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Retrieving Aspirated Pins by Flexible Bronchoscopy

Gokirmak, Munire M.D.*; Hasanoglu, H. Canan M.D.*; Koksal, Nurhan M.D.*; Yildirim, Zeki M.D.*; Hacievliyagil, S. Savas M.D.*; Soysal, Omer M.D.

Original Articles

Eleven women have been admitted to our clinic with turban pin aspiration since October 1996. All patients except two were admitted within the day of aspiration. The other two patients were admitted 5 days after pin aspiration. The aspirated pin was localized in the right lung in seven patients and in the left lung in four patients. The pins were retrieved successfully with a flexible bronchoscope in 8 of 11 patients. In one of these eight patients, the pin was removed using the flexible bronchoscope through a rigid bronchoscope. In one patient, the pin dropped from the forceps in the pharynx, and was later excreted in the feces. Thoracotomy was performed in two patients because both rigid and flexible bronchoscopies were unsuccessful in retrieving the pins. Flexible bronchoscopy alone or in combination with rigid bronchoscopy is a successful method for retrieving aspirated pins.

Departments of *Pulmonary Diseases and †Cardiovascular and Thoracic Surgery, Inonu University, Turgut Ozal Medical Center, Malatya, Turkey

Address reprint requests to Dr. Munire Gokirmak, Inonu University, Turgut Ozal Medical Center, Department of Pulmonary Diseases, 44069 Malatya, Turkey; e-mail:

FFB, flexible bronchoscopy

Aspiration of foreign bodies into the tracheobronchial tree is much more common in children than in adults. 1 Most adults who aspirate have underlying impairment of protective airway mechanisms, such as primary neurologic disorders, trauma with loss of consciousness, or sedative or alcohol use. 2 Turban pin aspiration, seen primarily in young healthy women, has recently been reported as a new form of aspiration. 3,4

The instrument of choice for extracting tracheobronchial foreign bodies was, traditionally, the rigid bronchoscope. However, several recent reports have suggested that flexible bronchoscopy (FFB) may be a valuable therapeutic option for adults with foreign body aspiration. 5–9 In the current study we evaluated retrospectively the characteristics of 11 women admitted to our clinic with turban pin aspiration to determine the success rate of FFB for treatment of this special type of aspiration.

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The characteristics of 11 women admitted to our clinic with turban pin aspiration since October 1996 were investigated. Age, duration of foreign body residence, the location of the aspirated pin, and the therapeutic method of all patients were recorded.

The patients had a mean age of 18.5 ± 7.9 years (range, 12–41 years). All were healthy young women and none had predisposing conditions for aspiration. These young women held the pins between their teeth while applying their turban and aspirated the pins while laughing or talking. All experienced coughing immediately after aspiration. On admission, however, none of them was symptomatic. Physical examinations were also normal. All patients except two were admitted the day of aspiration, 2 to 12 hours after the event. The other two patients were admitted 5 days after aspiration.

Posteroanterior and lateral chest radiographs were acquired in all patients to locate the pins before bronchoscopic intervention. Radiographically, the pin was localized in the right lung in seven patients (64%) and in the left lung in four patients (36%;Table 1, Fig. 1).



FIG. 1.

FIG. 1.

The pins were retrieved with a flexible bronchoscope (Olympus BF Type 1T30; Olympus Co., Tokyo, Japan) in eight patients (Fig 2.). Before FFB, the patients were sedated with 5 mg intravenous diazepam, and during the procedure local anesthesia was administered to all patients with instillation of 2% prilocaine solution. The transnasal route was used during the FFBs.

FIG. 2.

FIG. 2.

All pins were found “head down” in the bronchial system. Because they were seen directly in the bronchi, fluoroscopic guidance was not needed to remove any of them. After the pins were grasped with serrated forceps, the forceps was pulled up to the bronchoscope and removed along with the instrument in all patients except one, in whom the pin was extracted with simple suction (Fig. 3). In one of the patients, the pointed end of the pin was lodged in the bronchial mucosa. In this patient, by grasping the pin at the shaft and pushing it gently distally, we placed the pin in an intrabronchial position.

FIG. 3.

FIG. 3.

In all patients the pins were extracted during the first attempt of FFB. One of the patients experienced unsuccessful intervention of rigid bronchoscopy before the pin was retrieved using FFB. In another patient, the pin was retrieved by FFB introduced through a rigid instrument. Rigid endoscopy equipment was readily available during all FFB procedures.

In one patient the pin dropped from the forceps in the pharynx during an intervention of FFB. At follow-up, an abdominal radiograph revealed the pin in the colon, and the pin was later excreted in the feces.

Thoracotomy was performed in two patients after unsuccessful interventions of both flexible and rigid bronchoscopies. The pin was localized in the right lower lobe medial segmental bronchus in one of these patients (patient no. 1), and in the right lower lobe posterior segmental bronchus in the other (patient no. 8). In patient no. 1, the pin could not be removed with FFB, therefore rigid bronchoscopy was performed. A chest radiograph taken after the unsuccessful attempt with rigid bronchoscopy revealed that the pin moved farther distally. In patient no. 8 the pin was partially embedded in granulation tissue, which was covered with purulent secretions. Because the pointed end of the pin could not be grasped during these bronchoscopies, the patients underwent thoracotomy.

None of the patients experienced postbronchoscopic or intraoperative complications.

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Although aspiration of foreign bodies into the tracheobronchial tree occurs in all age groups, they are less common in adults than in children. Limper and Prakash, 2 in their study of 60 consecutive adult patients with tracheobronchial foreign body aspiration, found that the most common type of foreign body was vegetable matter. The second predominant group of aspirated objects consisted of dental equipment or prostheses, tracheostomy tube segments, and endobronchial tube appliances inadvertently lost during dental or medical procedures. Primary neurologic disorders were the most common predisposing factors for aspiration in this group of adult patients. Additionally, dental procedures, with their associated supine position and local anesthesia; medical procedures, particularly those involving cleaning, replacing, and manipulating tracheostomy or endotracheal tubes; trauma with associated loss of consciousness and cervicofacial injury; and alcohol or sedative use predisposed patients toward tracheobronchial foreign body aspiration. 2 However, foreign body aspiration can also occur without any predisposing conditions. 10 In our series, none of the subjects had a predisposing condition. The patients held the pins between their teeth while applying their turban and aspirated them while laughing or talking.

Recently, two large series with turban pin aspiration have been reported. 3,4 The first report, by Ucan et al., 3 involved 47 women admitted to five different centers between 1988 through 1994 in Turkey. In these centers, turban pins were calculated to comprise 24 to 86% of all foreign bodies aspirated. The second report, by Kaptanoglu et al., 4 described 63 subjects with turban pin aspiration admitted between the years 1987 and 1998.

The specific site where the foreign body is lodged depends on the body posture of the person at the time of aspiration, as well as the anatomic properties of the tracheobronchial tree. In our series of 11 patients, aspirated pins were localized primarily in the lower lobes (36% in the right lower lobe, 18% in the left lower lobe). In the series by Ucan et al., 3 51% of patients aspirated the pin into one of their lower lobes.

In patients with predisposing factors such as neurologic disorders, or drug or alcohol use, the diagnosis of foreign body aspiration may be difficult. Some cases may go undiagnosed for years, with the most common symptom being cough. However, if the patient is alert at the time of aspiration, as was the case in our study population, the diagnosis can be made easily according to the patient's history.

The site of localization of the foreign body can be revealed easily with posteroanterior and lateral chest radiographs for radiopaque materials, such as pins. In fact, the location of the aspirated pin was shown before the bronchoscopic procedure in all patients in the current study. In one patient, however, the pin was retrieved from the right lower lobe, although it was shown to be in the left main bronchus radiographically before the procedure. In a series of foreign body aspirations, Weissberg and Schwartz 11 reported an 8 year-old boy with pin aspiration. Although the pin was located in the right bronchus in the first roentgenogram, it was located in the left bronchus in another roentgenogram taken a few hours later. The authors suggested that this case was a good example of “wandering foreign body” and emphasized the importance of having a roentgenogram taken immediately preceding bronchoscopy. 11

Definitive treatment of foreign body aspiration is removal as soon as possible. Before the 1970s, removal was usually performed by rigid bronchoscope. More recently, FFB has become popular for the removal of foreign bodies. 5,6,9 In 1978, Cunanan 5 published his experiences with the removal of foreign bodies using FFB in 300 patients, most of whom were mentally retarded and physically handicapped, and had acute foreign body aspiration. He found that the mortality and morbidity rates dropped from 12% to 1% by using a flexible bronchoscope instead of a rigid bronchoscope. 5 In a study by Lan et al., 6 foreign bodies were retrieved successfully by FFB in 33 adult patients except one. In 1997, Chen et al. 9 reported the results of an analysis of 43 consecutive adult patients with foreign body aspiration. According to the study results, FFB removed the foreign body in 25 patients (58%) during the first attempt and in 32 patients (74%) in total. The authors suggested that FFB should be the first-line approach in the treatment of foreign body aspiration. 9 In the study by Limper and Prakash, 2 however, FFB had a 60% success rate, in contrast to a 98% success rate associated with rigid bronchoscopy.

Therefore, Limper and Prakash, 2 disagreed that the flexible bronchoscope is superior to the rigid bronchoscope for extracting foreign bodies. Nevertheless, they suggested that FFB does have a distinct advantage over rigid bronchoscopy for retrieving foreign bodies in peripheral bronchi in mechanically ventilated patients and in patients whose necks are unstable as a result of cervical or maxillofacial trauma.

In patients with pin aspiration, FFB can be more successful compared with other types of aspirated material because of the more peripheral localization of the aspirated pin. Shabb et al. 12 reported five patients with straight-pin aspiration who were treated successfully with FFB under general anesthesia. In another case report by Smith and Khan, 13 a metal pin was removed using FFB, after two unsuccessful attempts with the rigid instrument. In two other cases, the pin, although it could not be seen directly by FFB, was removed under fluoroscopic guidance. 14,15 Debeljak et al., 16 in their series of 62 patients, removed two endodontic needles successfully from segmental bronchi with FFB, and stated that they agree with other authors that FFB may be superior to rigid bronchoscopy for grasping tiny and far-reaching foreign bodies. In the two large series of turban pin aspiration reported from Turkey, however, rigid bronchoscopy was the management choice. 3,4

In our series, the pins were retrieved successfully by FFB with a success rate of 72.7%. In two patients in whom FFB was unsuccessful, rigid bronchoscopy was not successful either, and thoracotomy was performed. When the duration of the foreign body was taken into consideration, FFB was unsuccessful in one of the two patients (50%) with long duration (5 days); whereas the failure rate was one of nine patients (11%) with short duration (2–12 hours). Although there are many reports that show the success of FFB in the treatment of pin aspiration, in a case report by Savage and Dellinger 17 the pin could not be removed by FFB, and they proposed that a local mucosal reaction made it impossible to remove the pin bronchoscopically. In this case also, the duration of foreign body residence was at least 9 months. 17

Multiple instruments (grasping forceps, balloon catheters, baskets, snares, magnetic extractor) are available for use with the flexible bronchoscope for retrieval of a foreign body. However, pin aspiration is a special circumstance, and not all instruments are convenient for extracting pins. In previously mentioned reports, the pins were extracted primarily with alligator forceps. 12,16 In the report by Castro et al., 15 the metallic pin aspirated by a child was retrieved using ureteral biopsy forceps. In the current series, all pins were also removed using alligator forceps. We think that use of baskets, snares, and a magnetic extractor do not help in removing pins because the pointed end of the pin should be grasped to avoid complications. However, a magnetic extractor may be useful in pulling a distally located pin to a more proximal position. In a recent article by Rafanan and Mehta, 18 it was also emphasized that the sharp end of a foreign body should be freed before grabbing it, because grasping the shaft or the other end of a pointed instrument increases the difficulty in removal as a result of the risk of the object getting caught in the mucosa.

When a foreign body has been entrenched for extended periods of time, laser-assisted removal of the surrounding granulation tissue may help with retrieval. In a recently reported patient who aspirated a pushpin, attempts at removal of the pointed end were unsuccessful because of the granulation tissue surrounding the point. 18 After vaporizing the granulation tissue by laser photocoagulation, however, the pin was removed successfully with forceps through a flexible bronchoscope. Thoracotomy may have been avoided in one of our patients if laser equipment was available in the bronchoscopy unit.

In conclusion, FFB under local anesthesia is a method of treatment in patients with pin aspiration. However, the duration of foreign body residence may affect the success rate of the procedure.

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Flexible bronchoscopy; Rigid bronchoscopy; Pin aspiration

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