A 73-year-old woman, without relevant background history, was admitted to the emergency department two hours after a chocking event at lunch, followed by persistent dry coughing, dyspnea and right pleuritic pain. At physical examination, inspiratory wheezing was evident, without any oropharynx changes. Computed tomography (CT) scan was then performed.
Chest CT revealed an endoluminal round structure in the right intermediate bronchus, with 10 mm in diameter. The pulmonary parenchyma was normal. (Fig. 1a-1c)
The radiological findings in this case, along with the clinical history, were highly suggestive of foreign body aspiration. The final diagnosis was confirmed with flexible bronchoscopy procedure, and a pea was retrieved from the right intermediate bronchus. (Fig. 2a-2b)
Foreign body aspiration is a rare entity in adults, and children account for the vast majority of foreign body aspirations cases. In adulthood, there is a higher prevalence among geriatric patients with predisposing factors, such as neurological diseases. However, aspiration can occur without any obvious known risk factors. [1, 2]
The symptoms are determined by the size of the inhaled body and the location in which it becomes lodged. In adults, a silent presentation may be present, due to the distal impaction of the foreign body in the lower lobe bronchi, particularly in the right lower lobe, due to its more vertical orientation. A detailed patient history is a powerful tool in the evaluation of such patients. [2, 3]
Clinically, patients may present either with asphyxiation and acute respiratory failure particularly when impaction occurs in the trachea, or with recent onset of respiratory symptoms, including stridor, dyspnea, wheezing, cough, and absence of breath sounds on the side of the impaction. [1, 4]
Chest radiography and mainly CT examination can aid in the diagnosis, by correctly localizing and characterizing the foreign body and eventual complications. Radiopaque foreign bodies can be depicted on radiographic studies. However, most of the foreign bodies, such as food, are radiolucent and, therefore, not directly visible on chest radiograph. In such cases, chest CT is more sensitive in the identification of the foreign body. The indirect signs of airway obstruction include lobar consolidation, atelectasis, hyperinflation/air-trapping, lung abscesses, bronchiectasis or ipsilateral pleural effusion. [1, 3] The differential diagnosis of endobronchial lesions includes endobronchial tumors, namely carcinoid tumor or metastases, which usually enhance after contrast administration.
Bronchoscopy remains the gold standard for diagnosis and management of foreign body aspiration and it should be performed as soon as possible, to prevent granulation tissue formation or bacterial superinfection. 
When foreign body aspiration is suspected, chest CT is the main imaging tool for diagnosis work-up, providing valuable information for bronchoscopy planning, which is fundamental for a successful removal proceeding.
 Sehgal IS, Dhooria S, Ram B, Singh N, Aggarwal AN, Gupta D, Behera D, Agarwal R. (2015) Foreign Body Inhalation in the Adult Population: Experience of 25,998 Bronchoscopies and Systematic Review of the Literature. Respir Care 60(10):1438-48. (PMID: 25969517)
 Baharloo F, Veyckemans F, Francis C et al (1999) Tracheobronchial foreign bodies: presentation and management in children and adults. Chest 115:1357. (PMID: 10334153)
 Hewlett JC, Rickman OB, Lentz RJ, Prakash UB, Maldonado F. (2017) Foreign body aspiration in adult airways: therapeutic approach. Journal of Thoracic Disease 9:3398-3409 (PMID: 29221325)
 Boyd M, Chatterjee A, Chiles C, Chin R Jr. (2009) Tracheobronchial foreign body aspiration in adults. South Med J 102:171. (PMID: 19139679)
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