Journal of Surgical Case Reports, 2023, 3, 1–3

https://doi.org/10.1093/jscr/rjad147
Case Series

Case Series
High-flow nasal oxygen as an adjunct for the
safe removal of impacted metallic upper airway
foreign bodies

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Nadia van den Berg1, *, Moustafa Aly1 , Michael Callaghan2 and Ivan Keogh1,3
1 Department of Otolaryngology Head & Neck Surgery, Galway University Hospital, Galway, Ireland
2 Department of Anaesthetics, Galway University Hospital, Galway, Ireland
3 School of Medicine, National University of Ireland Galway, Galway, Ireland

*Correspondence address. Galway University Hospital, Galway, Ireland. Tel: 091-542-222; E-mail: nadia9559@gmail.com

Abstract
Foreign body airway obstruction is considered an airway emergency and is a challenging clinical scenario for both the otolaryngologist
and the anaesthetist. We present three cases of impacted upper airway metallic foreign bodies. Supra-glottic airways were obstructed
and precarious. Apnoeic oxygenation utilizing high-f low nasal oxygen (HFNO), a form of tubeless anaesthetic, was used in all three
cases, leading to the safe removal of the foreign bodies. Increased training, awareness and equipment availability to provide HFNO
apnoeic oxygenation in the emergency setting for otolaryngology airway procedures will lead to better outcomes for patients and
decreases the risk of a potential surgical airway.

INTRODUCTION
Metallic foreign body airway obstruction is considered an airway
emergency and is a challenging clinical scenario for both the
otolaryngologist and the anaesthetist, particularly when these
cases present in children. Most cases of upper airway foreign
bodies occur in children under the age of five [1–2], with an
associated mortality risk of 2.75–3.70% [3]. In certain cases, intu-
bation may not be possible due to airway obstruction by the
foreign body, or risk of further dislodgement of the foreign body.
Apnoeic oxygenation utilizing high-f low nasal oxygen (HFNO)
is a form of tubeless anaesthetic, which has recently gained
popularity in otolaryngology, and specifically microlaryngoscopy
procedures [4].

CASE SERIES
We present three emergency cases in which metallic foreign
bodies in the upper aerodigestive tract prevented endotracheal
intubation. Apnoeic oxygenation using high-f low nasal oxygena-
tion was used as a safe alternative in all three cases.
The first case is of a 7-year-old child presenting with a history
of barbed wire inhalation. X-ray imaging of his neck and chest
showed a radio-opaque object visible in the upper airway with
sharp edges (Figs 1 and 2). Due to the position of the foreign
body, endotracheal intubation was not feasible. A trial of apnoeic
oxygenation using high-f low nasal oxygenation was used as an
alternative, and this allowed for an unobstructed view of the
larynx, facilitating the safe removal of the foreign body (Fig. 3).
Figure 1. Lateral neck X-ray showing a radio-opaque object with sharp
edges visible.
The second case involved a 3-year-old child who presented
with sudden onset noisy breathing. Inspiratory stridor was evident
on examination. Radiographs of the neck again showed a radio-
opaque object in the upper airway (Fig. 4). Apnoeic oxygenation
allowed for tubeless anaesthetic and safe removal of the metallic
foreign body from the airway (Fig. 5).

Received: February 6, 2023. Accepted: February 26, 2023

Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2023.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which
permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
2 | N. van den Berg et al.

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Figure 5. Successful removal of staple block from the upper airway.

Figure 2. AP chest radiograph showing the sharp-edged radio-opaque

object.

Figure 3. Successful removal of the barbed wire measuring ∼2.0 cm.

Figure 6. Lateral neck X-ray showing radio-opaque object in the upper

airway.

The final case is of a 75-year-old female who presented to

hospital after inhalation of her dentures (Figs 6 and 7). After dis-
cussion with the anaesthetic team, apnoeic oxygenation was once
again utilized in order to remove the foreign body without risk
of dislodgement and to decrease the risk of a potential surgical
airway (Fig. 8).

Figure 4. Lateral neck X-ray showing a radio-opaque object in the upper
airway.
DISCUSSION
Metallic foreign bodies in the upper aerodigestive tract present
a difficult emergency scenario for both otolaryngologists and
anaesthetists. Laryngeal foreign bodies can be especially compli-
cated to manage, with an increased risk of airway obstruction
and risk of requiring a surgical airway [5]. These often prevent
endotracheal intubation due to the object either obstructing the
airway or risk of further dislodgement into the airway. Alternative
methods of managing the airway and providing a general anaes-
thetic to a patient with an upper aerodigestive tract foreign body
would traditionally include either jet ventilation or spontaneous

Figure 7. Anterior-posterior neck X-ray showing a radio-opaque object,
in keeping with metal dentures.
Figure 8. Successful removal of metal dentures.
ventilation. Jet ventilation has many potential complications such
as barotrauma, pneumothorax, pneumomediastinum, gastroin-
testinal insuff lation and increased risk of aspiration. Some of
these complications, for example aspiration, are more likely to
occur in the emergency setting [6]. Spontaneous ventilation may
limit the depth of anaesthesia and as a result impede on the
success of the procedure [4].
Apnoeic oxygenation using HFNO is a novel technique, which
is being increasingly utilized in laryngeal procedures [4]. The
technique allows for tubeless anaesthetic and consequently an
unobstructed laryngeal field. Using this technique, there is no
requirement for bag mask ventilation. HFNO delivers humidified
oxygen via nasal cannulae at a rate of greater than 15 L/min
compared to a standard nasal oxygenation rate of 6 L/min whilst
the patient is awake. After a period of pre-oxygenation using
the HFNO device, a general anaesthetic and muscle relaxant are
administered using intravenous access, allowing for the surgeon
to carry out the procedure. A recent case series evaluating the use
High-f low nasal oxygen for removal of upper airway foreign bodies | 3
of HFNO in microlaryngoscopy procedures, found this technique
can allow the surgeon up to 37 min to perform the procedure [4].
In order to allow for ventilation of accumulated carbon dioxide
levels, a laryngeal mask airway is typically inserted after comple-
tion of the procedure.
A previous randomized controlled trial comparing the use of
standard nasal oxygenation with HFNO to allow for apnoeic oxy-
genation in the removal of foreign bodies during bronchosocopy
showed a statistically significant higher level of oxygen saturation
and lower level of end tidal carbon dioxide levels in the immediate
post-operative period for those in the HFNO group. The use of
HFNO has also been shown to have decreased rates of post-
operative atelectasis [7].
In light of the novelty of HFNO for apnoeic oxygenation, as
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well as the associated high stress environment of difficult airway
management in the emergency setting, consideration must be
given for the anaesthetic experience and familiarity with this
technique. HFNO is delivered through specific devices designed
to provide humified oxygen at an increased rate. As a result,
lack of equipment availability may further hinder the use of
this oxygenation method. Increasing training and awareness of
this technique will lead to increased accessibility to HFNO in
the emergency setting, which may be greatly beneficial in the
successful removal of foreign bodies from the upper aerodigestive
tract in both the paediatric and adult population.
CONFLICT OF INTEREST STATEMENT
No conf licts of interest. Informed patient consents obtained.
FUNDING
None.
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