A 3-year-old boy is brought to the emergency department with acute onset of coughing and stridor after playing with peanuts. His mother reports he suddenly started coughing violently. On examination, he has unilateral decreased air entry on the right side with inspiratory stridor. Chest X-ray shows hyperinflation of the right lung with mediastinal shift to the left. What is the most appropriate next step in management?

Explanation

## Clinical Scenario Analysis This is a **classic presentation of lower airway foreign body (FB)** with: - Acute onset after choking episode - Unilateral decreased air entry (right lung) - Inspiratory stridor (laryngeal involvement suspected) - Hyperinflation with mediastinal shift (check-valve obstruction) ## Why Rigid Bronchoscopy Is Correct **Key Point:** Rigid bronchoscopy is the gold standard for diagnosis AND treatment of suspected lower airway foreign bodies in children. **High-Yield:** The clinical triad of: 1. History of choking/aspiration 2. Unilateral decreased air entry 3. Hyperinflation on CXR ...mandates **immediate rigid bronchoscopy** under general anaesthesia. **Clinical Pearl:** Rigid bronchoscopy allows: - Direct visualization of the FB - Instrument passage and removal under vision - Airway protection during removal - Ability to manage complications (bleeding, edema) ## Management Algorithm ```mermaid flowchart TD A[Suspected airway FB]:::outcome --> B{Stridor present?}:::decision B -->|Yes + unilateral findings| C[Rigid bronchoscopy urgent]:::action B -->|Stable, no distress| D[Confirm with CXR/fluoroscopy]:::action C --> E[FB removal under vision]:::action D --> F[Rigid bronchoscopy planned]:::action E --> G[Post-removal observation]:::outcome ``` **Timing:** This child has **signs of airway compromise** (stridor + unilateral obstruction). Rigid bronchoscopy should be performed **emergently** — not delayed. ## Why Observation Alone Is Dangerous **Warning:** Peanut aspiration is particularly dangerous because: - Peanuts are radiolucent (may not show on plain X-ray) - Oils cause chemical irritation → progressive edema - Risk of **complete airway obstruction** if FB migrates - Delayed diagnosis increases risk of bronchiectasis, lung abscess [cite:Dhingra Textbook of ENT 8e Ch 15]