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| CASE REPORT |
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| Year : 2020 | Volume
: 10
| Issue : 1 | Page : 7-9 |
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Foreign body removal using cryoprobe in a child
Sneha Yadav, Rajeev Chugh, Manu Chopra
Department of ENT and Head and Neck Surgery, Army Hospital Research and Referral, New Delhi, India
| Date of Submission | 04-Aug-2020 |
| Date of Acceptance | 14-Sep-2020 |
| Date of Web Publication | 4-Nov-2020 |
Correspondence Address:
Sneha Yadav
Department of ENT and Head and Neck Surgery, Army Hospital Research and Referral, New Delhi
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jlv.JLV_9_20
 Abstract | | |
Foreign body (FB) inhalation is a frequently encountered event in children. The diagnosis is reached by the presence of a clinical history of aspiration and the presence of respiratory symptoms. Management involves confirmation by flexible bronchoscopy, which may be both diagnostic and therapeutic. However, in certain situations including those with large FB, FB embedded in granulation tissue, or FB with very smooth margins, rigid bronchoscopy may be a better substitute. An alternative to rigid bronchoscopy may be the use of cryoprobe. Herein, we describe a child with tracheobronchial FB causing hyperinflated right middle and lower lobes with mild atelectasis. The FB was successfully extracted using a cryoprobe, obviating the need for rigid bronchoscopy.
Keywords: Bronchoscopy, cryoprobe, foreign body
How to cite this article:
Yadav S, Chugh R, Chopra M. Foreign body removal using cryoprobe in a child. J Laryngol Voice 2020;10:7-9 |
| Introduction | |  |
Tracheobronchial foreign body (FB) is a common occurrence in children with increased mortality and morbidity especially in the age group of 1–3 years.[1] At this age range, children have the frequent habit of putting small objects into their mouths, which may predispose to aspiration.[2] Commonly aspirated FBs in children are peanuts.[3]
Acute complications include asphyxiation, obstructive emphysema, atelectasis, pneumothorax, and pneumomediastinum. Late complications usually arise from the development of an obstructive infectious process that presents as a recurrent pneumonia, and can lead to the development of bronchopleural fistulas, secondary empyema, bronchiectasis, and occasional irreversible damage to the obstructed segment with development of airway stenosis. The complication rate is significantly higher when diagnosis is delayed beyond 24 h. Therefore, prompt recognition and removal is essential in these cases.[3]
Treatment involves extraction of the FB using flexible bronchoscopy or rigid bronchoscopy. The use of cryotherapy probes has proven to be an alternative approach to the removal of FBs through flexible bronchoscopy.[3],[4]
Cryotherapy is an evolving therapeutic and diagnostic tool used during bronchoscopy. Through rapid freeze–thaw cycles, cryotherapy causes cell death and tissue necrosis or tissue adherence that can be used via flexible or rigid bronchoscope.[5],[6] This extreme cold can be induced through the working channel of the bronchoscope via a specialized cryoprobe or directly with the use of spray cryotherapy. Bronchoscopic cryotherapy can be used in a variety of clinical scenarios, including treatment of malignant and benign central airway obstruction and low-grade airway malignancy, FB removal or cryoextraction, endobronchial biopsy, and transbronchial biopsy.[4] Cryotherapy with cryoprobe causes sudden drop in temperature to −40°C, resulting in the interface of the probe and FB to freeze rapidly, enabling quick and easy removal.[1]
Here, we describe the use of cryoprobe in the successful extraction of tracheobronchial FB using flexible bronchoscopy in a child.
| Case Report | | |
A 2-year-old male with no known comorbidities presented with intermittent episodes of cough of 3 months' duration. He had a history of recurrent episodes of fever, chills, and night sweats. On examination, he was tachypneic and had audible wheeze localized in the right paraspinal area. The room air oxygen saturation was 94%. Chest radiograph and laboratory blood tests were interpreted as normal. Computed tomography of the thorax revealed soft-tissue density in the distal part of the right bronchus with hyperinflated right middle and lower lobes with mild atelectasis [Figure 1]. Due to chronic history and increased chances of adhesions and fibrosis, a flexible bronchoscopy (Olympus, Tokyo; BF1T180; working channel diameter, 2.8 mm) was performed through oral route under general anesthesia for diagnostic and therapeutic purposes. Bronchoscopy confirmed the presence of a large FB in the right main bronchus with inspissated secretions [Figure 2]a. The cryoprobe (ERBE, Tubingen, Germany; outer diameter 2.4 mm, length 780 mm) was introduced through the working channel of the flexible bronchoscope and was placed adjacent to the FB, avoiding any contact with the surrounding mucosa. The cryoprobe was then activated for 5 s, and thereafter the adhered FB was removed along with the flexible bronchoscope [Figure 2]b. Following the procedure, the patient was nebulized with salbutamol (2.5 mg) and administered systemic corticosteroids (50 mg of hydrocortisone). The patient was discharged after observation of 1 day. | Figure 1: Computed tomography chest showing soft-tissue density in the distal part of the right bronchus with hyperinflation and mild atelectasis
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 | Figure 2: (a) Bronchoscopic view of the foreign body with inspissated mucous that is occluding the right main bronchus. (b) Flexible bronchoscope with cryoprobe and the adhered foreign body
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| Discussion | | |
The case highlights a successful use of cryoprobe in the removal of tracheobronchial FB using cryoprobe. Most patients present with innocuous symptoms due to the peripheral location of the FB. The index case presented with chronic symptoms and was found to have an FB in the right main bronchus.
The diagnosis of airway FB is made based on the history of aspiration and the clinical presentation with respiratory symptoms. The diagnosis is supported by chest imaging, either chest radiograph or computed tomography of the thorax. The index case had characteristic history and symptoms of FB inhalation and radiological feature of hyperinflated right middle and lower lobes with mild atelectasis. The most common location of a tracheobronchial FB is the right lower lobe or the right intermediate bronchus due to the vertical orientation of the right main bronchus; however, it may also be seen in the other locations such as the left main bronchus. The diagnosis is confirmed by flexible bronchoscopy.
Cryoprobe has been used to extract large mucus plugs and blood clots that could not be removed using a flexible grasping forceps. Cryoextraction has been used in the removal of metallic and inorganic tracheobronchial FBs that are embedded in the granulation tissue. Cryoprobe has shown decreased chances of bleeding and postoperative complications. This made the authors to use a flexible bronchoscope in the place of a rigid one in the index case. Presence of airway secretions over the FB enables crystallization of the water molecules. This results in strong attachment of the cryoprobe to the FB ideally for about 10 s, leading to successful removal and reduced trauma, as demonstrated in our case.
Finally, the use of cryoprobe is not without any limitations. It is important to realize that patients with comorbid conditions and those with low cardiorespiratory reserve may not tolerate even transient hypoxemia. In such conditions, flexible bronchoscopy may not be safe, and one should directly resort to rigid bronchoscopy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
This study was financially supported by the Department of Respiratory Medicine, Army Hospital Research and Referral, New Delhi.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Karakoc F, Cakir E, Ersu R, Uyan ZS, Colak B, Karadag B, et al. Late diagnosis of foreign body aspiration in children with chronic respiratory symptoms. Int J Pediatr Otorhinolaryngol 2007;71:241-6.  |
| 2. | Rodrigues AJ, Scussiatto EA, Jacomelli M, Scordamaglio PR, Gregório MG, Palomino AL, et al. Bronchoscopic techniques for removal of foreign bodies in children's airways. Pediatr Pulmonol 2012;47:59-62. |
| 3. | Rubio E, Gupta P, Ie S, Boyd M. Cryoextraction: A novel approach to remove aspirated chewing gum. Ann Thorac Med 2013;8:58-9. [ PUBMED] [Full text] |
| 4. | DiBardino DM, Lanfranco AR, Haas AR. Bronchoscopic cryotherapy. clinical applications of the cryoprobe, cryospray, and cryoadhesion. Ann Am Thorac Soc 2016;13:1405-15. |
| 5. | Sehgal IS, Dhooria S, Behera D, Agarwal R. Use of cryoprobe for removal of a large tracheobronchial foreign body during flexible bronchoscopy. Lung India 2016;33:543-5. [ PUBMED] [Full text] |
| 6. | Schumann C, Kropf C, Rüdiger S, Wibmer T, Stoiber KM, Lepper PM. Removal of an aspirated foreign body with a flexible cryoprobe. Respir Care 2010;55:1097-9. |
[Figure 1], [Figure 2]
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