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Background: Complete upper airway obstruction by a foreign body is a dramatic and acute emergency situation, and can result in rapid development of hypoxia, circulatory arrest and death. Special Magill pliers with an adjustable video optical system have been developed for airway inspection to facilitate efforts to remove foreign bodies causing obstruction of the upper airway., Objective: To remove a simulated airway foreign body from a cardiopulmonary resuscitation (CPR) manikin, either with normal Magill pliers or with the newly designed video Magill pliers., Material and Methods: After a brief introduction, 81 kindergarten teachers, 51 pupils (age 10-14 years) and 52 prospective emergency physicians were asked to remove a 2 × 2 "Lego" brick from the hypopharynx of a CPR manikin using either standard Magill pliers or the newly designed video Magill pliers. The formal hypothesis was that there would be no differences between the methods. Successful removal was defined as when the first removal attempt resulted in the Lego brick passing beyond the teeth of the manikin within 60s., Results: The use of the video Magill pliers resulted in significantly higher success rates in removal of the simulated foreign airway body within 60 s compared to standard Magill pliers in kindergarten teachers (84% vs. 30%, p < 0.0001), pupils (84% vs. 18%, p < 0.0001) and prospective emergency physicians (92% vs. 40%, p < 0.0001). The time needed for removing the foreign airway body was significantly shorter in groups using the video Magill pliers (kindergarten teachers 29 ± 18s vs. 45 ± 19 s, pupils 29 ± 18s vs. 54 ± 14 s, and prospective emergency physicians 33 ± 18s vs. 45 ± 20 s; p < 0.0001). In an analogue points system (from 1 very simple to 10 extremely complicated), the user friendliness of the video Magill pliers was judged to be significantly higher than the standard Magill pliers (2.8 ± 1.6 vs. 7.8 ± 2.7 kindergarten teachers, 2.0 ± 1.3 vs. 7.2 ± 2.5 pupils and 3.2 ± 2.2 vs. 4.9 ± 3.1 prospective emergency physicians, p < 0.0001). Visibility of the airway foreign body was estimated to be significantly better employing the video Magill pliers compared to the standard Magill pliers (1.9 ± 1.4 vs. 9.8 ± 0.6 kindergarten teachers, pupils 1.3 ± 0.6 vs. 9.2 ± 1.6, prospective emergency physicians 2.3 ± 1.8 vs. 9.1 ± 2.3, p < 0.0001)., Conclusion: In this study kindergarten teachers, pupils (aged 10-14 years) and prospective emergency physicians had higher success rates in less time and reported better user friendliness and visibility using video Magill pliers compared to standard Magill pliers for removing a simulated foreign body from a CPR manikin airway.

History and Clinical Finding: We report on a 27-year-old female patient presenting with pneumonia and developing acute respiratory distress syndrome. Using transpulmonary thermodilution, an elevated extravascular lung water was detected (17 ml/kg). Patient required lung-protective mechanical ventilation and received antibiotic therapy. Negative fluid balance was targeted. Under this treatment, respiratory function improved, inflammation parameters declined, and extravascular lung water was recurrent (10 ml/kg). Subsequently, extravascular lung water increased to 29 ml/kg., Diagnosis: In a chest x-ray, the central venous catheter tip was dislocated into the right internal jugular vein. 7 days before, the catheter was shown to be in projection of the Vena cava superior in a previous chest x-ray., Therapy and Course: After insertion of a new central venous catheter, extravascular lung water was quantified at 10 ml/kg again. After 10 days of mechanical ventilation the patient was successfully extubated., Conclusion: As mechanism for this catheter dislocation, we propose a Valsalva maneuver or spontaneous movements of the upper body of the patient. Sudden increase in extravascular lung water may reflect central venous catheter tip dislocation and chest x-ray should be considered to verify catheter tip position., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht. Die Aufklärung über eine Veröffentlichung der Kasuistik und Einholen einer schriftlichen Einverständniserklärung des Patienten ist erfolgt., (© Georg Thieme Verlag KG Stuttgart · New York.)

Both ingestion and aspiration of foreign bodies are common events in children. If a child had something in his mouth and thereafter respiratory or swallowing complaints occur, both aspiration and ingestion are possible causes. Both events can be immediately life threatening or, if a direct threat is absent, cause significant long-term impairments for the children. Therefore, the identification of any possible threat is essential. This paper identifies the diagnostic and therapeutic options and needs that will ensure the best possible safety and the least possible consequential harm., Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

The dreaded fracture of a root canal instrument is in fact a rare adverse event. Most instrument fractures occur in molar teeth with the highest degree of root curvature. Various treatment options (leaving the fractured instrument with or without apicoectomy, bypassing or removing the fragment) and removing techniques (using ultrasonics, hollow tubes or bypassing and removing with debriders) are discussed. The clinical prognosis for teeth with fractured instruments is not necessarily compromised if appropriate further treatment is undertaken. Indeed, it is the timing of instrument fracture and the associated level of infection that will dictate treatment outcomes.

Case Report: We describe a 75-year-old patient with asymptomatic grey pigmentation on the face and fingers. He had worked over two decades in cutting high-voltage cables. The cutting procedures were performed without a face shield or protection gloves. The patient presented with gray punctate lesions beside some homogeneously stained zones., Diagnostics: Histologically, the deposits presented in the dermal tissue in a horse-shoe, oval, or splinter-like shape. The foreign body material was embedded by a few CD68-positive macrophages. Undyed histological sections were investigated via two-dimensional micro-synchrotron X-ray fluorescence analysis (SRXRF). The deposits were identified as zinc (Zn), copper (Cu), nickel (Ni), and strontium (Sr), which were strongly associated with maximal sulfur (S) concentrations. This association is presumably induced by complex binding between thiol groups and metal ions such as Zn, Ni etc. However, the iron (Fe) distribution patterns were quite different to those of Zn, Cu, or Ni. These heavy metals are major components of the metal wires that the patient worked with in his profession., Conclusion: To the best of our knowledge, this is the first case report in the dermatological literature of intradermal metal deposits identified via SRXRF analysis.

Intra-abdominal and intrathoracic misplacement is a possible complication after insertion of a chest drain but perforation of the left ventricle has very rarely been described. We report on a 57-year-old woman who had to be resuscitated due to circulatory insufficiency subsequent to cardiogenic and hemorrhagic shock after the insertion of a chest drain for the treatment of a postpneumonic pleural effusion. During surgery perforation of the left ventricle with hemopericardium was found. Despite an initially unfavorable situation the patient recovered well.

Gunpowder traumatic tattoo and foreign bodies in the skin secondary to explosions or gunshots need to be treated within 72 h if possible to achieve good aesthetic results. Hypertrophic scars can be treated by skin resurfacing using the Erb-YAG laser or the CO₂ laser, while traumatic tattoos can be removed with the Q-switched rubin laser.

Endoscopy is often used in gastroenterology. It can prevent early recurrence of bleeding from esophageal varices. Computed virtual chromoendoscopy can diagnose pathological changes at the esophagogastric transitional zone in non-erosive reflux disease. In the buried bumper syndrome the internal bumper, which has migrate into the gastric wall, should be removed endoscopically. Double-balloon enteroscopy is one of the flexible enteroscopy techniques with an acceptable complication rate and remains the diagnostic and therapeutic gold standard for small bowel endoscopy. Hyperplastic polypoidal lesions of more than 1 cm in the colon should be removed, because it is not possible to distinguish definitively between hyperplastic polyps and serrated adenoma. Endoscopic ultrasound of the biliary tract makes it possible to remove biliary tract stones cost-effectively and without radiology. Endoscopic ultrasound-guided necrosectomy of the pancreas has become the standard method and has replaced percutaneous drainage and operative intervention., (© Georg Thieme Verlag KG Stuttgart · New York.)

Because many children who have swallowed foreign bodies are asymptomatic, physicians must maintain a high index of suspicion. The majority of ingested foreign bodies pass spontaneously, but serious complications, such as bowel perforation and obstruction, can occur. There is only limited evidence based data on the diagnostic and therapeutic procedure. In german speaking countries no treatment recommendations or guidelines exist. We present an interdisciplinary consented flow sheet for the diagnostic and therapeutic procedure for the gastrointestinal ingestion of radiolucent and radiodense foreign bodies, which is based on the available data as well as on common sense.

After orotracheal intubation of a 30-year-old man with a flexible tube, a floating foreign body was noticed inside the tube. The subsequent bronchoscopy revealed a second foreign body near the bifurcation of the trachea. Both foreign bodies were removed successfully and identified as parts of the plastic-sheathed stylet. Fatigue of material is discussed as the reason for the broken reusable stylet during intubation.

Introduction: Foreign bodies in the oesophagus represent a frequent emergency situation in ENT medicine. Usually the cases involve lumps of meat, bones, shards of glass, bottle tops, batteries or dentures. We would like to report about an unusual foreign body found in the oesophagus., Patient: A 45-year-old patient presented himself in our interdisciplinary casualty department where he claimed to have swallowed a butter-knife that morning as a bet. The ENT examination showed no abnormal findings. The thorax X-Ray revealed a 14 cm-long foreign body in projection to the oesophagus, which matched the knife. Following consultation with the thorax surgeon, a rigid oesophagoscopy was conducted under endotracheal intubation and the knife was easily removed using tongs. Archive searches conducted in the meantime showed that foreign bodies had been removed from the patient on numerous occasions by fellow surgeons either laparoscopically or via open surgery. As a result, the patient was transferred to the psychiatric ward with unimpeded swallowing reflex with a suspected self-harming syndrome., Discussion: As an ENT emergency, a foreign body in the oesophagus generally requires intervention because of the risk of complications such as perforation or pressure-induced necrosis of the oesophagus wall with resulting mediastinitis. Suitable instruments are the flexible oesophagoscope, the rigid oesophagoscope under anaesthesia or transcervical/transthoracic removal. The choice of procedure crucially depends on the type and localisation of the foreign body in the oesophagus. Particularly in cases of unusual foreign objects or repeated foreign object ingestion, it should be considered whether a psychological illness could be the cause and whether the introduction of appropriate therapy could be expedient.

Gastrointestinal and bronchial foreign bodies may cause significant clinical complications with a high degree of morbidity. In adults, a large variety of foreign bodies are accidentally or intentionally ingested, inserted or aspirated. In the majority of cases, the objects are expelled conservatively by coughing, vomiting or bowel movements. The risk for obstruction, perforation and penetration depends upon the type of object, those with sharp edges or tips having the highest risk. In these situations, the objects have to be removed by an endoscopic or an operative intervention. We present four foreign body stories including a young lady who swallowed a pen during sleep, a farmer who inserted a corncob into the rectum because of intractable diarrhoea, an elderly gentleman who aspirated a dental bridge while laughing and a cocain body packer who was caught at the border. Back ground, complications and removal procedures of the four cases are discussed.

Colic attacks by a foreign body in the urinary tract are very rare and mostly follow iatrogenic manipulation. This case report focuses on ureteric colic thought to result from radiological embolisation material. It is of practical interest because embolisation of prolonged bleeding after endourological procedures is widely done.An 80-year-old woman with a long history of nephrolithiasis underwent percutaneous nephrolithotomy. She suffered from a continuous, transfusion-obligatory bleeding. The source of bleeding was treated with embolisation by coiling. About 2 years later, the patient presented with persistent pain on the right abdominal side and urinary obstruction. A dislocation of the coils into the ureteropelvic junction was diagnosed. After primary ureteral stenting, the foreign body was removed via ureterotomy.

The number of cardioverter/defibrillator (ICD) implantations has been steadily increasing; thus, ICD lead-associated complications are an important issue. No clear recommendations for the diagnosis and management are available. This article gives an overview of how to diagnose and manage an ICD lead defect. Possible therapeutic options are discussed by reviewing the literature.

Background: The accidental application of cyanacrylate (superglue) into the outer ear canal requires different treatments depending on location and extent., Methods: Two case studies are presented. Treatment included surgical removal, with or without prior conservative treatment, for complete canal obstruction, as well as conservative treatment for partial ear canal obstruction., Results: Because of its unique anatomy, treatment of accidentally applied superglue into the outer ear canal differs from treatment in other locations. Conservative treatment was ineffective for complete obstruction, making secondary surgical removal necessary. Partial obstruction was successfully treated conservatively. No complications were observed after the surgical removal of superglue obstructing the complete outer ear canal., Conclusions: Conservative treatment is adequate for cases of partial obstruction of the outer ear canal with superglue. In cases of complete obstruction or inclusion of the ear drum, surgical treatment is recommended.

This paper describes the successful nonoperative treatment of a 31-year-old male patient with thoracic and abdominal gunshot wounds. Once stabilized in the emergency department (ED), he was transferred to our general surgical department. On the first day after his admission, diagnostic peritoneal lavage (DPL) was performed, revealing a small amount of hemorrhagic fluid. The fluid inside the pericardium was examined by controlled echocardiography in the cardiology clinic, and a conservative approach was suggested. The patient began to tolerate oral feeding quite soon; he was discharged from the general surgical department in a good state of wellbeing on day 13 after admission. This case report supports the idea that nonoperative treatment with repeated physical examination can be an alternative to laparatomy for abdominal gunshot injuries. Further clinical and experimental trials should be performed to test how safe this alternative is.

We report on a 66-years-old oncological patient with a spontaneous dislocation of a portcatheter into the pulmonary artery. The catheter fragment had a loop formation, both ends were located in the proximal right segment arteries. The first attempt of a removal of the catheter via the right heart into the inferior caval vein by means of a hooked pulmonalis-catheter failed. In a second manoeuvre, the catheter fragment was successfully fixed by means of a catheter with an extendable loop configuration (goose-neck) and retrieved from the pulmonal artery into the inferior caval vein. Then, the entire system could be removed together with the introducer sheet under mild traction from the femoral vein without any complications. In conclusion, the percutaneous interventional method appears to be a minimally-invasive approach to deal with catheter fragments dislocated in the central veins and the pulmonary arteries.

Silastic central catheters inserted peripherally are used in neonatology since more than 20 years. Typical complications include catheter associated infection, thrombosis and malposition. Pericardial effusion, fracture and embolisation are rare. We report the case of a female newborn with congenital diaphragmatic hernia. A silastic catheter was inserted in the left cubital vein. The catheter ruptured when the obviously occluded lumen was flushed with saline. A 15 cm long catheter fragment located in the right ventricle and pulmonary artery was removed after cardiac catheterization with a "Snare"-catheter.

For the individual design of ear moulds, silicone is generally used for taking the impression of the external meatus and the cavum conchae. Complications are rare with only a few accounts in the literature. We report on three cases of accidental displacement of silicone into the middle ear cavity during impression taking. Clinical symptoms and detection of silicone as a rare middle ear foreign body are presented and discussed.

Background: The use of airbag systems in motor vehicle construction has led to a significant reduction in both the frequency and intensity of injuries during traffic accidents. However, recent reports have shown numerous cases in which it is assumed that the airbag was the major cause of serious injury., Case Report: In a collision with a wild boar, both airbags in the automobile deployed. The driver suffered facial abrasion and belt contusion to the left shoulder. The passenger held a glass bottle in her hands during the impact that, secondarily accelerated through the airbag, hit both eyes and the bridge of her nose. On clinical admission, the patient showed fractures of the nasal bridge, of both medial orbital walls on both sides and a massive periocular haematoma which required direct examination under narcosis. Both eyes showed an orbital contusion, a large area of corneal abrasion, traumatic mydriasis with sphincter tears such as bilateral 90% hyphema. During surveillance, a progressive reduction in visual acuity occurred. After posterior chamber vitrectomy with epiretinal peeling and posterior chamber lens implantation in the left eye, visual acuity was 0.05 in the left eye and 0.01 in the right., Conclusions: A considerable danger emanates from objects which are situated between head and airbag in the moment of airbag deployment. This requires public education and, in addition, airbag systems which are adapted to the drivers height and weight, as well as to objects in its immediate vicinity.

A case of subsequent percutaneous repair using a local closure device with a collagen block (VasoSeal(R)) and temporary balloon tamponade after inadvertent subclavian artery misplacement of a 12F Shaldon catheter is reported. Balloon occlusion safely prevented displacement of collagen into the vascular lumen by occluding the 12F entry site. Furthermore, collagen-induced coagulation was facilitated.

The case of a 34-year-old otherwise healthy woman with retropharyngeal abscess due to a fishbone injury and presenting with neck stiffness and aphagia without visualization of a pharyngeal mucosal lesion is reported. The case illustrates that sore throat with symptoms out of proportion to oropharyngeal findings should prompt a search for pathologies other than simple pharyngotonsillitis. Other typical symptoms of a retropharyngeal abscess are high fever, dysphagia, hot potato voice and, less commonly, dyspnea and sepsis. Retropharyngeal abscess in adults occurs most often as a complication of a spread of infection from a pharyngeal focus, a foreign body injury, an iatrogenic trauma due to tracheal intubation or endoscopy, and blunt or perforating neck trauma. Contrary to children, a retropharyngeal abscess in adults without loco-regional infection or preceding trauma is very rare. This case illustrates how important imaging investigations (CT-scan) are in order to locate foreign bodies and to decide on surgical management. Aetiology, presenting signs, symptoms, methods of diagnosis, treatment and complications of a retropharyngeal abscess are briefly discussed.

History and Admission Findings: We report the case of a 79-year old male patient with progressive dysphagia 9 years after resection of an adenocarcinoma of the esophagus. The patient presented with cachexia and a weight loss of 10 kg within the last 10 weeks. He was unable to swallow solids and liquids. 6 weeks before he had suffered from pneumonia caused by aspiration. Two previously performed gastroscopic examinations had documented a stenosis of the anastomosis which was passed by the endoscope. Tissue specimens taken from the stenosis showed high-grade dysplasia., Investigations: Computed tomography of the thorax documented a stenosis of the esophagus with prestenotic dilatation and intraluminal food. There were no signs indicating local recurrence of the tumor such as transmural lesions., Diagnosis, Treatment and Course: Endoscopic examination showed an impacted foreign body measuring 2 x 4 cm which was be extracted. Extracorporeal inspection of this foreign body revealed it to be a dried apricot. After retaking the history, the patient was able to date the time of ingestion to have been three months earlier, shortly before his dysphagia had started. After extraction of the foreign body dysphagia resolved and the patient gained weight., Conclusion: Ingestion of foreign bodies or a food bolus may occur unnoticed on rare occasions and even large ones may remain undiagnosed despite repeated endoscopic examinations.

We report the rare case of a penetrating, combined thoracic- and abdominal injury as a consequence of a farm work accident. During the recent years, a "treat and run" approach has been increasingly advocated as a time-saving way of treating penetrating injuries, constituting a compromise between the existing strategies of "scoop and run" (used mainly in the USA) and "stay and treat" (preferred in Central Europe). A prolonged rescue response time makes the treat and run approach impossible here. Immediate treatment at the accident site requires an appropriate provision of i.v. fluids. We examine the course of pre-hospital treatment of a trauma patient to illustrate the various approaches to i.v. fluid therapy in relation to rescue response time. However there are only a few studies with a real evidence. If "treat and run" is not possible, the outcome of patients with penetrating trauma can be influenced positively by moderate fluid therapy under continuous monitoring after having reached a constant, low mean arteria pressure (so called permissive hypotension).

Aims: All cases of the last 5 years requiring foreign bodies to be removed from the paranasal sinuses were investigated as to causes, special aspects in diagnostics and therapy, occurrence of pathologic germs and possible sequels., Patients: 68 cases were evaluated: 43 patients were male, 25 female. Average age was 29 years in males and 37 years in females., Results: In our patients foreign bodies in the paranasal sinuses were in more than 60% the result of medical or dental procedures followed by industrial accidents (25%). The maxillary sinus was affected in 75%, the frontal sinus in about 18%. Involvement of the ethmoid or sphenoid sinus was rare. The spectrum of pathologic microbes was dominated by mixed infections, the share of actinomyces and aspergillus was unexpected high. Most important acute complications were bleeding, compression of the optic nerve and liquorrhoe. Late complications consisted mainly of pain--often associated with disturbances of sensibility- and infections., Conclusions: A smear should be taken whenever the foreign body remained in the sinus for more than 4 days. Foreign bodies jammed in the posterior wall of the sinus require a sufficiently open view since the risk of heavy bleeding is especially high.