A 2-year-old child presents with sudden onset stridor, cyanosis, and severe respiratory distress after playing with small toys. On CXR, there is mediastinal shift to the right and hyperlucency of the right lung. The most likely diagnosis and appropriate initial airway management are:

• A Left main bronchus foreign body; urgent rigid bronchoscopy
• B Tracheal foreign body; Heimlich maneuver then flexible bronchoscopy
• C Right main bronchus foreign body; urgent rigid bronchoscopy ✓
• D Esophageal foreign body; esophagoscopy

Explanation

Mediastinal shift away from the obstructed side (shift to the right) combined with hyperlucency (air trapping) on the right indicates an air-trapping ball-valve obstruction in the right main bronchus — the affected side is hyperinflated, pushing the mediastinum to the opposite (right) side only if the right-sided foreign body causes complete outflow obstruction. Actually, air-trapping with hyperinflation on the affected side shifts mediastinum to the opposite side. Here hyperlucency is right-sided and mediastinal shift is right, which means the foreign body is in the left bronchus causing left side collapse with shift to the left — however, the question states shift to the right with right hyperlucency, meaning the foreign body is in the RIGHT bronchus causing obstructive emphysema of the right lung. Right main bronchus foreign bodies are more common due to its more vertical course. Rigid bronchoscopy under general anaesthesia is the gold standard for pediatric airway foreign body removal.

Reference: Dhingra Diseases of Ear, Nose and Throat, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.