Right lower lobectomy following inhalation of a toy traffic cone
A 46-year-old man presented in early 2012 having a 16-year history of recurrent respiratory tract infections. He had originally presented to the respiratory physicians in 1996, and in 2004, he developed an empyema which required thoracotomy and drainage. Following drainage, he remained relatively well requiring infrequent oral antibiotics for exacerbations of bronchiectasis on a background of repeated episodes of right basal pneumonia. A sputum specimen from the patient cultured positive for Haemophilus influenzae. A high-resolution computed tomography scan (HRCT) in 2004 demonstrated bronchiectasis and this was confirmed on repeat imaging eight years later. His background history included right lower lobe childhood bronchiectasis diagnosed after an episode of haemoptysis. A further HRCT scan demonstrated an area of high attenuation in the right lower lobe bronchus intermedius ( and ). This was intra-luminal and solid in keeping with appearances of a foreign body or simply a calcified secretion: it looked like a toy traffic cone.\nOn enquiry, the patient recalled swallowing a toy traffic cone over 40 years ago when he was six years old. He had choked at the time but assumed it had been swallowed. Ongoing respiratory review resulted in a referral to our thoracic department for surgical assessment. A rigid bronchoscopy showed the right lower lobe bronchus was narrowed to a tiny orifice continually discharging pus. The bronchus intermedius was short and the middle lobe was inflamed. The right main bronchus and upper lobe were both normal as was the apical segment of the right lower lobe.\nFurther surgical management included a flexible bronchoscopy under general anaesthetic to assess the bronchus to the lower lobe. Due to the protracted clinical history, it was doubtful that extraction would be possible and the patient was scheduled for an elective thoracotomy. Preoperative investigations included a chest X-ray which demonstrated obliteration of the right costodiaphragmatic angle and normal pulmonary function tests (). At operation, a bronchoscopy revealed an indurated area at the bifurcation of the middle lobe and right lower lobe bronchi. This area still discharged pus and bronchial lavage and suctioning revealed a yellow foreign body which was extraluminal. The surgical team proceeded to perform a right lower lobectomy and wedge excision of the middle lobe.\nIntraoperatively, multiple inflammatory adhesions were discovered. The right inferior pulmonary vein and right pulmonary artery were both identified and divided. The right apical segmental artery and right basilar artery were also identified and divided enabling the posterior hilar artery to be visualized and the bronchus exposed. During dissection of the bronchus, profuse quantities of pus were aspirated (). The toy traffic cone was identified in the same location as that determined on CT (). Once removed, the right lower lobe bronchus was stapled and oversewn using a 3-0 Vicryl suture. A small section of the middle lobe was excised after dividing the inferior segmental bronchus of the middle lobe.\nThere were no postoperative complications reported and a short course of intravenous antibiotics was given. Histopathological examination revealed a significantly underdeveloped right lower lobe having areas of focal consolidation and changes consistent with bronchiectasis. The right lower lobe bronchi had diffuse dilatation and associated peribronchial fibrosis and scarring. The toy traffic cone was returned to the patient ().