Foreign body inhalation, is common in children and is usually hazardous and potentially lethal. The larynx performs a very efficient sphincteric function to protect the lower respiratory tract and, therefore, it is unusual for a foreign body to be inhaled rather than swallowed.1 In 1921, Jackson suggested that spontaneous expulsion of intrapulmonary foreign bodies occurs so rarely that removal should be performed early to avoid subsequent complications.23
We report a case of inhaled nail into the right lower lobe bronchus with spontaneous expulsion after 2 hours.
A 23-year-old male prisoner presented to our hospital with a history of having attempted to swallow a nail while under surveillance. A struggle had ensued, and the patient had had bouts of coughing followed by right-sided and retrosternal chest pain which was relieved almost instantly. There was no associated dyspnoea, hemoptysis or abdominal pain. He was fully conscious, alert and cooperative on arrival to the Emergency Room. Physical examination showed no abnormality. Chest roentegenogram demonstrated a curved nail lodged in the right lower lobe bronchus (Figure 1 & 2). This was confirmed by CT scan. It was decided that bronchoscopic removal would be attempted; in case it fails failed surgical removal would be adopted. During the pre-operative preparation, the patient turned on his left side, started to cough and expectorated the foreign body spontaneously. It was about 2 cm long and weighed 2.6 gm (Figure 3).
There was no post expectoration dyspnoea, hemoptysis or chest pain. He was kept for 24 hours under observation. Repeated chest roentegnogram was normal and he was discharged.
Intrathoracic foreign bodies are classified into intrapulmonary and extrapulmonary. Extrapulmonary foreign bodies are usually due to penetrating injuries such as bullets or shrapnel. These are usually asymptomatic because they are encapsulated by fibrous tissue and, therefore, have minimal propensity to impinge upon surrounding structures.4 Bronchial erosion and migration by retained intrathoracic foreign bodies is an extremely rare event. To our knowledge there are only 5 reported cases in literature. On the other hand, intrapulmonary foreign bodies are usually aspirated most commonly by children with peak incidence between 1 and 2 years.5 From anatomic consideration, inhaled foreign bodies are commonly located in right bronchial system as compared to the left (Table 1).5
Types of inhaled foreign bodies are usually food items such as peanuts, water melon seeds etc. Metallic foreign body aspiration is rare and often requires surgical removal.
Clinical manifestations depend on type, size and location of the foreign body. The diagnosis can be immediately established as in our patient, or, it can be delayed for the weeks or months especially if the history is not clear. Such cases may present with established complication such as emphysema, atelectasis, bronchectasis, pneumonia or lung abscess.
Roentegnograms are mandatory in establishing the diagnosis, locating the site of the foreign body and can also be helpful in demonstrating the presence of respiratory complications.
Removal of intrabronchial foreign bodies should be performed once the diagnosis is made. This can be achieved either by bronchoscopy or thoracotomy. 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.
In conclusion, extrapulmonary foreign bodies, if asymptomatic, are best left alone. Intrapulmonary ones on the other hand, should be diagnosed promptly both clini-cally and radiologically and early intervention is advised to avoid complications.10
1. Kent SE, Watson MG. Laryngeal foreign bodies The Journal of Laryngology and Otology. 1990;104:131–3
2. Jackson C. Prognosis of foreign body in the lung JAMA. 1921;77:1178
3. Marc SS, Alan JC, Munir A. Spontaneous endobronchial erosion and expectoration of a retained intra thoracic bullet: Case report The Journal of Trauma. 1992;33(6):909–11
4. Van W CW III. Intrathoracic and intravascular migratory foreign bodies Surg Clin North Am. 1989;69:125
5. Liancai Mu, Ping He, Degiang Sun. Inhalation of foreign bodies in Chinese children: A review of 400 cases Laryngoscope. 1991;101
6. Ryndin VD, Octavio F. Two cases of spontaneous expulsion of aspirated needles from the lungs Grundn Khir. 1986;6:90–1
7. Cohen SR, Herbert WI, Lewis GB Jr. Foreign bodies in the airway. Five year retrospective study with special reference to management Ann Otol Rinol Laryngol. 1980;89:437–42
8. Brooks JW. Foreign bodies in the air and food passages Ann Surg. 1972;175:720–31
9. Banaszews Ki-B. Case of spontaneous expectoration of pin from the primary bronchus of the posterior segment of the lower lobe of the right lung Pol Tyg Lek. 1972;27:108–9
10. 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