Spontaneous Expulsion of Foreign Body (Seewing Machine Needle) From Right Middle Lobe Bronchus - A Rare Case Report Keywords: Bronchoscopy, Foreign body bronchus, Otorhinolaryngologists, Tracheobronchial tree

Aspirated foreign bodies continue to present challenges to the Otorhinolaryngologists. The major issues involve the accurate diagnosis at the earliest and speedy, safe removal of the foreign body. Endoscopic removal is the mainstay of management of foreign body in tracheobronchial tree. Spontaneous expulsion of foreign body bronchus is a rare entity with few cases reported in literature. We report a rare and interesting case of 18-year-old male patient presented with sharp and pointed metallic foreign body in Right Middle lobe Bronchus i.e., sewing machine needle. Patient was admitted and planned for bronchoscopy. But prior to it, foreign body was spontaneously expelled out. The patient was discharged next day without any complication. Spontaneous expulsion saves the patient from the dangers of endoscopic removal of foreign body, but impose a great danger of subglottic lodgement of foreign body. [Table/Fig-1]: CXR PA view and lateral view showing radioopaque metallic F.B.in right middle lobe bronchus [Table/Fig-2]: CT scan thorax showing linear radio-opaque metallic density in medial segment of right middle lobe [Table/Fig-3]: Foreign body (Seewing machine Needle) Ashwin Ashok Jaiswal et al., Spontaneous Expulsion of Foreign Body (Seewing Machine Needle) From Right Middle Lobe Bronchus www.jcdr.net Journal of Clinical and Diagnostic Research. 2014 Aug, Vol-8(8): KD01-KD02 2 expulsion and a danger of foreign body lodgement into subglottis during such rare but possible occurrence should be kept in mind [5]. Removal of intrabronchial foreign bodies should be performed once the diagnosis is made. This can be achieved either by bronchoscopy or thoracotomy. Rigid bronchoscopy is the gold standard for removal of foreign bodies from tracheobronchial tree under direct vision. Spontaneous expectoration of foreign bodies is rare. Since time is of essence, delay in intervention complicates the picture and makes subsequent removal even more difficult [10]. Extrapulmonary foreign bodies, if asymptomatic, are best left alone. Intrapulmonary ones on the other hand, should be diagnosed promptly both clinically and radiologically and early intervention is advised to avoid complications [12]. Education is the best preventive measure for decreasing the incidence of this problem. CONClUSIONSponataneous expulsion of sharp metallic foreign body frombronchus is a rare entity. Endoscopic removal is the mainstay ofmanagement of foreign body in tracheobronchial tree. Irrespectiveof size, shape and nature of foreign body, there is always a rare butexisting possibility of spontaneous expulsion. On one hand, it savesthe patient from the dangers of endoscopic removal of foreign body,but it may also impose a great danger of subglottic lodgement offoreign body. REFERENCES[1] Charalambos E. Skoulakis, Panagiotis G, Doxas, Chariton E. Papadakis ,Efklidis Proimos, Panos Christodoulou, Emmanuel S. Helidonis. BronchoscopyFor Foreign Body Removal In Children. A Review & Analysis of 210 Cases.International Journal of Pediatric Otorhinolaryngology. 2000; 53:143-48.[2] Kent SE, Watson MG. Laryngeal foreign bodies. The Journal of Laryngology andOtology. 1990; 104:131-33.[3] Jackson C. Prognosis of foreign body in the lung. JAMA. 1921; 77:1178.[4] Marc SS, Alan JC, Munir A. Spontaneous endobronchial erosion and expectorationof a retained intra thoracic bullet: Case report. The Journal of Trauma. 1992;33(6):909-11.[5] SK Gupta, RK Mundra , A Goyal. Indian Journal of’ Otolaryngology and Head andNeck Surgery. 2004;56(3):233-34.[6] Negus VE. Diseases of nose and throat. Cassell and Co.Ltd., London.(1948)[7] Jackson and Jackson: Diseases of nose, throat and ear. W.B. Saunders Co.,Philadelphia and London; 2nd Ed (1959).[8] Gupta IS and Sood VP. Foreign body in the air passage (spontaneous expulsion).Indian Journal of Otolaryngology. 1967;19(4):173-76.[9] Ryndin VD, Octavio F. Two cases of spontaneous expulsion of aspirated needlesfrom the lungs. Grud Serdechnososudistaia Khir.”[jour].1986;6:90-1. [10] Hadi MA, Al-Telmesani LM. Spontaneous expulsion of intrabronchial metallic foreign body: A case report. J Fam Community Med. 1997; 4:77-9. [11] Liancai Mu, Ping He, Degiang Sun. Inhalation of foreign bodies in Chinese children: A review of 400 cases. Laryngoscope. 1991; 101:657-60. [12] Mital OP, Prasad R, Singhal SK, Malika A, Singh PN. Spontaneous expulsion of a long standing endobronchial metallic foreign body. Indian J Chest Dis Allied Sci. 1979; 21:45-7.few hours after its inhalation [8]. Ryndin VD reported two casesof aspirated needles which were expelled out spontaneously [9].While SK Gupta reported spontaneous expulsion of iron nail fromLeft main bronchus [5] whereas Hadi MA mentioned spontaneousexpulsion of iron nail from Rt lower lobe bronchus [10]. In our case, it is quite interesting and uncommon to see such asharp & pointed metallic sewing machine needle which was lodgedin Right Middle lobe bronchus was spontaneously expelled outwithout any complications. Definite history of inhalation and clinicalmanifestations such as choking, cough, respiratory distress andwheeze are important in diagnosis of foreign body inhalation [11].Clinical manifestations depend on type, size and location of theforeign body. The diagnosis can be immediately established as inour patient, or, it can be delayed for the weeks or months especiallyif the history is not clear. Such cases may present with establishedcomplication such as emphysema, atelectasis, bronchectasis,pneumonia or lung abscess [10]. Roentegnograms are mandatoryin establishing the diagnosis, locating the site of the foreign bodyand can also be helpful in demonstrating the presence of respiratorycomplication [10]. One more interesting thing is that it should beeasier to lodge into as well as to be removed for a foreign bodyfrom right main bronchus due to obvious anatomical reasons. Fromanatomic consideration, inhaled foreign bodies are commonlylocated in right bronchial system as compared to the left [11] [Table/Fig-4]. In our case too, foreign body sewing machine needle waslodged in Right segmental bronchus & due to anatomical reasonsmust have expelled out spontaneously. PArTiCulArs oF ConTriBuTors:1. Senior Medical Officer, Department of ENT & Head Neck Surgery, J.L.N. Hospital & Research Centre, Bhilai, Chhattisgarh, India.2. Joint Director & Head of Department, Department of ENT & Head Neck Surgery, J.L.N.Hospital & Research Centre, Bhilai, Chhattisgarh, India. nAmE, ADDrEss, E-mAil iD oF ThE CorrEsPonDinG AuThor:Dr. Ashwin Ashok Jaiswal,MBBS, DLO, DNB (ENT), SR. Medical Officer, Department of ENT & Head Neck Surgery, J.L.N. Hospital & Research Centre,Sector 9, Bhilai, Dist. Durg, Chhattisgarh-490009, India.Phone: 9407983605 E-mail: [email protected] FinAnCiAl or oThEr ComPETinG inTErEsTs: None.Date of Submission: Feb 02, 2013Date of Peer Review: may 01, 2014Date of Acceptance: may 03, 2014 Date of Publishing: Aug 20, 2014[Table/Fig-4]: Comparison of inhaled foreign bodies in the right andleft bronchial systems absolute and interpeak latencies of BAEP fromprevious studies [11]site% Right main stem bronchus42.0-70.0 Left main stem bronchus18.7-32.6 Right segmental bronchi22.0 Left segmental bronchi3.0