Airway obstruction and perforation secondary to mussel ingestion

A 35-year-old female comes to the ER with dyspnea, cough, and dysphagia after eating a typical Spanish dish (paella). She refers to having accidentally ingested a mussel. She was clinically stable with correct oxygen saturation and subcutaneous crepitation. Suspecting a perforation of the upper airway, a CT-scan was performed.

In Figure 1 there is a hyperdense linear object (calcium) in a transverse position occupying the glottis in the laryngeal conduct (Figure 2) corresponding to the ingested foreign body. This finding is accompanied by free air in the cervical visceral space suggesting perforation of the upper airway.

In the 3-dimensional (3D) reconstruction, (Figure 3) we can see the characteristic morphology of this foreign object similar to a mussel which the patient had previously ingested.

In Figure 4 we present the surgical specimen (mussel) that was extracted in the operating room by bronchoscopy.

Background: Foreign body aspiration is a life-threatening event very uncommon in the adult population (only 0.16 to 0.33% of adult bronchoscopy procedures) being much more frequent in pediatric patients[1]. Risk factors for foreign body aspiration in adults are poor mental or neurological status, sedative drug use, and dental prosthesis[2].

Clinical perspective: A high degree of clinical suspicion is needed for the orientation of this entity which is usually referred to during the patient’s interrogation. In children, trachea-bronchial foreign bodies aspiration can cause asphyxia, but this entity is rarely seen in adult patients due to the larger airway. The most common initial symptom is cough, rhonchus, and diminished breath sounds. Dyspnea and asphyxia are not common in adult patients[2].

Imaging Perspective: When airway impaction of a foreign body is suspected; cervical and thoracic x-ray should be performed as a first imagining approach. This technique allows us to assess the characteristics of the foreign body and the level of the obstruction. Sometimes chest radiography in expiration can be useful when the foreign body is partially obstructing[3]. Even though chest x-ray is recommended as the first imaging approach it has a low sensitivity and specificity; 60% and 37% respectively [4].

Nowadays CT-scan is considered to be the best imaging technique (100% sensitivity and specificity[4]) to assess this entity. This technique is very useful to accurately characterize and localize the foreign body, detect potential complications (such as perforation as in our case) and plan the best therapeutic option (bronchoscopy or tracheotomy)[5].

Outcome: Bronchoscopy is the gold standard therapeutic approach to foreign body aspiration in both adult and pediatric patients[1]. In the presence of airway perforation, a surgical approach should be considered. When starting the bronchoscopy, the patient presents an acute onset of dyspnea and stridor, and a tracheotomy was needed to preserve the airway. The post-surgical evolution was correct, the cervical emphysema diapered and the patient was discharged after ensuring oral tolerance.

Take home message: A chest x-ray can be useful when airway obstruction secondary to a foreign body is suspected. In this context, CT-scan is the gold standard to localize the obstruction, assess possible causes, complications, and to plan the best therapeutic approach.