplinary collaboration is recommended. Besides, mass education on eating habits is necessary.

Fractured aluminum nasopharyngeal swab during drive-through testing for COVID-19: radiographic detection of a retained foreign body

The ongoing coronavirus disease 2019 (COVID-19) pandemic has increased the need for safe and efficient testing as a key containment strategy. Drive-through testing with nasopharyngeal swab has been implemented in many places in the USA as it allows for expeditious testing of large numbers of patients, limits healthcare workers' risk of exposure, and minimizes the use of personal protective equipment. We present a case where the aluminum shaft of the nasopharyngeal swab fractured during specimen collection at a drive-through testing facility and was suspected to have remained in the asymptomatic patient. Initial evaluation with a series of radiographs covering the skull base, neck, chest, and abdomen did not reveal the swab. On further clinical evaluation, the swab was found endoscopically, lodged between the left inferior turbinate and nasal floor, and was removed by an otorhinolaryngologist. Using a phantom model, we aimed to delineate an imaging technique to better visualize the aluminum shaft of the nasopharyngeal swab on radiographs to help in identification. A technique using lower tube voltage (kVp) with tight collimation centered at the nasal bones area produced the best visualization of the aluminum shaft of the swab. Recognition that aluminum foreign bodies may be difficult to visualize radiographically and  optimization of radiograph acquisition technique may help guide clinical management in unusual cases. Further evaluation with computed tomography or endoscopy should be considered in suspected cases where radiographs are negative.

Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-Based Review

BACKGROUND

Patients with esophageal foreign bodies or food bolus impaction may present to the emergency department with symptoms ranging from mild discomfort to severe distress. There is a dearth of emergency medicine-focused literature concerning these conditions.

OBJECTIVE OF THE REVIEW

This narrative review provides evidence-based recommendations for the assessment and management of patients with esophageal foreign bodies and food bolus impactions.

DISCUSSION

Esophageal foreign bodies and food bolus impaction are common but typically pass spontaneously; however, complete obstruction can lead to inability to tolerate secretions, airway compromise, and death. Pediatric patients are the most common population affected, while in adults, edentulous patients are at greatest risk. Foreign body obstruction and food bolus impaction typically occur at sites of narrowing due to underlying esophageal pathology. Diagnosis is based on history and examination, with most patients presenting with choking/gagging, vomiting, and dysphagia/odynophagia. The preferred test is a plain chest radiograph, although this is not required if the clinician suspects non-bony food bolus with no suspicion of perforation. Computed tomography is recommended if radiograph is limited or there are concerns for perforation. Management requires initial assessment of the patient's airway. Medications evaluated include effervescent agents, glucagon, calcium channel blockers, benzodiazepines, nitrates, and others, but their efficacy is poor. Before administration, shared decision making with the patient is recommended. Endoscopy is the intervention of choice, and medications should not delay endoscopy. Early endoscopy for complete obstruction is associated with improved outcomes.

CONCLUSIONS

This review provides evidence-based recommendations concerning these conditions, focusing on evaluation and management.

Chronic ileitis with transmural migration of ingested foreign body treated by laparoscopy

BACKGROUND

Ingestion of foreign bodies such as fish bone or chicken bone is relatively common in adults; however, resultant transmural migration is extremely rare.

METHODS

We present a case of a 79-year-old woman with chronic low-grade abdominal pain, worsening over the last 4 days. Computed tomography revealed segmental small bowel wall thickening with chronic inflammation suggestive of Crohn's ileitis and oral steroids were commenced; only later, ingestion of a foreign body was suspected.

RESULTS AND CONCLUSION

At diagnostic laparoscopy, a linear foreign body resembling a wooden splinter was identified. It had partly migrated through the chronically inflamed bowel wall without causing perforation or abdominal contamination. It was removed laparoscopically without an enterotomy or bowel resection. Microscopy revealed non-viable bone, likely fish or chicken bone. The patient made an uneventful recovery and was discharged 3 days later. Herein we emphasise on the differential diagnosis and presentation of chronically ingested foreign bodies, as well as the feature of chronic ileitis with uncomplicated transmural migration of the ingested foreign body that was treated laparoscopically without an enterotomy.

Foreign Body Aspiration: An Unusual Presentation and Outcome

Foreign body aspiration mostly presents as acute emergency with cough, choking and dyspnoea. Rarely aspiration of foreign body may be the underlying cause in patients presenting with long term symptomatologies. Here is a case of 60-year-old male who came for surgical management of cholelithiasis. During his workup, X-ray chest revealed right paracardiac opacity. Fibre-optic bronchoscopy showed a mass lesion in right main bronchus. It was taken out of the airways by flexible bronchoscope but could not be retrieved. Subsequent chest radiographs showed marked improvement.

Cervical Esophagotomy for Removal of an Ingested Clam Shell: A Very Uncommon Foreign Body Ingestion

OBJECTIVE

To report the removal of an ingested clam shell that was firmly impacted in the esophagus.

CLINICAL PRESENTATION AND INTERVENTION

A 77-year-old man presented at our hospital with acute dysphagia after eating a seafood risotto. An urgent dedicated examination (noncontrast helical multislice computed tomography scan of the neck and flexible esophagoscopy) detected a clam shell lodged in the upper esophagus. After several unsuccessful endoscopic attempts, a lifesaving cervical esophagotomy was performed and the foreign body was retrieved.

CONCLUSION

This patient who ingested clam shell recovered well following the retrieval of the foreign body by performing a lifesaving cervical esophagotomy.