Valsalva Manoeuvre-Assisted Retrieval of a Challenging Aspirated Mechanical Pencil Tip in a Child: A Staged Multidisciplinary Airway Management Case Report

Abstract

Introduction:
Foreign body aspiration in paediatric patients poses considerable diagnostic and airway management challenges, especially in cases of delayed presentation and complex retrieval. This report describes a case involving the challenging extraction of an aspirated plastic mechanical pencil tip, necessitating staged multidisciplinary intervention and the adjunctive use of the Valsalva manoeuvre.

Case Presentation:
An 8-year-old boy presented with a two-week history of cough, fever, and intermittent chest discomfort. Imaging demonstrated a foreign body lodged within the left lower lobar bronchus, associated with left lung collapse-consolidation and mediastinal shift. He underwent examination under anaesthesia, direct laryngoscopy, and tracheobronchoscopy under total intravenous anaesthesia (TIVA) while maintaining spontaneous ventilation.
Intraoperatively, the foreign body, identified as a mechanical pencil tip, was found in the left secondary bronchus with surrounding oedema and copious pus. During retrieval, the object became lodged at the subglottic region, causing severe desaturation due to the inability to ventilate. The foreign body was pushed back into the airway and migrated to the right secondary bronchus, allowing ventilation to resume. Multiple retrieval attempts using optical forceps, flexible graspers, and a Fogarty balloon catheter by paediatric Otorhinolaryngology (ENT) and paediatric surgical teams were unsuccessful. The prolonged procedure was complicated by subcutaneous emphysema, bilateral pneumothoraxes, pneumomediastinum, pneumopericardium, and pneumoperitoneum, leading to abandonment of the procedure and subsequent Paediatric Intensive Care Unit (PICU) admission requiring bilateral chest tube insertion.
After optimization with dexamethasone, adrenaline nebulization and escalation of antibiotics, a second procedure was performed 48 hours later. Bronchoscopy demonstrated persistent impaction of the foreign body within the right secondary bronchus with granulation tissue formation. Multiple retrieval attempts were made, and the foreign body was successfully dislodged into the trachea, with an adjunctive Valsalva manoeuvre performed concurrently by the anaesthetist. At the same time, the surgeons secured it using a flexible endoscopic grasper through the rigid bronchoscope and removed it en bloc.

Conclusion:
This case underscores the significance of staged, multidisciplinary management and demonstrates the efficacy of the Valsalva manoeuvre as an adjunctive technique in the difficult retrieval of impacted paediatric airway foreign bodies.