2005 Presidential Citation for Foreign Body Management

Management of a Chronic Tracheal Foreign body with a Microdebrider
Matthew Bolinger, MD, Stacey L. Halum, MD, Gregory N. Postma, MD


A 45 year old mentally challenged white male presented to our institution with dyspnea on exertion and chronic cough worsening over the past several weeks. The patient was diagnosed with respiratory distress of unknown etiology and admitted to the Pulmonology service. O2 saturation was 90% on room air and improved to 94 % with albuterol therapy and nasal cannula. Physical examination revealed bilateral inspiratory and expiratory wheezing and biphasic stridor. Examination of his neck revealed a scar consistent with a previous tracheotomy, however, the patient was unable to provide any details. Computed tomography revealed a tracheal stenosis centered around a tubular foreign body located several centimeters above the carina.

The patient's family was able to provide his previous medical history consisting of mental retardation, gastro esophageal reflux disease, chronic shortness of breath, chronic cough and wheezing. Family members stated the airway symptoms had been attributed to a remote history of smoking. Further questioning revealed the patient had undergone a tracheotomy in 1996 for obstructive sleep apnea and the tracheotomy tube provided constant irritation to the patient who was constantly manipulating the tracheotomy appliance. A decision was made to convert the patient to a shortened Montgomery-like tracheotomy appliance. In1996, after playing in the snow, he told family members that he had coughed and had lost his tracheotomy appliance. A brief search failed to yield the appliance, and the decision was made to leave the patient decannulated.

The patient underwent flexible bronchoscopy by the pulmonology service that revealed an approximate 10 percent tracheal stenosis proximal to the foreign body (believed to be a stent) and a ball valve granulation area just above the carina. Patient was immediately taken to the operating room where a suspension microdirect laryngoscopy was performed. Exposure was obtained using a Jako laryngoscope and jet ventilation was initiated. Periodically throughout the case the patient's oxygen saturations dropped to the low 90s and a 6.0 endotracheal tube was passed through the laryngoscope to provide adequate ventilation until oxygen saturation returned to 100 percent. Initial tracheoscopy confirmed the flexible bronchoscopy findings. At the superior end of the foreign body, granulation tissue was present with a 60 percent stenosis. Debridement with forceps was attempted, but was unsuccessful. A 27 cm 4.0mm skimmer type microderider was used to remove the granulation tissue. The foreign body was then grasped with forceps and removed. The foreign body appeared to be the tracheal appliance assumed lost 8 years earlier.



Distal to the foreign body there was an almost complete obstruction of the patient's airway by a large granuloma, with a failure to visualize the patient's carina or either main stem bronchi. Jet ventilation revealed a pedunculated region of granulation tissue exerting a ball valve effect on the airway. This tissue was partially removed with forceps, while further debridement was accomplished with the microdebrider. Hemostasis was accomplished with the use of epinephrine soaked cotton pledgets.



The patient remained intubated at the end of the case and was transferred to the ICU where he was successfully extubated the next day. Operative examination several days later revealed decreased granulation tissue that was removed with the microdebrider.











After the second procedure the patient stated he was breathing easier and the wheezing and stridor had improved. The patient no longer had a supplemental oxygen requirement and was discharged from the hospital.

This case represents the novel use of the microdebrider in the management of granulomatous stenosis due to a chronic foreign body of the trachea and the importance of the cooperation and communication among the otolaryngology, anesthesia, pulmonolgy, and intensive care teams.



From: The Department of Otolaryngology, Wake Forest University, Winston-Salem, North Carolina