CASE REPORT
Laryngeal Foreign Bodies Among Adults Mahendra S. Hada, MS, Sunil Samdhani, MS, ENT, Vinit Chadha, MS, ENT, Rathod S. Harshvardhan, MBBS, and Mishra Prakash, MS, ENT
Summary: Impacted foreign body of the larynx in the
middle-aged man is a rare occurrence. Occupational and habitual surroundings make them prone to foreign body aspiration and impaction in the larynx. Proper history helps in establishing the diagnosis. We report 2 cases of unusual laryngeal foreign body in middle-aged adults who presented with complaints of sudden onset of change in their voice without any respiratory difficulty with accurate history of aspiration. Foreign bodies were successfully removed by direct laryngoscopy under general anesthesia. Key Words: foreign body, larynx, direct laryngoscopy (J Bronchol Intervent Pulmonol 2015;22:145–147)
T
racheobronchial foreign body (FB) can be a life-threatening event that often requires immediate intervention. Its impaction in the larynx, however, is very uncommon, occurring in approximately 4% of all patients with FB aspiration. Laryngeal FB is especially encountered in older people.1 Clinical history helps in the diagnosis as adults can relate to the history more precisely than children. The clinical signs and symptoms may range from mild distortion of the voice to an airway emergency, the latter requiring lifesaving first aid, such as the Heimlich maneuver. Rima glottis is the narrowest part of the adult airway and it is a sagittal plane, common site for foreign body impaction. However, a foreign body having a sharp or irregular shape can get lodged in the larynx.1 Kansara and colleagues reported an unusual case of laryngeal foreign body presenting with sudden loss of voice of 6 days’ duration. There was no history of trauma or fever. Indirect laryngoscopy revealed a shiny material attached to left vocal cord.2 We would
Received for publication May 12, 2013; accepted February 17, 2014. From the Department of ENT, SMS Medical College, Jaipur, India. Disclosure: There is no conflict of interest or other disclosures. Reprints: Mahendra S. Hada, MS, H.N. 28/304 “Amar House”, Gumanpura, Kota 324007, India (e-mail: drmshada@ rediffmail.com). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Bronchol Intervent Pulmonol
like to present 2 such unusual cases of foreign body aspiration in adults. CASE REPORTS Case 1 A 45-year-old man presented with a sudden onset of change in his voice without any respiratory difficulty after accidental ingestion of a coin. The patient was a bus conductor and was suffering from upper respiratory infection for 5 days and accidentally ingested the coin kept in his mouth following a bout of cough. On indirect laryngoscopy the coin was seen sitting vertically between the 2 vocal cords. The presence of the coin was also seen on the roentgenograms of the neck [anteroposterior (Fig. 1); and lateral views (Fig. 2)]. A direct laryngoscopy was performed under general anesthesia (GA) and the coin was found impacted in the sagittal plane between the vocal cords. It was disimpacted and successfully removed. Postoperative period was uneventful with immediate recovery of the symptoms. Case 2 A 42-year-old man presented with accidental inhalation of a crepe bandage holding a metallic pin, followed by hoarseness and foreign body sensation in the throat with mild difficulty in breathing. Indirect laryngoscopy and radiologic examination (Fig. 3)
FIGURE 1. Radiograph of neck soft tissue. Anterioposterior (AP) view showing radiopaque foreign body, a coin in saggital plane (case 1).
Volume 22, Number 2, April 2015
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Hada et al
J Bronchol Intervent Pulmonol
FIGURE 2. Radiograph of neck soft tissue. Lateral view showing radiopaque foreign body in saggital plane (case 1).
revealed a radiopaque foreign body in supraglottic and glottic larynx. Metallic pin was removed by direct laryngoscopy under GA. Postoperative period was uneventful. DISCUSSION
Impaction of foreign body in the larynx is a rare condition, children are more susceptible but it is uncommon in adults. Extremes of age group are most susceptible to foreign body aspiration because of: (A) the lack molars necessary for proper grinding of the food, (B) poor coordination of the swallowing and decreased laryngeal movements and glottic closure, and (C) inadequate cough reflex.3 Older children and adolescents may have an anatomic abnormality or a neurologic impairment, which may result in foreign body aspiration.4 Most commonly aspirated foreign bodies are organic materials such as nuts and seeds in
Volume 22, Number 2, April 2015
children and food and bones in adults.5 Inhalation of metallic foreign body is very uncommon. Yadav et al6 in their study of 132 patients reported that only 6 (4.5%) cases had aspiration of a metallic foreign body. In both our cases, a metallic foreign body was found impacted in the larynx. Cultural and regional differences can lead to variations in foreign body aspiration. Specific adult lifestyle and profession may predispose to unusual types of aspiration.7,8 In our case 1, the patient was a bus conductor with a habit of keeping coins in his mouth, which made him susceptible to inhalation of coin. In the second case he inhaled a crepe bandage holding pin while wrapping the bandage around his hand with keeping pin in mouth. The spectrum of presentation varies widely, ranging from sudden death due to respiratory obstruction to accidental finding during routine investigation. Lima9 in a review of 91 inhaled foreign bodies, found 11 to be true glottis, 5 of 11 had fatal outcome and transient hypoxic encephalopathy occurred in 3 patients. In most cases a history of choking followed by a transient cough was seen. A foreign body lodged in the larynx can cause laryngospasm and complete respiratory obstruction.10 However, both of our patients presented with only change in voice without difficulty in breathing with clear-cut history of aspiration that helped to establish the diagnosis early. In case 1, a coin was lying in sagittal plane causing partial obstruction. In addition, the foreign body was metallic in nature, which is less inflammatory than organic foreign bodies. Apart from difficulty in breathing the patient can also present with change of voice, dysphagia, sore throat, etc., which are more common complaints in older age group. The risk of aspiration is greater in the presence of upper respiratory infections (URI) because of forceful inspiration following a sudden bout of cough. This can cause any material in oral cavity to be aspirated into the airways. Our 2 cases had URI, which predisposed them to foreign body inhalation. CONCLUSIONS
FIGURE 3. Radiograph of neck soft tissue. Lateral view showing radiopaque foreign body, a “crepe bandage holding metallic pin” (case 2).
146 | www.bronchology.com
In the middle-age group foreign body of the larynx are uncommon. URI may be a predisposing factor of foreign body larynx. Sudden development of hoarseness of voice should raise a suspicion of a laryngeal foreign body. The nature of foreign body of the larynx is variable and may be associated with occupational environment and habits of the patient. Early diagnosis and intervention is the key in such cases as
Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
J Bronchol Intervent Pulmonol
Volume 22, Number 2, April 2015
delay can lead to catastrophic complications and long-term sequelae. REFERENCES 1. Cohen SR, Herbert WT, Lewis GB Jr, et al. Foreign bodies in the airways. Ann Otol Laryngol. 1980;89: 437–442. 2. Kansara AH, Shah HV, Patel MA, et al. Unusual case of laryngeal foreign body. Ind J Otolaryngol Head Neck Surg. 2007;59:63–65. 3. McGuirt WF. Tracheobronchial foreign bodies. Laryngoscope. 1988;98:615. 4. DeRowe A, Massick D, Beste DJ. Clinical characteristics of aero-digestive foreign bodies in neurologically impaired children. Int J Pediatric Otorhinolaryngol. 2002;62:243.
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Laryngeal Foreign Bodies Among Adults
5. Gencer M, Ceylan E, Koksal N. Extraction of pins from the airway with flexible bronchoscopy. Respiration. 2007;74:674–679. 6. Yadav SPS, Singh J, Aggarwal N, et al. Airway foreign bodies in children: experience of 132 cases. Singapore Med J. 2007;48:850–853. 7. Dikensoy O, Usalan C, Filiz A. Foreign body aspiration: clinical utility of flexible bronchoscopy. Postgrad Med J. 2002;78:399–403. 8. Hada MS, Chadda V, Mishra P, et al. Unusual metallic foreign bodies in the larynx: two case reports. Indian J Pediatr. 2012;79:1100–1102. 9. Lima JA. Laryngeal foreign bodies in children: a persistent life threatening problem. Laryngoscope. 1989;99:415–420. 10. Ganguly SN, Reddy NS, Shrestha A, et al. Unusual case of laryngeal foreign body. J Coll Med Sci. 2010;6:45–46.
2015 Wolters Kluwer Health, Inc. All rights reserved.
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147
Laryngeal Foreign Bodies Among Adults Mahendra S. Hada, MS, Sunil Samdhani, MS, ENT, Vinit Chadha, MS, ENT, Rathod S. Harshvardhan, MBBS, and Mishra Prakash, MS, ENT
Summary: Impacted foreign body of the larynx in the
middle-aged man is a rare occurrence. Occupational and habitual surroundings make them prone to foreign body aspiration and impaction in the larynx. Proper history helps in establishing the diagnosis. We report 2 cases of unusual laryngeal foreign body in middle-aged adults who presented with complaints of sudden onset of change in their voice without any respiratory difficulty with accurate history of aspiration. Foreign bodies were successfully removed by direct laryngoscopy under general anesthesia. Key Words: foreign body, larynx, direct laryngoscopy (J Bronchol Intervent Pulmonol 2015;22:145–147)
T
racheobronchial foreign body (FB) can be a life-threatening event that often requires immediate intervention. Its impaction in the larynx, however, is very uncommon, occurring in approximately 4% of all patients with FB aspiration. Laryngeal FB is especially encountered in older people.1 Clinical history helps in the diagnosis as adults can relate to the history more precisely than children. The clinical signs and symptoms may range from mild distortion of the voice to an airway emergency, the latter requiring lifesaving first aid, such as the Heimlich maneuver. Rima glottis is the narrowest part of the adult airway and it is a sagittal plane, common site for foreign body impaction. However, a foreign body having a sharp or irregular shape can get lodged in the larynx.1 Kansara and colleagues reported an unusual case of laryngeal foreign body presenting with sudden loss of voice of 6 days’ duration. There was no history of trauma or fever. Indirect laryngoscopy revealed a shiny material attached to left vocal cord.2 We would
Received for publication May 12, 2013; accepted February 17, 2014. From the Department of ENT, SMS Medical College, Jaipur, India. Disclosure: There is no conflict of interest or other disclosures. Reprints: Mahendra S. Hada, MS, H.N. 28/304 “Amar House”, Gumanpura, Kota 324007, India (e-mail: drmshada@ rediffmail.com). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Bronchol Intervent Pulmonol
like to present 2 such unusual cases of foreign body aspiration in adults. CASE REPORTS Case 1 A 45-year-old man presented with a sudden onset of change in his voice without any respiratory difficulty after accidental ingestion of a coin. The patient was a bus conductor and was suffering from upper respiratory infection for 5 days and accidentally ingested the coin kept in his mouth following a bout of cough. On indirect laryngoscopy the coin was seen sitting vertically between the 2 vocal cords. The presence of the coin was also seen on the roentgenograms of the neck [anteroposterior (Fig. 1); and lateral views (Fig. 2)]. A direct laryngoscopy was performed under general anesthesia (GA) and the coin was found impacted in the sagittal plane between the vocal cords. It was disimpacted and successfully removed. Postoperative period was uneventful with immediate recovery of the symptoms. Case 2 A 42-year-old man presented with accidental inhalation of a crepe bandage holding a metallic pin, followed by hoarseness and foreign body sensation in the throat with mild difficulty in breathing. Indirect laryngoscopy and radiologic examination (Fig. 3)
FIGURE 1. Radiograph of neck soft tissue. Anterioposterior (AP) view showing radiopaque foreign body, a coin in saggital plane (case 1).
Volume 22, Number 2, April 2015
www.bronchology.com |
145
Hada et al
J Bronchol Intervent Pulmonol
FIGURE 2. Radiograph of neck soft tissue. Lateral view showing radiopaque foreign body in saggital plane (case 1).
revealed a radiopaque foreign body in supraglottic and glottic larynx. Metallic pin was removed by direct laryngoscopy under GA. Postoperative period was uneventful. DISCUSSION
Impaction of foreign body in the larynx is a rare condition, children are more susceptible but it is uncommon in adults. Extremes of age group are most susceptible to foreign body aspiration because of: (A) the lack molars necessary for proper grinding of the food, (B) poor coordination of the swallowing and decreased laryngeal movements and glottic closure, and (C) inadequate cough reflex.3 Older children and adolescents may have an anatomic abnormality or a neurologic impairment, which may result in foreign body aspiration.4 Most commonly aspirated foreign bodies are organic materials such as nuts and seeds in
Volume 22, Number 2, April 2015
children and food and bones in adults.5 Inhalation of metallic foreign body is very uncommon. Yadav et al6 in their study of 132 patients reported that only 6 (4.5%) cases had aspiration of a metallic foreign body. In both our cases, a metallic foreign body was found impacted in the larynx. Cultural and regional differences can lead to variations in foreign body aspiration. Specific adult lifestyle and profession may predispose to unusual types of aspiration.7,8 In our case 1, the patient was a bus conductor with a habit of keeping coins in his mouth, which made him susceptible to inhalation of coin. In the second case he inhaled a crepe bandage holding pin while wrapping the bandage around his hand with keeping pin in mouth. The spectrum of presentation varies widely, ranging from sudden death due to respiratory obstruction to accidental finding during routine investigation. Lima9 in a review of 91 inhaled foreign bodies, found 11 to be true glottis, 5 of 11 had fatal outcome and transient hypoxic encephalopathy occurred in 3 patients. In most cases a history of choking followed by a transient cough was seen. A foreign body lodged in the larynx can cause laryngospasm and complete respiratory obstruction.10 However, both of our patients presented with only change in voice without difficulty in breathing with clear-cut history of aspiration that helped to establish the diagnosis early. In case 1, a coin was lying in sagittal plane causing partial obstruction. In addition, the foreign body was metallic in nature, which is less inflammatory than organic foreign bodies. Apart from difficulty in breathing the patient can also present with change of voice, dysphagia, sore throat, etc., which are more common complaints in older age group. The risk of aspiration is greater in the presence of upper respiratory infections (URI) because of forceful inspiration following a sudden bout of cough. This can cause any material in oral cavity to be aspirated into the airways. Our 2 cases had URI, which predisposed them to foreign body inhalation. CONCLUSIONS
FIGURE 3. Radiograph of neck soft tissue. Lateral view showing radiopaque foreign body, a “crepe bandage holding metallic pin” (case 2).
146 | www.bronchology.com
In the middle-age group foreign body of the larynx are uncommon. URI may be a predisposing factor of foreign body larynx. Sudden development of hoarseness of voice should raise a suspicion of a laryngeal foreign body. The nature of foreign body of the larynx is variable and may be associated with occupational environment and habits of the patient. Early diagnosis and intervention is the key in such cases as
Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
J Bronchol Intervent Pulmonol
Volume 22, Number 2, April 2015
delay can lead to catastrophic complications and long-term sequelae. REFERENCES 1. Cohen SR, Herbert WT, Lewis GB Jr, et al. Foreign bodies in the airways. Ann Otol Laryngol. 1980;89: 437–442. 2. Kansara AH, Shah HV, Patel MA, et al. Unusual case of laryngeal foreign body. Ind J Otolaryngol Head Neck Surg. 2007;59:63–65. 3. McGuirt WF. Tracheobronchial foreign bodies. Laryngoscope. 1988;98:615. 4. DeRowe A, Massick D, Beste DJ. Clinical characteristics of aero-digestive foreign bodies in neurologically impaired children. Int J Pediatric Otorhinolaryngol. 2002;62:243.
Copyright
r
Laryngeal Foreign Bodies Among Adults
5. Gencer M, Ceylan E, Koksal N. Extraction of pins from the airway with flexible bronchoscopy. Respiration. 2007;74:674–679. 6. Yadav SPS, Singh J, Aggarwal N, et al. Airway foreign bodies in children: experience of 132 cases. Singapore Med J. 2007;48:850–853. 7. Dikensoy O, Usalan C, Filiz A. Foreign body aspiration: clinical utility of flexible bronchoscopy. Postgrad Med J. 2002;78:399–403. 8. Hada MS, Chadda V, Mishra P, et al. Unusual metallic foreign bodies in the larynx: two case reports. Indian J Pediatr. 2012;79:1100–1102. 9. Lima JA. Laryngeal foreign bodies in children: a persistent life threatening problem. Laryngoscope. 1989;99:415–420. 10. Ganguly SN, Reddy NS, Shrestha A, et al. Unusual case of laryngeal foreign body. J Coll Med Sci. 2010;6:45–46.
2015 Wolters Kluwer Health, Inc. All rights reserved.
www.bronchology.com |
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