Thank you for identifying the controversy about the role of spontaneous ventilation and neuromuscular blockade. The management of airway foreign bodies and use of neuromuscular blockade should be individualized based on factors such as the location and type of foreign body.1The image of a sunflower seed wedged at the cricoid ring reinforces the anesthetic management principle of maintaining spontaneous ventilation and avoiding neuromuscular blockade.2 

In this child, neuromuscular blockade and positive pressure ventilation could displace the larger proximal portion of this sunflower seed further into the airway and convert this partial airway obstruction into complete airway obstruction.1,3Spontaneous ventilation remains the preferred method when a foreign body is at the level of the glottis and cricoid ring.1,3 

A glottic or subglottic location for a foreign body is often associated with complete airway obstruction in the prehospital and emergency department setting. The majority of children who survive the initial aspiration of nuts or seeds usually require bronchoscopy for a foreign body lodged in a tracheal or bronchial location. In these children, as the literature and Baum's letter suggest, neuromuscular blockade and positive pressure ventilation is an option that offers the benefit of a “quiet” airway. The use of neuromuscular blockade facilitates the bronchoscopic removal and prevents the coughing and breath-holding that frequently accompany rigid bronchoscopy, particularly when foreign bodies are distal to the carina.1The glottic location is less common in the child who presents to the operating room for foreign body removal, and we believe the image reinforces the wisdom of maintaining spontaneous ventilation during anesthesia induction.

Darrow DH, Hollinger LD: Foreign bodies of the larynx, trachea and bronchi. In: Bluestone CD, Stool SE, eds. Pediatric Otolaryngology. Philadelphia: WB Saunders; 2003:1543–57
Motoyama EK: Anesthesia for Pediatric Otorhinolaryngologic Surgery. In: Motoyama EK, Davis PJ, eds. Smith's Anesthesia for Infants and Children, 8th ed. Philadelphia: Mosby-Elsevier; 2011:818
AuBuchon J, Krucylak C, Murray DJ: Subglottic airway foreign body: A near miss. ANESTHESIOLOGY 2011; 115:1300