Organic FBs such as vegetables, fruits, and meats (without bones) are excellent candidates for removal with cryotherapy. Medication pills are also often retrievable with cryotherapy. Objects without water content (i.e. metals, plastics, etc.) will not attach to the cryotherapy probe. Another technique reported in the literature that has been used in FBs without water content is instilling normal saline around the FB and then applying cryotherapy until ice forms around the object [56]. This allows for solidifcation of the normal saline and subsequent encasement of the FB. Cryotherapy can also be used in the resection of the associated granulation tissue caused by FBs.

Laser Therapy

Laser therapy has three potential uses in the management of FBs: resection of granulation tissue, photocoagulation to minimize or treat bleeding, and intentional fracturing of FBs. As stated earlier, it is important to ensure that the FB in question is non-combustible and that the inspired fraction of oxygen concentration is less than 40%. Laser therapy can be performed with a variety of different types of lasers. Photodesiccation can be used to destroy granulation tissue obstructing the FB or attached to it when this tissue interferes with the removal of the FB. If mucosa in the vicinity is in amed or demonstrates a signifcant bleeding potential during retrieval, photocoagulation techniques can be used to minimize mucosal bleeding prior to instrumentation. Laser has also been used to reduce the size of a FB, referring to a report of neodymium-doped yttrium aluminum garnet (Nd:YAG) being used to fracture a large broncholith into smaller fragments to allow retrieval [57]. In the GI literature, there is a case report of using laser to intentionally fracture a denture impacted in an esophagus to allow for successful retrieval [58].

Electrocautery and APC

Electrocautery and APC are not tools used in FB retrieval; however, they can be used for those situations where granulation tissue has grown

around the FB, impeding retrieval. Before using, the bronchoscopist must know what the FB is and ensure that it is non-combustible. As in any case using thermal energy, the inspired fraction of oxygen concentration must be reduced below 40% during use. Electrocautery and APC can be used to resect granulation tissue with or without the FB attached and provide coagulation effects to the affected mucosa, limiting bleeding, which can negatively affect visualization.

Surgical Management

Surgical intervention should be used as a last resort. Bronchoscopic retrieval is considered to be frst-line therapy as it is minimally invasive, safe, and highly effective. However, there are a few indications that may warrant surgical resection for retained FBs. For distally impacted FBs that are not amenable to FB retrieval or were unable to be retrieved successfully, thoracic surgery consultation should be sought for consideration of surgical resection. Another indication is for deeply embedded FBs. These FBs usually represent retained FBs that may have been aspirated months or years earlier and can be associated with intense in ammation, infection, excessive granulation tissue, or fbrosis. If bronchoscopic retrieval is unsuccessful or considered to be high-risk for complications, surgical intervention should be considered.

Sharp foreign bodies may require surgical resection as they can be challenging to retrieve and pose risks such as mucosal tearing, airway perforation, and bleeding. Additionally, sharp FBs can be “wedged” or embedded into tissue, which can make retrieval more high-risk. Surgery may be considered for FBs that have penetrated the airway wall and are in contact with mediastinal or hilar structures/vessels. Bronchoscopic retrieval may lead to undesired communications and/or bleeding. Regardless, a multidisciplinary approach should be used as it is very valuable to provide the best plan of action for each patient with such circumstances.