Rigid-Flexible Bronchoscopy With Holmium Laser Cauterization for Pine Nut Shell Removal and Balloon Dilation for Subsequent Bronchial Stenosis in a 16-Month-Old Girl

Objective:Unusual clinical course Background:Foreign body aspiration (FBA) is a life-threatening pediatric emergency, most common in 1-3-year-olds due to immature swallowing reflexes and exploratory oral behaviors.Common aspirated items include nuts, food particles and small toys, presenting with variable symptoms such as cough, dyspnea, wheezing or acute respiratory failure.Delayed diagnosis or improper management causes severe complications like post-obstructive pneumonia, atelectasis, bronchiectasis and irreversible airway stenosis, increasing morbidity and treatment complexity. Case Report:A 16-month-old girl was admitted with persistent cough, progressive dyspnea, intermittent fever, hoarseness, and occasional cyanosis that developed 6 days after accidental pine nut ingestion.Initial flexible bronchoscopy at a local hospital failed due to the foreign body's rigid texture and deep impaction in the right lower lobe basilar bronchus.Chest CT confirmed a pine nut shell in the B9/B10 segmental bronchus with surrounding inflammation.She was transferred for combined rigid-flexible bronchoscopy to establish a secure airway and enable precise visualization before holmium laser fragmentation broke the shell into retrievable fragments for complete removal.Two-week follow-up showed symptomatic B9/B10 stenosis, which improved significantly after sequential 3.5 mm and 4.0 mm balloon dilation.Her respiratory symptoms resolved and imaging confirmed restored lobar ventilation. Conclusions:Rigid-flexible bronchoscopy synergy benefits removal of large rigid foreign bodies in sub-main bronchi by combining rigid bronchoscopy's airway security with flexible bronchoscopy's maneuverability and visualization.Holmium laser safely fragments hard foreign bodies with minimal airway trauma, and sequential balloon dilation effectively treats post-FBA stenosis.Individualized application guided by clinical assessment and imaging optimizes pediatric FBA outcomes.