long-standing intrabronchial foreign bodies

TAorax (1957), 12, 164.

LONG-STANDING INTRABRONCHIAL FOREIGN BODIESBY

J. S. A. LINTONFrom the London Chest Hospital, London, E.2

(RECEIVED FOR PUBLICATION FEBRUARY 22, 1957)

The long-standing intrabronchial foreign bodypresents problems of diagnosis and treatmentwhich are very different from those associatedwith the recently inhaled foreign body. Theremay be no history to suggest the original incident;the clinical picture is usually clouded by super-added pathological changes-atelectasis, pneu-monitis, bronchiectasis, or lung abscess-and thebronchoscopic appearances are often misleading.Even when correctly diagnosed, the choice oftreatment is not always easy.

Sixteen such cases are presented in an attemptto find common characteristics, recognition ofwhich may assist correct diagnosis in this notuncommon condition.

In addition, the problems of treatment are con-sidered.

CASE HISTORIESCASE 1.-A man aged 31 was admitted with 10

months' history of cough with purulent sputum andno haemoptysis. He was febrile (102' F.), producing4 oz. of purulent sputum daily. Physical and radio-logical signs were those of consolidation of the rightlower lobe. With antibiotics and postural drainage hebecame afebrile in four days, and there was someradiological resolution. Bronchoscopy showed thatthe mucosa of the right lower lobe was hyperaemic,granular, and exuding pus. A bronchogram showedthe basal segmental bronchi crowded, but not bronchi-ectatic.He was discharged after three weeks and followed

up as an out-patient. Physical and radiological signsof infection persisted and he lost weight. He wasreadmitted two years after discharge. He was afebrile(having had antibiotics as an out-patient) with mucoidsputum. A radiograph showed diffuse opacity of theright lower lobe. Bronchography showed contractionof the right basal segments with incomplete filling(Fig. 1).At bronchoscopy the appearances were unchanged,

but in addition a white object was seen which couldnot be removed. Biopsy of the mucosa showed intensechronic inflammation of the subepithelial layers andhaemorrhagic granulation tissue.

At operation the right lower lobe bronchus wasincised and a rabbit vertebra removed. The basal

segments looked and felt normal. The vertebra layso that its canal acted as an airway.

His post-operative course was uneventful. Theradiograph cleared and a subsequent bronchogramshowed no bronchiectasis (Fig. 2).No history of inhaling the foreign body was obtain-

able.CASE 2.-A woman aged 57 was admitted with

four years' history of cough, purulent sputum, andwheeziness. There was occasional slight haemoptysis.A febrile incident had confined her to bed for sixweeks. On admission she was afebrile and producing4 oz. of mucopurulent sputum daily, containing nomalignant cells. There were moist sounds throughoutboth lung fields. A radiograph showed collapse ofthe left lower lobe with a calcified shadow at the lefthilum, which later disappeared. Bronchography(Fig. 3) showed unfilled basal segments with nobronchiectasis. Bronchoscopy showed pus welling upfrom the lower lobe. An irregular "tumour" wasseen obstructing the basal segments. Biopsy showedsquamous metaplasia. Bronchoscopy was repeated.The "tumour" was seen to be granulation tissue,beyond which a bone was seen and was removed.A subsequent bronchogram (Fig. 4) showed no

abnormality.No history of inhaling the bone was obtainable.CASE 3.-A man aged 66 was admitted with three

years' history of cough and purulent sputum, whichwas often blood-stained. He was febrile with signsof collapse and consolidation of the right middle andlower lobes. The pyrexia subsided with antibioticsand physiotherapy, but there was no radiologicalimprovement. Bronchoscopy showed granulations inthe right lower lobe, but the biopsy was negative. Themiddle lobe reaerated but not the lower lobe.Bronchoscopy was repeated and a portion of wish-bone was removed from the right lower lobe. Theright lower lobe subsequently reaerated.On direct questioning the patient's wife recalled that

he had had a choking attack during a meal severalyears before.CASE 4.-A girl aged 9 gave a history of many

months of cough, which had recently become moretroublesome with mucopurulent sputum, loss ofweight, and anorexia. She remembered swallowing acollar stud when she was much younger. Her motherstated there had been no metal studs in the house for

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LONG-STANDING INTRABRO NCHIAL FOREIGN BODIES 165

FIG. 1.-Case 1: Pre-operative bronchogram showing contraction FIG. 2.-Case 1: Post-operative bronchogram showing good fillingof the right lower lobe with incomplete filling of lower obe of the right lower lobe with no bronchiectasis.bronchi.

1>.

* . ~~~~~~~. W.... -

FIG. 3.-Case 2: Pre-bronchoscopy bronchogram showing that the FIG. 4.-Case 2: Post-bronchoscopy bronchogram showing theleft basal segments have not filled: left lower lobe filled, with no bronchiectasis.

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166 J. S. A. LINTON

FIG. 5.-Case 4: Pre-bronchoscopy radiograph showing collar stud FIG. 7.-Case 7: Radiograph showing a tin-tack in the right lowerin the right main bronchus with consolidation of the right lobe.basal segments.

FIG. 6.-Case 4: Bronchogram two weeks after bronchoscopic FIG. 8.-Case 7: After expectoration of the tin-tack a bronchogramremoval of a foreign body, showing no bronchiectasis. shows minor bronchiectasis in the posterior basal segment.

-A




LONG-STANDING INTRABRONCHIAL FOREIGN BODIES

at least five years. A radiograph (Fig. 5) showed thecollar stud at the right hilum, with consolidation ofthe basal segments. At bronchoscopy this was re-moved from the right lower lobe bronchus. Therewas some stenosis and considerable granulation tissue.A bronchogram two weeks later (Fig. 6) showed noabnormality.CASE 5.-A woman aged 48 had been in another

hospital six months before with cough, stridor, andpurulent sputum, occasionally blood-stained. A thyroidadenoma was found and removed, but cough andsputum persisted. A radiograph showed consolidationof the right upper lobe. At bronchoscopy a largepiece of bone was found in the right main bronchusopposite the upper lobe with surrounding granulationtissue. It was easily removed, and there was rapidresolution of the radiological opacity with disappear-ance of symptoms.She subsequently gave a history of choking on a

mutton bone 18 months before.

CASE 6.-A boy aged 8 gave a history of sevenmonths' irritating cough, and developed left-sidedpneumonia. A radiograph showed a metallic foreignbody, whose nature was obscure, with atelectasis ofthe left lower lobe. Bronchoscopy revealed a shiningmetallic object in the left main bronchus, opposite theupper lobe orifice. Beyond its presenting roundedsurface was a mass of granulation tissue. On removalit proved to be a note-book pencil with flanged metalend.The child became symptom-free, but was lost sight

of, and no follow-up is recorded.CASE 7.-A man aged 55 gave a history of inhaling

a tin-tack three months previously, with subsequentcough and mucopurulent sputum, never blood-stained.A radiograph (Fig. 7) showed the tin-tack in the rightlower lobe. Before investigations could be startedthe patient expectorated the tack and has beensymptom-free ever since. Subsequent bronchography(Fig. 8), however, showed minor bronchiectasis of theposterior basal segment.

CASE 8.-A girl aged 11 had bilateral bronchiectasiswith symptoms since infancy. When aged 5, middlelobectomy was performed. After post-operativebronchoscopy, it was suspected that part of the rubbersucker tip might have been left in the bronchial tree,but a search was unsuccessful. Cough and sputumpersisted, and she was thought to have chronic bron-chitis, which was improved by a prolonged course ofterramycin. A bronchogram, six years after opera-tion, showed bronchitic changes in the right lowerlobe, with minimal bronchiectasis. Two weeks latershe coughed up a piece of rubber tube 8 mm. long,and since then, with no treatment, has had no furthersymptoms.CASE 9.-A woman aged 54 gave a history of in-

haling a peanut seven months previously, and hadhad cough and purulent sputum, with occasionalhaemoptysis, ever since. A radiograph showed col-

lapse and consolidation of the right middle and lowerlobes, and a bronchogram demonstrated bronchiectasisof these lobes. Bronchoscopy showed reddening andpurulent secretion in the middle and lower lobes, butno foreign body. She was treated by resection ofthe diseased lobes. At pre-operative bronchoscopy awhole peanut was removed by the sucker. The speci-men showed bronchiectasis and pneumonitis withulceration at the origin of the apical lower bronchus.CASE 10.-A man aged 40 inhaled a tin-tack two

and a half years before admission. He had had coughand purulent sputum ever since with repeated haem-optysis. A radiograph showed the tack in the rightlower lobe. A bronchogram showed poorly filled,bronchiectatic basal segments with the foreign bodyin the posterior basal segment. At bronchoscopy thetack could not be seen. He was treated by right lowerlobectomy. The specimen showed severe bronchi-ectasis, wih fibrosing collapse and fibrous thickeningof the septa and pleura.CASE 11.-A boy aged 8 gave a history of cough

and purulent sputum since a rather indefinite incidentof inhaling food one year before. A radiographshowed consolidation of the right basal segments.Bronchography showed poor filling of these segmentsbut no definite bronchiectasis. At bronchoscopy theright lower lobe was seen to be obstructed by a lumpof purulent material, which was removed by suction,causing some bleeding. Treatment was right lowerlobectomy. The specimen showed a foreign body ina basal bronchus which had caused bronchiectasis,infection, fibrosis, and collapse.CASE 12.-A woman aged 43 had aspirated a tooth

into the right lung during a dental extraction undergeneral anaesthesia six years previously. She had beenbronchoscoped several times, but the tooth could notbe removed. She developed cough, purulent sputum,and haemoptysis. A radiograph showed collapse ofthe right basal segments with a calcified shadow, pre-sumed to be the tooth. Bronchography showedpoorly filled, contracted basal segments with slightbronchiectasis. At operation the tooth was felt in theposterior basal segment. It was removed by broncho-tomy, but the basal segments remained solid and air-less and were therefore removed. The specimenshowed bronchiectasis with peribronchial fibrosis.CASE 13.-A man aged 66 had had cough and

sputum for years, worse for nine months, with recenthaemoptysis. He was admitted to another hospitaland treated with penicillin for collapse and infectionof the right lower lobe. Bronchoscopy showednodular friable " growth " in the right lower lobe, butbiopsy was reported as squamous metaplasia. He wagadmitted as a case of bronchial carcinoma. No malig-nant cells were found in the sputum and radiographsshowed reaeration of the previously collapsed lobe,though with residual patchy opacities. Bronchoscopywas repeated and showed the right lower lobe bronchusreddened and narrowed, with friable nodular projec-tions. Biopsy was negative. He developed pyrexia

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J. S. A. LINTON

which subsided with penicillin. A bronchogramshowed absent filling of the right basal segments withover-expansion of the middle and upper lobes. Treat-ment was right lower lobectomy for a presumedcarcinoma. The specimen showed a piece of boneembedded in the basal bronchi with ulceration of theepithelium and extreme squamous metaplasia.No relevant history was obtainable.CASE 14.-A man aged 54 had had right-sided chest

pain, loss of weight, and mucopurulent sputum forfive months. A radiograph showed consolidation andcavitation of the right upper lobe. The sputum con-tained no malignant cells. Bronchoscopy was negative.A bronchogram was technically poor, with little fillingof the right upper lobe. Carcinoma was diagnosed.At operation there was a mass in the right upper lobe,possibly extending into the middle lobe, with enlargedhilar lymph nodes. The upper and middle lobes wereresected. The specimen showed the apical segmentof the upper lobe to be fibrotic, with areas of necrosisand partial excavation. Sections of the abscess showedpurulent material surrounded by fibrosis. Othermaterial was present which appeared to be the remainsof a foreign body. Other portions showed areas ofpneumonia and collapse.No relevant history could be obtained.CASE 15.-A woman aged 52 had had cough with

blood-stained purulent sputum for six months. A radio-graph showed an opacity at the apex of the left lowerlobe, with a small calcified object, appearing like acalcified lymph node. One specimen of sputum outof seven had cells suspicious of carcinoma. Broncho-scopy was negative. At operation an irregular, hardmass was present in the apex of the left lower lobe.Lobectomy was performed. The specimen showed afirm, pale area, 1I in. in diameter, lying peripherally,with the crown of a carious tooth occluding thebronchus. Section showed a chronic lung abscess.The patient later stated that she had had a dentalextraction under general anaesthesia nine years pre-viously.CASE 16.-A man aged 52 had right-sided pneu-

monia 18 months previously, with persistent cough andfoul sputum ever since and occasional haemoptysis.Bronchoscopy at another hospital showed no abnorm-ality except pus in the right main bronchus. A radio-graph showed a large abscess in the apex of the rightlower lobe. The sputum contained no malignantcells. Bronchoscopy was repeated and showed pusin the right lower lobe with a large slough, whichwas removed. His general condition improved, butthe abscess remained. At operation the pleura wasdensely adherent and the fissures fused. For technicalreasons pneumonectomy was performed. The speci-men showed the lobe largely replaced by an abscess,surrounded by collapsed fibrotic lung. The contentswere purulent and contained a vegetable pea. Theappearances suggested that this was aspirated into theapical bronchus of the lower lobe.No relevant history was obtainable.

DISCUSSIONHISTORY.-Of these 16 cases, only five volun-

teered a history of inhaling a foreign body. Fiverecalled the incident only after the foreign bodyhad been removed. In the other six no relevanthistory was obtainable, even in retrospect.Where it was possible to assess the length of

time between inhalation and removal of theforeign body, this varied from nine years to sixmonths.The presenting symptoms were those of the

resulting pathological changes. Cough and puru-lent sputum were constant. Febrile incidents werecommon. In several cases the symptoms did notappear for some time after the original obstruc-tion occurred and were readily relieved bysymptomatic treatment with antibiotics andphysiotherapy, only to recur at intervals until theforeign body was eventually removed. Jacksonand Jackson (1950) comment on these symptom-less intervals as a source of error in diagnosis.Haemoptysis occurred in nine cases; it was

severe in three. Moore (1951) makes the pointthat "simple" bronchiectasis seldom produceshaemoptysis, but that it is common with bronchi-ectasis caused by foreign bodies. Laurance (1954)considers haemoptysis unusual with foreignbodies.

INVESTIGATION.-As might be expected, the rightside (13 cases) was affected more often than theleft (three cases) and the lower lobe more com-monly than the upper.

Physical examination indicated the super-imposed pathological lesion. There is no recordof the detection of a localized wheeze.A plain radiograph revealed the foreign bodies

where these were metallic. Bone fragments andtooth fragments were sometimes visible in retro-spect when the opacities were noticed to have dis-appeared. At first sight they appeared simply asparahilar calcification, indistinguishable fromcalcified tuberculous lymph nodes. Glennie, Dark,and Lindars (1952) had the same experience. Theappearances otherwise were those of atelectasis,pneumonitis or abscess, with no indication of thecause.Bronchography, when performed, was in no

case helpful in making the diagnosis. It merelyconfirmed the presence of bronchiectasis, atelec-tasis, or bronchial obstruction.Bronchoscopy should have been conclusive

where the diagnosis was still in doubt. Thecharacteristic finding, even when the foreign body

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LONG-STANDING INTRABRONCHIAL FOREIGN BODIES

itself cannot be seen, is the presence of heaped-up,friable granulation tissue, surrounding the foreignbody and often obscuring it. This appearance isprobably well known and is recorded in mostpapers on the subject (Jackson and Jackson,1950; Laurance, 1954; Moore, 1951). It is unfor-tunate that, in five cases, the significance of thisfinding was not appreciated by experiencedbronchoscopists who, in each case, made the diag-nosis of carcinoma. Where biopsy material was

obtained this showed normal mucosa, granulationtissue, or squamous metaplasia. This coincidenceof a carcinoma-like bronchoscopic appearancewith a biopsy showing inflammatory changesshould certainly have suggested a diagnosis offoreign body. In three of these five cases broncho-scopy was repeated and established the diagnosis.The superadded pathological changes were

those of atelectasis and pneumonitis in 10 cases,bronchiectasis (demonstrated by bronchography)in three, and chronic lung abscess in three.Jackson and Jackson (1950) maintain thatbronchiectasis is a rare sequel of exogenousforeign body, contrary to statements in theliterature, and that these statements are madechiefly on the basis of foul sputum without corro-boration by bronchography. They are also of theopinion that true lung abscess is rare, though"drowned lung" can occur which recovers afterremoval of the foreign body. Laurance (1954)also considers that lung abscess is an uncommon

sequel to inhaled foreign body. Thomson andNegus (1955) probably speak nearest to the truthwhen they say that bronchial abscess is to beexpected after impaction of a foreign body. Theyalso stress that a bronchial abscess will heal with-out permanent damage to the lung after thebronchial obstruction has been relieved.Twelve patients were of an age when carcinoma

should be suspected, and in six cases this was theprovisional diagnosis on admission. Three cameto operation with this diagnosis. Sputum wasexamined for malignant cells in eight cases-aninvestigation found to be of considerable signifi-cance in this hospital (Jennings and Shaw, 1953):all were negative except in one case, where one

specimen in seven was reported as showing cellssuspicious of carcinoma, and this was fromanother hospital.At the end of these investigations foreign body

had been correctly diagnosed in 11 of the 16 cases.

Carcinoma remained the presumed diagnosis inthree patients. One was thought to have residualbronchiectasis with bronchitis and one a simplechronic lung abscess.

TREATMENT.-AS previously mentioned, thechoice of treatment is not always easy even aftercorrect diagnosis.Of the incorrectly diagnosed cases in this series,

three were thought to be malignant and had resec-tions, the foreign body being identified only onexamination of the specimen. The case diagnosedas lung abscess was also treated by resection. Thepatient thought to have residual bronchiectasiscoughed up her foreign body after six years andhas been symptom-free ever since.Of the foreign bodies correctly diagnosed (11),

one was coughed up; five were extracted atbronchoscopy; one was removed by bronch-otomy; and four were resected.

All the patients treated without resection hadcomplete relief of symptoms and resolution ofphysical and radiological signs, although theiraverage length of history was three years. Wherebronchography was performed at a later date(four cases), only one showed bronchiectasis andthis was of minor degree.

Jackson and Jackson (1950) state that the prog-nosis is good after removal of the foreign body,even after long sojourn. In more than 200 ofsuch cases in their report, all recovered completehealth except four. They noted that foreignbodies of vegetable origin caused more rapid per-manent damage than relatively inert material suchas metal, teeth, and bone. Weinberg (1937, 1938)agrees with this and explains it on the groundsthat these foreign bodies, by virtue of their rigidityand irregular shape, are less likely to cause earlycomplete obstruction of the bronchus. In hisexperiments with vegetable foreign bodies, arti-ficially introduced into the bronchi of rabbits, hefound obstructive emphysema occurring in the first20 minutes, infection and collapse in six to 42hours, followed by frank bronchiectasis in 14 to58 days. Inert foreign bodies (teeth, tacks) pro-duced first ulceration at the site of impaction, theninfection leading to complete obstruction withatelectasis and bronchiectasis. The extent of thedamage varied with the degree of obstruction andthe pathogenicity of the organisms present. In-complete obstruction produced patchy atelectasisand bronchial dilatation of variable degree.These statements are partially supported by the

findings in our 16 cases. The correctly diagnosedforeign bodies treated by resection (four) hadirreversible bronchiectatic changes. Of theforeign bodies treated without resection, one wasa tin-tack which had produced incomplete obstruc-tion, though with minor bronchiectasis; four werebone fragments; one was a rubber sucker tip, one

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J. S. A. LINTON

a metal-tipped pencil, and one a metal collar stud.These, although causing ulceration with infectionand granulation tissue, had not produced irrever-sible damage, in spite of long histories. Theobstruction was demonstrably incomplete in threecases, but appeared complete in the others.

Cooley, Ginsberg, Olsen, and Kirklin (1956)state that surgical .resection is the treatment ofchoice when the condition has already developedand gives excellent results.

Permanent, irreversible lung damage may notoccur even with obvious infection and apparentlycomplete obstruction. It is therefore suggestedthat simple removal of the foreign body bybronchoscopy or bronchotomy should suffice inmany cases which are at present treated byresection. Neither the length of history, thedegree of radiological abnormality, nor thepresence of profuse, purulent sputum is anabsolute contraindication to an attempt at pre-serving lung tissue. Only when obvious irre-versible changes have occurred, such as true lungabscess or gross bronchiectasis with fibrosis andparenchymal destruction, is it necessary to resectthe affected part.

SUMMARYSixteen cases of " chronic" intrabronchial

foreign body are reported. The difficulties ofdiagnosis are outlined and an attempt is made tofind common features in these cases. Considera-tion of the possibility of the condition is probablythe most important factor in arriving at thecorrect diagnosis. The possible lines of treatmentare discussed, with particular reference to thedesirability of conserving lung tissue when thishas not suffered permanent damage.

My thanks are due to Mr. T. Holmes Sellors, Mr.V. C. Thompson, Mr. D. Barlow, and Mr. J. R.Belcher for permission to publish their cases, to Dr.K. Hinson for the pathological reports, and to Mr.D. Kemp, of the Brompton Hospital, for preparationof the illustrations.

REFERENCESCooley, J. C., Ginsberg, R. L., Olsen, A. M., and Kirklin, J. W.

(1956). J. thorac. Surg., 31, 615.Glennie, J. S., Dark, J. F., and Lindars, D. C. (1952). Brit. med. J.,

1, 1009.Jackson, C., and Jackson, C. L. (1950). Bronchoesoohagology,

pp. 16, 20, 106, 107, and 175. Saunders, Philadelphia.Jennings, R. C., and Shaw, K. M. (1953). Thorax, 8, 288.Laurance, B. (1954). Brit. med. J., 1, 125.Moore, B. P. (1951). Ibid., 2, 1259.Thomson, St. Clair, and Negus, V. E. (1955). Diseases of the Nose

and Throat, 6th ed. Cassell, London.Weinberg, J. (1937). J. thorac. Surg., 6, 402.-- (1938). Ibid., 7, 488.

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Foreign BodiesLong-standing Intrabronchial

J. S. A. Linton

doi: 10.1136/thx.12.2.1641957 12: 164-170 Thorax

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