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An unusual CT scan image.

Corresponding Author: Roberto Carbone, MD; e-mail: patriarca125@tiscali.it Dear Editor, In the last years the flexible bronchoscope (FB) has replaced the rigid bronchoscope and has become the diagnostic procedure of choice for extraction of foreign bodies, an uncommon accident in adults. We present a 64 year-old Caucasian male admitted to our Hospital with a six months history of chronic dry cough and recurrent pneumonia. A chest CT scan had previously been performed which showed an unusual pedunculated lesion in the right lower lobe (Figure 1), interpreted as a cancerous growth. However, the same lesion visualized by flexible bronchoscopy was identified as an aspirated cherry sized stone or so called foreign body aspiration (FBA), surrounded by airway oedema and granulation tissue (Figure 2). A Dormia basket was used in order to remove the FBA. The closed basket was positioned distally to the FBA, in such a way to permit anchoring and capturing of the FBA within the closing arms of the device. Once the FBA was captured, the basket was pulled back towards the FBA permitting its wedging between the top of the bronchoscope and the basket, and enabling the joint withdrawal of the bronchoscope and the Dormia basket (Figure 3). Overall, death caused by suffocation following FBA is among the most common causes of mortality due to unintentional-injury in the United States. Suffocation by ingested objects has supplanted fires and burns as the fifth leading cause of death. Over 4100 fatal episodes of FBA were reported in the United States during 20021. Nevertheless extraction of foreign body is uncommon in adults2. The case reported of FBA in an adult, demonstrates the importance of flexible bronchoscopy allowing the removal of inhaled objects without needing for invasive thoracotomy. In the last years the rigid bronchoscope has been replaced by the FB which has become the diagnostic procedure of choice for FBA in adults and with the development of expertise and experience, FB has almost completely supplanted the rigid bronchoscope; 99% of all bronchoscopies in the US are performed with the FB3. According to our case load, the operator should be aware that even patients who are stable with regards to their respiratory status, may incur respiratory de-compensation during the diagnostic procedure, due to accidental dislodgement of the foreign body. Consequentially, FB should be performed in a room equipped for resuscitation, definitive airways management, and mechanical ventilation. FB can be performed under local anesthesia using intravenous sedation (midazolam 0, 3 mg/kg). In adults, the clinical presentation of FBA is often subtle or silent while tracheobronchial FBA is uncommon in pediatric patients. Signs and symptoms of adult FBA are most often non specific4,5. Misdiagnosis and delay in diagnosis frequently occur. A missing or delayed diagnosis of FBA can cause respiratory problems including life-threatening airway obstruction, chronic wheezing mimicking asthma, chronic cough and recurrent pneumonia. Controversy