Introduction:
Pen cap aspiration, though seemingly benign in origin, poses significant airway risks in children. Its smooth surface and cylindrical shape make removal technically demanding; delays in diagnosis and inappropriate manipulation may lead to complications.

Aim:
To highlight the diverse retrieval strategies for pen cap aspiration in children, emphasizing individualized management and the importance of multidisciplinary collaboration.

Case Study:
Case 1, a 7-year-old boy, aspirated a mechanical pencil cap that lodged in the left main bronchus and was removed via rigid bronchoscopy using optical grasping forceps. In Case 2, a 7-year-old girl developed extensive subcutaneous emphysema after aspirating a pen cap. Rigid bronchoscopy failed to extract the object safely, and an emergency tracheal incision was performed for successful removal. In Case 3, an 8-year-old boy with concurrent COVID-19 infection aspirated a pen cap that was successfully retrieved using flexible bronchoscopy-guided cryotherapy, minimizing aerosol exposure and procedure time.

Results and Discussion:
The choice of removal technique depends on the foreign body’s characteristics, airway anatomy, and clinical stability. Rigid bronchoscopy remains the gold standard; however, open surgical or cryotherapy-assisted approaches may be warranted in select cases. Cryotherapy is effective for smooth or slippery objects, offering a safe, rapid, and minimally traumatic retrieval option.

Conclusions:
Pen cap aspiration in children presents a diverse range of clinical scenarios that require tailored management. Awareness of various retrieval methods, including rigid bronchoscopy, tracheal access, and cryotherapy, improves safety and outcomes in paediatric airway foreign body cases.