A 5-year-old girl is brought to the ENT clinic 4 days after suspected aspiration of a peanut. She has persistent dry cough and mild dyspnoea. Chest X-ray shows hyperinflation of the right lung with mediastinal shift to the left, suggesting a radio-lucent FB in the right mainstem bronchus. She is haemodynamically stable and has adequate oxygen saturation. What is the most appropriate immediate next step?

Explanation

## Foreign Body Airway — Delayed Presentation with Radiological Confirmation ### Clinical Scenario Analysis This child presents with: - **Delayed presentation** (4 days post-aspiration) - **Radio-lucent FB** (organic material — peanut) - **Radiological confirmation** (hyperinflation, mediastinal shift = check-valve obstruction) - **Haemodynamic stability** and adequate oxygenation - **Persistent symptoms** (cough, dyspnoea) ### Why Rigid Bronchoscopy is Indicated Immediately **Key Point:** Once foreign body aspiration is radiologically confirmed (even if radio-lucent), rigid bronchoscopy for removal should not be delayed, regardless of clinical stability. **High-Yield:** Delayed removal of airway FBs leads to: 1. **Granulation tissue formation** around the FB (increases removal difficulty) 2. **Bronchiectasis** (irreversible lung damage) 3. **Recurrent respiratory infections** 4. **Bronchial stenosis** (long-term sequelae) 5. **Risk of FB migration** to distal airways ### Radiological Findings Interpretation | Finding | Significance | Action | |---------|--------------|--------| | **Hyperinflation** | Check-valve obstruction (FB acts as one-way valve) | Urgent removal needed | | **Mediastinal shift** | Significant air-trapping | Confirms functional obstruction | | **Radio-lucent FB** | Organic material (peanut, food) | Does NOT delay bronchoscopy | | **Stable vitals** | No acute airway emergency | Allows planned rigid bronchoscopy | **Clinical Pearl:** Radio-lucent FBs (organic materials, food, foam) are actually MORE likely to cause complications because they absorb moisture, swell, and incite inflammation. They are NOT less urgent than radiopaque FBs. **Mnemonic: CONFIRM & REMOVE** — Confirmed FB on imaging, Only rigid bronchoscopy removes it, No delay for stability, Flexible is diagnostic only, Imaging confirms but doesn't replace bronchoscopy, Radiolucent FBs are equally urgent, Mediastinal shift = check-valve = urgent. ### Why Additional Imaging is Unnecessary CT chest adds time and radiation without changing management. Chest X-ray already confirms the diagnosis and location. Proceeding directly to rigid bronchoscopy is appropriate. ### Why Conservative Management Fails Physiotherapy and postural drainage cannot remove a FB. The check-valve obstruction will persist, leading to progressive lung damage and infection. [cite:Dhingra Textbook of ENT 8e Ch 24; Harrison 21e Ch 296]