Case:
A 12-year-old girl presented with 3 year history of cough andpurulent expectoration, responding partially to inhaled bronchodilators. There was no seasonal or diurnal variation, wheezing, chest pain, hemoptysis or cyanosis. There were intermittent undocumented fever episodesoverthe past twoyears. There was decreased exertional capacity over the past 6 months. There was no history of change in appetite, ear or nasal symptoms, aggravating or relieving factors, vomiting, epigastric discomfort, severe multi-systemic infections, or malabsorption. There was no contact with active tuberculosis. Examination revealed normal vital signs and oxygen saturation in room air. Weight, height, body massindex of 41kg, 156cm and 16.85 respectively were normal for age and height. There was pandigital clubbing but no pallor, cyanosis, or lymphadenopathy. Respiratory system examination revealed coarse cracklesin right infra-scapular area with increased vocal resonance and fremitus. Chest roentgenogram (Figure 1A) and Contrast enhanced computer tomography (CECT)(Figure 1B, 1D) showedright lower lobe volume loss with cystic bronchiectasis and foreign body in right lower lobe bronchus. Review of history revealed an episode of inhaling a plastic whistle about 5 years back. The child did not tell her parents and hence no attempt was made to remove it.
Flexible bronchoscopy revealed a foreign body in the right lower lobe bronchus with purulent secretions and granulation tissue. Rigid bronchoscopy (7.5 french sheath, 43 cm length) done under general anesthesia confirmedtheforeign body but it could not be removed despite multiple attempts using optical forceps (5.5mm with length 50 cm) as the object was out of reach of the forceps. A second attempt was made after administering oral prednisolone for 48 hours. Still, the foreign body could not be removed after multiple attempts using.
Therefore aflexible bronchoscope (Olympus BF-Q190, outer diameter 4.9 mm) as inserted through the rigid scope size (7.5 french sheath, 43 cm length). After placing the flexible bronchoscope tip just above the foreign body, rat-toothed forceps was inserted through the suction channel of the flexible scope. The foreign body was grasped with rat-toothed forceps and pulled into the rigid scope. The rigid scope along with the flexible scope and the foreign body inside was removed (Figure 1C) and child reintubated.The post-operative period was uneventful and the child was discharged after three days with advice to continue chest physiotherapy to drain the right lower lobe. During follow-up over 8 months,thechild had markedly improved. There were no episodes of cough or fever or exercise intolerance. She had gained 12 kg weight (from 41kg).