Multiple Foreign body aspiration (FBA) into the airway is a sudden and life-threatening condition that causes many complications and usually requires emergency intervention. FBA is generally seen in children; although rare, it may also be encountered in adults ( 1 ). Of the pediatric FBA cases, 80% are below the age of 15 years ( 2 ). FBA is more frequent in children as their swallowing functions and neurological and dental structures have not developed completely. Although FBA is rarely encountered in adults, many predisposing factors have been reported including neurological and muscular diseases, alcohol consumption, head trauma, and use of audio devices ( 3 ). In the USA, approximately 500- 2000 deaths due to FBA have been reported each year ( 4 ). An aspirated foreign body may lead to acute respiratory distress in case it obstructs a great part of the airway, whereas a smaller aspirated foreign body may cause symptoms such as coughing, hemoptysis or shortness of breath by generally moving into the distal airways. Although FBA is usually considered as a condition requiring emergency intervention, complications such as pneumonia, atelectasis, lung abscess, empyema, bronchiectasis, and stricture are mostly encountered in the event of late diagnosis and treatment ( 5 , 6 ). Even a thoracotomy may be required in such cases ( 7 ). Herein, we aimed to present a case of left pneumonectomy in a female patient who aspirated a wishbone 20 years ago. With this case report, we aimed to contribute to the literature by demonstrating significant pulmonary problems caused by FBA in case of its late diagnosis.

A 71-year-old Syrian female patient, who had had a complaint of coughing up blood for approximately two years, was referred to our clinic for the etiology of hemoptysis to be investigated. Detailed medical history of the patient, which was obtained with the help of a translator, revealed that she had had occasional hemoptysis for approximately 2 years and progressively increasing shortness of breath for the last 5 years. However, the patient stated that she had never consulted a physician because of social conditions in Syria, where she had been living. When the medical history of the patient was further investigated, the patient mentioned that she had experienced sudden coughing and shortness of breath while eating chicken 20 years ago; however, she had never consulted a physician because her complaints had relieved. On her physical examination, decreased respiratory sounds and predominating crackles on auscultation with increased dullness on percussion were determined on the left side. Posteroanterior chest X-ray showed reduced ventilation on the left side, deviation of the mediastinum to the left and there were patchy bronchiectatic formations in the parenchyma. Computed tomography (CT) of the thorax was performed on the patient. In the thoracic CT, opacity with bone density was observed in the left main bronchus (Figure-1).

In addition, reduced ventilation in the left lung and bronchiectatic formations were observed. The patient was prepared for rigid bronchoscopy and if required for fiber optic bronchoscopy (FOB). Rigid bronchoscopy was performed under general anesthesia. It was observed that the left main bronchus was obstructed by granulation tissue (Figure-2). The granulation tissue was tried to be excised using forceps. The procedure was discontinued due to excessive bleeding and failure in reaching to the foreign body. Thereafter, left thoracotomy was planned for the patient. Bronchotomy was performed by turning the tip of bronchoscope to the left main bronchus; however, foreign body could not be found. Left pneumonectomy was decided to be performed due to poor pulmonary ventilation during the operation, unhealthy parenchymal structure, and failure in reaching to the foreign body. The procedure was finalized without any complication. Lobar bronchi of the resected left lung were opened after the surgery. A wishbone extending to the upper and middle lobes was encountered (Figure-3 and Figure-4). After being followed in the intensive care unit for 1 day, the patient was transferred to the ward. No complication was observed during followup period and the patient was discharged from the hospital with recommendations.

Bronchoscopic methods are the gold standard in the diagnosis and treatment of tracheobronchial foreign body ( 8 , 9 ). It remains a debatable issue whether the bronchoscopic method would be FOB or rigid bronchoscopy ( 10 ). The primary approach recommended on this issue is to perform rigid bronchoscopy in conditions, such as emphysema or decreased ventilation in a hemothorax, resulting from obstruction due to size of the foreign body; otherwise, it is recommended to perform FOB firstly for determining the localization of foreign body and then rigid bronchoscopy for removal of it ( 11 ).

In our clinic, we first perform rigid bronchoscopy for patients who present with FBA and FOB is performed when a foreign body is detected in distal airways. However, current studies have revealed that the use of FOB technique in the treatment of FBA is gradually increasing with high success rates ( 3 , 8 , 12 , 13 ). However, success rates reported in the published studies could not reach to those obtained by rigid bronchoscopy ( 3 , 8 , 12 ). Accordingly, rigid bronchoscopy has been performed in FBA cases, in which FOB has failed ( 13 ). In a study conducted in Turkey, 28 adult FBA patients were evaluated; FOB was performed for diagnostic purposes in 5 patients and a foreign body was removed by FOB only in 3 of the patients ( 13 ).

Thoracotomy can be required at a rate of 2% in FBA cases in which foreign body could not be removed by endoscopic procedures ( 14 ). In thoracotomy, a foreign body can be removed by bronchotomy or lung resection can be performed according to the symptoms, in case of permanent injury in the pulmonary parenchyma, and due to the fact that injury to one side of the lung may affect contralateral side. In the present case, we tried to remove the foreign body by bronchoscopic intervention for three times; however, we failed despite excision of granulation tissue. During open surgical intervention, bronchotomy should be primarily performed to remove the foreign body. However, lung resection can be performed in patients with an impaired parenchyma and, as the last option, in case of failure to remove the foreign body. Likewise, we also had to perform lung resection in the present case due to the facts that we failed to remove the foreign body and the lung was damaged.

In conclusion, FBA is a clinical emergency condition. Endoscopic intervention should be performed following detailed physical examination and radiological analyses in cases with suspicious FBA despite regression of their complaints. FBA may cause loss of lung tissue by leading to permanent lung injury in patients with delayed diagnosis. A case presenting with FBA should immediately be prepared for endoscopic procedures after providing appropriate conditions and physicians should be ready for surgical intervention in case of failure to remove foreign bodies or due to possible development of complications.