Surgical Basket for Kidney Stones Used for Clearing Pediatric Upper Airway Obstructions

Main Category: Ear, Nose and Throat
Article Date: 29 May 2005 - 0:00 PDT

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Airway foreign bodies are most commonly seen in children under age five. Foodstuffs, particularly nuts, are usually the offending objects. Signs and symptoms vary widely, ranging from vague (wheezing which can mimic asthma) to specific (coughing and gagging, or frank airway obstruction). These cases require immediate medical attention often involving physicians from different specialties.

Rigid bronchoscopes are most often used to remove aspirated foreign bodies. This instrumentation not only provides ample working room for insertion of grasping forceps, but also allows for ventilation of the patient and suction of secretions through separate ports while the procedure is performed. Traditionally, most instruments used for actual removal of foreign bodies have been of the rigid grasping type such as the optical foreign body forceps. Rigid instruments, however, tend to fragment organic matter complicating its removal.

A team of pediatric ear, nose, and throat specialists recently used a wire urological stone basket in conjunction with the rigid bronchoscope for removal of airway foodstuff foreign bodies. Their experience is now recounted in a study with two phases. First, a preliminary feasibility study using the selected stone basket and various foreign bodies was undertaken in the pig bronchoscopy lab. Video documentation was taken. After efficacy of the technique had been demonstrated, the stone basket was used in two patients by one of the authors (CTM), both of whom had airway foreign bodies consisting of organic matter removed in the operating room without incident.

Authoring "The Urological Stone Basket for Pediatric Airway Foreign Body Retrieval" is Brian W. Downs MD, from the University of North Carolina Neurosciences Hospital, Chapel Hill, NC. Their findings will be presented at The Twentieth Annual Meeting of the American Society of Pediatric Otolaryngology (ASPO) www.aspo.us being held May 27-30, 2005, at the J.W. Marriott Las Vegas Resort in Las Vegas, NV.

Cases: Use of the basket was with two patients.

Patient #1:

Patient #1 was a two year-old female with a history of a witnessed aspiration two weeks prior who subsequently developed pneumonia and was referred to the otolaryngology office for evaluation of suspected airway foreign body. Physical examination was remarkable for wheezing over the lower left lung field. Preoperative imaging was suggestive of foreign body, and the patient was taken to the operating room for rigid bronchoscopy. Intraoperatively, a peanut was identified in the left mainstem bronchus. The urologic stone basket was passed through the suction port of the bronchoscope and the peanut was grasped and removed without incident. The patient recovered uneventfully without additional injury.

Patient #2:

Patient #2 was a three year-old male with a history of a witnessed choking episode several days prior who was evaluated for suspected foreign body aspiration. Physical examination was inconclusive and, based on the history the patient was taken to the operating room for endoscopic evaluation. Intraoperatively, the patient was found to have a peanut in the right mainstem bronchus, which was removed without difficulty with the rigid bronchoscope and the urologic stone basket. The patient recovered without further complications.

Results: The author believes that these case studies demonstrate that urological stone baskets could be used in a large number of cases of airway foodstuff foreign bodies. Although these materials that obstruct the airway are firm and difficult to swallow when dry and hard, they become friable and difficult to grasp when they become moist (i.e. come into contact with oral and tracheobronchial secretions). As a result, they tend to "fragment" when rigid graspers are applied. Using the stone basket facilitates removal.

The use of wire snares for airway foreign body removal is not a novel idea. Single-loop wire snares have been used to remove various foreign bodies from the airway, ranging from dental crowns to hairpins to fractured thermometers4. Urological stone baskets have even been used, but primarily in conjunction with the flexible bronchoscope or the flexible bronchoscope passed through the rigid bronchoscope

The author suggests that the utilization of the stone basket passed through the suction port of the rigid bronchoscope alone is a superior (but underappreciated) technique for selected foreign body extraction. Use of the rigid bronchoscope allows for the ultimate control of the airway. Ventilation is possible through the side ports in the bronchoscope, and video with rigid endoscopes is superior to that of flexible endoscopes.

There are several other advantages to the stone basket design for airway foreign body removal. The multi-loop nature of the basket allows for circumferential grasping and decreased fragmentation of organic foreign bodies. This basket design could also prove advantageous for spherical, inorganic materials as well. In addition, the stone basket can be passed distally and potentially obviates the use of fogarty catheters and their attendant risk of rupture.

Accordingly, the authors believes the urological stone basket used on conjunction with the rigid bronchoscope is an effective method for removal of selected airway foreign bodies and should be included in the armamentarium of surgeons removing such items.

American Society of Pediatric Otolaryngology (ASPO)
http://www.aspo.us

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