Aspiration of a speaking valve

Abstract

Foreign body aspiration (FBA) is a relatively common and serious condition that can result in a spectrum of presentations ranging from incidental to acutely life-threatening. Described here is a case of aspiration of a tracheo-oesophageal speaking valve through a permanent tracheostomy that went unnoticed for a number of years, and an overview of the technique used for its removal. A 70-year-old ex-heavy smoker with a permanent tracheo-oesophageal fistula presented with a relatively recent history of increasing shortness of breath, sputum purulence and haemoptysis. Further investigation with a CT scan and bronchoscopy revealed the presence of a foreign body within his right lower lobe bronchus which was later removed by advancing a flexible bronchoscope over a rigid one.

Figure 1

Plain anteroposterior radiograph of the chest shows a prominent right hilum and a focus of ill-defined opacification just medial to the right heart border. The horizontal fissure is shifted inferiorly, and is at the level of the sixth rib. The opacity seen in the middle zone of the right lung was later deemed to be due to a longstanding healed rib fracture. No radioopaque foreign bodies were evident on plain radiography.

Figure 2

Selected axial image at the level of the right lower lobe bronchus depicting an endobronchial foreign body with an outer high-attenuation rim and an inner lucent core. These appearances raised the possibility of a previously aspirated mammalian bone, but were later confirmed to be secondary to an impacted tracheo-oesophageal valve on subsequent rigid bronchoscopy.

Figure 3

Coronal multiplanar reconstructed views of the chest in mediastinal and lung window settings (left and right images, respectively). The collapsed right lower lobe is seen as a triangular heterogeneous opacity at the right cardiophrenic angle. The tracheo-oesophageal valve is visualised as an endobronchial foreign body with an outer rim of higher attenuation and an inner lucent core. It is lodged within the right lower lobe bronchus, and accounts for the chronic right lower lobe collapse. Note is also made of a tree-in-bud pattern within the lateral segment of the middle lobe. Centrilobular emphysematous changes with upper lobe predominance are also seen.

Figure 4

Sagittal oblique multiplanar reconstructed views of the right lung in mediastinal and lung window settings (left and right images, respectively) centred along the right parahilar region. The tracheo-oesophageal valve is again seen lodged within the right lower lobe bronchus. The lower lobe shows clear chronic volume loss and assumes the appearances of a complex cystic mass secondary to cystic and tubular bronchiectasis. The horizontal fissure is again not seen in its usual location, secondary to the right lower lobe collapse.

Figure 5

Colour photograph of cleaned out tracheo-oesophageal valve following extraction.