Foreign-body aspiration during microlaryngoscopy: an unusual case of instrument failure.

Instrument failure leading to patient morbidity is a recognized surgical complication that has been reported most commonly in the orthopedic and obstetrical literature [Small NC. Complications in arthroscopy performed by experienced arthroscopists. Arthroscopy 1989;4:215-221; Price MV, Molloy S, Solan MC, Sutton A, Ricketts DM. The rate of instrument breakage during orthopaedic procedures. Int Orthop 2002;26(3):185-7; In Y, Bahk WJ, Park JB. Detachment of the tip of a motorized shaver within the knee joint: a complication of arthroscopic surgery. Arthroscopy 2003;19(6):E29-31; Ostrzenski A. An intraoperative method of localizing a missing piece of a broken laparoscopic instrument. Am J Obstet Gynecol 1997;176:726-7]. Instrument failure resulting in airway foreign bodies, to our knowledge, has been reported only once in the English medical literature [Roach JM, Ripple G, Dillard TA. Inadvertent loss of bronchoscopy instruments in the tracheobronchial tree. Chest 1992;101(2):568-9]. This case report describes the aspiration of a fractured portion of a microlaryngeal instrument caused by metal fatigue and corrosion. The authors recommend vigilant and routine inspection of microlaryngeal instruments for early detection of metal corrosion and fatigue.