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Unusual case of laryngeal foreign body

S.N. Ganguly1, N.S. Reddy2,  A. Shrestha3,  D. Shah4,  N. Shakya5,  S. Acharya 6

1,2Professor, 3Lecturer, 4,5,6 Residents Department of ENT , College of Medical Sciences, Bharatpur, Nepal

Abstract:

The foreign bodies in respiratory tract have been major cause of morbidity and present as challenge

to otolaryngologist. The spectrum of presentation varies widely from sudden death due to respiratory

obstruction to accidental finding during routine investigation. One case of unusual  presentation of laryngeal

foreign body with loss of voice is described here.

Key words: Respiratory obstruction laryngeal, foreign body,.

Introduction

Laryngeal foreign body is less common than

bronchial foreign body and is potentially dangerous.

The foreign bodies in respiratory tract usually occurs

as an emergency. Diagnosis is made by clinical and

radiological examination. The foreign body in larynx

needs quick intervention. Due to delayed intervention,

most of the complications including death may occur.

Laryngeal impaction of foreign body is rare, as most

aspirated foreign bodies pass through laryngeal inlet

and get lodged down in the airway. Here we report a

rare case of laryngeal foreign body presented as

hoarseness of voice.

Case report:

A female patient aged 29 years, from Chirchisae

Nawalparasi-8 lumbini admitted to C.M.S .T.H.

Bharatpur on 27.02.09 with history of blood mixed

sputum and change of voice for last 2 months.

Breathlessness was also there which was felt more when

she lied  down on supine position. She had also feeling

of something moving in the throat. There was no history

of  trauma, fever, stridor or pain in the throat. Indirect

Laryngoscopy and Nasopharyngeal laryngoscopy

(Flexible) showed one thick black colour leech visible

in glottic chink, which was moving. Detailed history

revealed that she used to go to the forest to bring wood.

She used to drink river water present in the forest which

may have contained leech. During interrogation it was

found that she had taken many medicines for change

of voice and feeling of something moving in throat. She

was taken to O.T. and direct laryngoscopy was done.

An alive leech which was seen coming out of laryngeal

inlet which was grasped with forceps and pulled out..

It was about 5cm long and 1.5 cm thick. Post

procedure antibiotic was given and followed up. The

patient regained her voice within 2 days and had no

complaints.

Pathology

Foreign body can settle in hypopharynx (5%)

larynx (2-9%), trachea (12%) or bronchus (83%). The
Correspondence: Dr. S.N. Ganguly

E-mail:soumen_ganguli@yahoo.co.in

Case Report, 45-46Journal of College of Medical Sciences-Nepal, 2010, Vol. 6, No. 1

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airway obstruction may he partial or complete. Partial

obstruction occurs when the upper airways are partially

occluded or obstruction is distal to carina.

Patient may present within weeks to months after

foreign body aspiration. Most foreign body lodge in

periphery, distal to Larynx or Trachea. However

foreign body having a sharp or irregular body gets

lodged in larynx or Trachea .1,2

Discussion

 In 1897 Gustav Killer removed a foreign body

from lower respiratory Tract with a rigid bronchoscope.

During 1st past of 20th century Chevalier Jackson

perfected endoscopic technique The incidence of

foreign bodies in the airway is around 0.60% among

the total foreign bodies. This is due to protection of

the airway with epiglottis, arytenoid and coughing

reflex.3

Foreign bodies are most common in children up to

3-4 yrs.1,3,4  The incidence is between 55-75% .This is

because children in that age group  are curious in nature,

have strong oral tendency and  no molar teeth. 1,3,4

Laryngeal foreign bodies as such are very rare as most

inhaled objects pass into bronchus.5

Lima et al 6 in a review of 91 inhaled foreign bodies,

found 11 to be true glottic. 5 out of 11 had fatal outcome

and transient hypoxic encephalopathy occurred in 3

patients.

     Rothman et al 2 found only 5 cases of laryngeal

foreign bodies in a series of 225 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.7

Ambu et al 8  have reported a case of one and half

month neglected laryngeal foreign body in 3 years old

boy. Delay in diagnosis was because there was no

symptom suggestive of a foreign body in airway

passage. On plain x-ray of neck a bird bone was

detected. Tracheostomy was required due to

granulation tissue. A  Part of bone was removed by

direct laryngoscopy and remaining part through

tracheostomy.

Metallic foreign bodies in the larynx are rare and

safety pin is commonly detected. Hussain et al 9

reported a case of open safety pin in the larynx in a 6

month old boy.

Vian et al 7 described the use of high frequency jet

ventilation to maintain gaseous exchange in a 16 month

old child who  had impacted  safety pin in the larynx

which was  removed by a tracheostomy.

 Bhatt et al 10 reported an unusual foreign body in the

larynx in an 18 month old baby who presented with

two days history of fever, refusal of feeds and stridor.

History of foreign body inhalation, cough and choking

was absent. Radiological investigation revealed the

pathological finding. Initial diagnosis of croup was

made. The child was given antibiotics, adrenaline

nebulization and  parenteral fluid. General condition

improved but stridor (Inspiratory) persisted. ENT

consultation was sought and endoscopy revealed

artificial fingernail lodged between the vocal cords.

Stridor improved after removal of foreign body.

Man  et al 11 reported an unusual case of laryngeal

impaction of cervical vertebra of a toad in an infant.

This was diagnosed with C.T.scan as  more

conventional methods failed to diagnose.

Kansara et al 12 reported an unsual case of laryngeal

foreign body presented with sudden loss of voice since

6 days. There was no history of trauma or fever. Indirect

laryngoscopy showed shiny material attached to left

cord Direct laryngoscopy was passed and with forceps

the foreign body was carefully removed.

S.N. Ganguly et al. Unusual case of laryngeal foreign body

45



Bakshi et al 13 reported two interesting cases in

which the diagnosis of foreign body in the larynx was

not suspected preoperatively. A three and half year

old female child was diagnosed as a case of bronchitis

and was later found to have a metallic spring in the

supraglottic region which was removed by direct

laryngoscopy under general anesthesia. The other

patient, a 32-year-old male, was diagnosed to have a

fibrous lesion in the larynx one year previously, and on

laryngoscopy a vegetable, speculated foreign body was

found after excising the fibrous lesion on the left false

cord. Both the cases are symptom free 18 months after

endoscopy.

Conclusion

Unusual foreign body like the case which we reported

may miss the diagnosis as there was no history of

respiratory symptom. Moreover, the foreign body was

radiolucent. Complete detailed history helps to detect

such case. It is important to diagnose the case as early

as possible, so that there may not be any catastrophe.

Acknowledgement

We are thankful to the superintendent of C.M.S-T.H,

Bharatpur, Nepal for publication of this article.

Fig-1

 ……………………………………………………………………………………

Black colour Leech visible in the glottis.

 References:
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