presentations vary , complications differ and yet , management remains the same , which is removal .
nothing galvanizes the team as when the code for a foreign body ( fb ) is communicated , especially if the case is a kid where such situation is usually encountered .
presentation is acute in vegetable foreign body aspiration , especially in kids of age group 1 - 3 years , with new onset wheeze , breathlessness or fever .
it tends to be less dramatic in non - organic foreign bodies unless there is lung collapse or involvement of trachea .
occasionally non - organic fb can be retained for years with bizarre presentation , which can be mistaken for endobronchial tumors or bronchiectasis .
such fb is a cause for a significant heartburn to both the patient and treating physician as unless it is removed it causes chronic symptoms and leads to irreversible damage .
the case of interest is one such with the diagnosis missed for over 14 years .
a 16-year - old male was diagnosed with bronchial asthma since childhood , had recurrent hospital admissions with exacerbations .
patient reported a recent worsening of symptoms for the last year for which he was evaluated and chest radiology revealed left lower lobe collapse . he was taken up for a bronchoscopy , which revealed a web - like stenosis of distal left main stem bronchus with a residual lumen of about 4 mm [ figure 1 ] and in view of small residual lumen an ultrathin pediatric bronchoscope ( olympus bf type 3c160 ) was used .
bronchoscope could be negotiated past the stenotic segment and to our surprise found a freely mobile object moving between upper and lower lobes with each breath [ figure 2 ] .
patient was questioned after the procedure regarding history of aspiration and he denied recollecting any incident .
whistle was blown when the patient 's father said that the patient had aspirated a whistle or part of one when he was about 2 years of age .
he had a violent bout of cough for which he was evaluated and suspected whistle was removed .
now with the diagnosis clear , patient was taken up for rigid bronchoscopy , intubated with size 6 ventilating tracheobronchosope and bevel was positioned at distal left main bronchus .
flexible bronchoscope was introduced through this conduit and mercedes benz like peripheral cuts given using eletrocautery knife to the web like stenosis [ figure 3 ] .
serial balloons introduced across the stenotic segment and gradually dilated up to 10 mm , bronchoscope negotiated beyond to visualize the foreign body .
the fb was extracted using cryoprobe introduced through the channel of flexible bronchoscope [ figures 4 and 5 ] .
the fb turned out to be a piece of plastic probably part of the whistle aspirated 14 years back [ figure 6 ] .
stenosis at distal left main stem bronchus foreign body beyond stenosis electrocautery knife to make radial incisions cryo - extraction of foreign body from bronchus foreign body being taken into rigid barrel plastic foreign body after removal
retained non - organic foreign bodies are great masqueraders presenting with non - specific symptoms and high propensity of being missed unless index of suspicion is high .
the longest duration of retained fb in english literature is 39 years , a case of wooden chip reported from japan .
history of fb is the first clue to making a diagnosis but is unfortunately forthcoming only in few of the cases that too in retrospect .
evaluation should be undertaken even if fb was removed previously and patient has symptoms as part of it could have been retained as it was in our case .
symptoms range from none to chronic cough , wheezing , hemoptysis and recurrent episodes of chest infections . in our country
profile of symptoms are generally non specific but documented episodes restricted to one side or lobe warrant evaluation for endobronchial lesions .
chest x - ray is the next step in assessing these patients ; it has a high sensitivity for detecting metallic foreign bodies and can also reveal subtle signs like lobar collapse or hyperinflation .
chest x - ray has been shown to reveal the fb as opacity in only 14 - 20% among both adults and pediatric population .
this has been the case in all reports of retained fb of over 10 years in english literature including ours .
flexible bronchoscopy should be undertaken if radiology reveals or suspects fb ; also in cases of unexplained longstanding non - specific symptoms with negative radiology and no alternate diagnosis .
luminal appearance of fb after years of residence is rarely clear , especially if one is unsure of what they are looking for .
granulation tissue can be exuberant and mimic tumor in appearance , attempts to biopsy it can result in significant bleeding which can further compromise vision .
stenosis of bronchus like the one seen in our patient is a relatively uncommon complication seen in about 8% of cases as against 62.9 - 76.5% incidence of granulations in two large series . even among patients with stenosis
only minority require management of the same and in our case was required due to presence of tight stricture in the main stem bronchus .
there is consensus regarding rigid bronchoscopy for management of fb in pediatric patients as these patients are sicker , hypoxemic , can not cooperate , have poor reserve and flexible bronchoscope lacks robust instruments for retrieval due to small working channel .
further , flexible bronchoscopy is useful in only confirming the presence of fb in stable pediatric patients , thus avoiding a negative rigid bronchoscopy .
flexible versus rigid bronchoscopy for management in adults is a long - standing argument with various operators having different points of view .
rigid bronchoscopy is the preferred modality for either long - standing fb or in case of failed attempt with flexible bronchoscope .
long - standing fb is also notorious for failure of rigid bronchoscopy due to excessive granulation , which then requires bronchotomy and/or lobectomy for retrieval . in our
case rigid bronchoscopy was done in view of long - standing fb and presence of web - like stenosis that required dilatation .
long - standing fb is a challenge both to diagnose and manage , needs a high index of suspicion and low threshold for detailed evaluation .
management requires personnel with adequate experience and availability of appropriate instruments both flexible as well as rigid .
there should be seamless switch over to rigid if flexible is not successful in recovery of fb .
 16 years old boy with childhood history of chronic respiratory symptoms requiring several admissions presented with recent worsening of symptoms . 
 chest x - ray showed left lower lobe collapse and flexible bronchoscopy revealed stenosis of left main bronchus . 
 foreign body was seen beyond the stenosis , which was removed after dilatation of narrowed bronchus under general anesthesia using rigid bronchoscopy . 
 patient 's father gave a history of aspiration of whistle 14 years ago , which had then been removed . 
 patient is now free of symptoms after removal of foreign body . 