A Potential Danger of Flexible Endoscopy Sheaths: A Detached Tip and How to Retrieve It

J Laryngol Otol. 2009 Feb;123(2):243-4. doi: 10.1017/S0022215108002107. Epub 2008 Apr 3.

Abstract

Objective: To report an unrecognised complication of fibre-optic nasendoscopy, and its management.

Case report: A protective, transparent nasendoscopy sheath is often used to reduce nasendoscope 'downtime' and to prevent cross infection, with minimal effect on the obtained image quality. We report the case of a subcutaneous tracheostomy procedure during which, without undue strain, the tip of the sheath became detached and acted as a foreign body within the trachea. A urological stone retrieval basket was used to retrieve the sheath, after failure of conventional methods.

Discussion: Clinicians should be aware that any instrument introduced into the airway has the potential to fail and in the process produce a foreign body which may cause serious complications. The urological stone retrieval basket may be a useful addition to the current set of instruments used to deal with difficult airway foreign bodies.

Publication types

  • Case Reports

MeSH terms

  • Device Removal
  • Endoscopes / adverse effects*
  • Equipment Failure
  • Foreign Bodies / etiology*
  • Foreign Bodies / therapy
  • Humans
  • Surgical Instruments / adverse effects*
  • Trachea*
  • Tracheostomy