| | Removal of longstanding laryngopharyngeal foreign bodies from three childrenReceived 17 December 2008; received in revised form 15 March 2009; accepted 20 March 2009. published online 04 May 2009. Summary Impaction of a foreign body in the laryngopharynx is a rare but serious event, due to the potential for complete laryngeal obstruction and associated high mortality. Children with positive aspiration histories and typical symptoms are generally admitted to an ear, nose and throat department, where the foreign body can be promptly extracted. However, those children with atypical symptoms and/or with no history of foreign body aspiration noted by their caregivers are often misdiagnosed, and treatment is therefore delayed, leading to the development of complications. The presence of longstanding foreign bodies may cause tissue hypertrophy and the development of granulation tissue, making diagnosis and treatment more difficult. There have been few reports of longstanding laryngopharyngeal foreign bodies in the literature. In this report, we present our experience in dealing with longstanding laryngopharyngeal foreign bodies in three children. Introduction  The inhalation of foreign bodies into the respiratory tract occurs most frequently in children, with a higher incidence in boys [1], [2], [3], [4], [5]. Food is the most common type of foreign body to be aspirated, but common household and non-food objects, such as metals and plastics, rocks, coins, toys or parts of toys, are also sometimes inhaled [6], [7], [8]. In a review of 20 cases with inhaled laryngotracheal foreign bodies, 90% of the patients had a history of choking or aspiration [9], [10], [11]. The common presenting symptoms were stridor, wheezing, sternal recession, and cough [9]. Patients with foreign bodies are usually promptly admitted to hospital. After accurate diagnosis and localization by X-ray examination and laryngoscopy, the foreign bodies are easily extracted by bronchoscopy, assuming no formation of granulation tissue. In most cases, endoscopic-assisted removal of foreign bodies was the immediate treatment approach used. Foreign bodies might lodge in the hypopharynx (5%), larynx (2%), trachea (10%), or bronchus (83%) [12], [13]. The chances of foreign bodies lodging in the hypopharynx and larynx are therefore rare, but these laryngopharyngeal foreign bodies are especially life-threatening due to their potential to cause sudden, complete respiratory obstruction. However, if the foreign body is annular, hollow or irregular in shape and so unable to completely block the glottis, it can move within the respiratory tract due to the strong airflow caused by coughing or vomiting. It can therefore settle in a position allowing adequate airflow, so resulting in atypical symptoms. Diagnosis in these patients may be delayed without direct evidence of aspiration. Generally, the longer a foreign body stays in the laryngopharynx, the more it stimulates the surrounding tissues. The foreign body then gradually becomes encapsulated by hyperplastic granulation tissue. Respiratory compromise subsequently develops and becomes conspicuous over the following months. There are few reports concerning the treatment of longstanding laryngeal foreign bodies. We treated three children who were suffering from longstanding laryngopharyngeal foreign bodies, with intervals between inhalation and presentation ranging from 7 months to 3 years (mean 17 months). When they were admitted to our department, the foreign bodies were found buried within granulation tissue and were difficult to remove. We used a CO2 laser and a Xomed XPS powered laryngeal shaver with a Skimmer laryngeal blade (Medtronic Model 2000 power system, Medtronic Xomed, Jacksonville, FL) to separate and excise the granulation tissue under a microscope. The patients included two boys, aged 7 and 9 years, and one girl, aged 14 months. In these patients, intubation though the larynx was difficult due to the impaction of the foreign bodies in the laryngopharynx and the associated granulation tissues. Preoperative tracheotomies were therefore necessary. In two patients, the operation was performed using a CO2 laser, while a powered laryngeal shaver was used in the other patient. Case reports Case 1 Case 1 was a boy aged 7 years who had aspirated a metal foreign body 3 years earlier. He developed coughing and vomiting for several minutes after aspiration, but subsequently only complained of a little pain on swallowing, which his parents did not consider to be significant. Two years later, he developed progressively worsening hoarseness, snoring and sleep apnea. When he presented to our hospital, a neoplasm of the left false vocal fold blocking the glottis was found by pedo-fibrolaryngoscopy examination (Fig. 1). A high-density annular object was detected beside the pre-epiglottic space by computed tomography (CT) scan (Fig. 2). A preliminarily diagnosis of a foreign body in the larynx was made. A preoperative tracheotomy was performed prior to surgery and the tracheal cannula was attached to the anesthesia machine. The patient was then placed supine on the operating table with his neck extended by placement of a shoulder roll. The epiglottis and the laryngeal ventricle were exposed using a pedo-support laryngoscope. An irregularly shaped neoplasm with a smooth surface was found on the left false vocal fold, blocking the glottis. The neoplasm was grasped using a micro-instrument, exposing a metal foreign body buried within it. The foreign body was clamped, separated and extracted successfully using micro-pincers It was a ring-shaped iron wire impacting at the base of the epiglottis and extending to the left vocal cord. The neoplasm was comprised of the surrounding granulation tissue. The powered laryngeal shaver was used to excise the granulation tissue after which bleeding was stopped by applying a cotton ball soaked in 1:1000 epinephrine to the site. The patient was discharged with a tracheal cannula to prevent regrowth of the granulation tissue. One month later, the granulation tissue had completely disappeared and the cannula was removed. Case 2 Case 2 was a boy aged 9 years who presented with hoarseness, stridor and apnea, and who had aspirated a plastic button 1 year earlier. He had experienced a choking spell at the time, but had since appeared perfectly healthy, except for occasional stridor and dyspnea. His parents thought he had a cold and referred him to a local clinic. He had been treated for pneumonia, a common cold and asthma, with antibiotics, steroid hormones, and other treatments. These treatments occasionally produced some improvements, but the problems persisted. One year later, the child was admitted to our hospital, where a chest X-ray examination showed increased pulmonary markings with no occupying lesion, and the bronchus and lung fields were normal. No foreign body was detected except for local swelling of the mucus of the larynx, detected by CT scan. A white foreign body was detected just below the glottis using an electronic laryngoscope examination (Fig. 3). A preoperative tracheotomy was performed. The child was positioned and a pedo-support laryngoscope was employed, as in the previous case. Using the microscope, a white plastic foreign body was visible just below the glottis, with less granulation tissue than in Case 1. The foreign body was successfully removed using micro-pincers and was identified as a white plastic conduplicate button, with the tip of one side stuck into the mucus under the vocal cords. A CO2 laser was used to excise the granulation tissue. The boy recovered quickly and resumed normal activities, and was decannulated on postoperative day 3. Using the electronic laryngoscope examination, most of the larynx was found to be normal, except for a small projection on the anterior wall under the glottis. The patient was discharged the following day. Case 3 Case 3 was a girl aged 14 months, weighing 5.5 kg, with a 7-month history of bucking while feeding, stridor, and dyspnea. Her mother had found her crying 7 months earlier with sialorrhea and dyspnea. The infant had been listless, and had refused to eat since then. She was admitted to the local hospital, where a chest X-ray failed to detect any foreign bodies or inflammation. Medical treatment with antibiotics and anti-inflammatory was ineffective. She was weak and dystrophic when she was referred to our department. A pedo-fibrolaryngoscopic examination revealed a foreign body in the hypopharynx (Fig. 4). A neck X-ray also revealed a 1.8-cm diameter high-density tubiform foreign body in the laryngohypopharynx (Fig. 5). Surgery was performed and an annular metal object was found encircling the epiglottis, inset into the aryepiglottic fold. Local hyperplastic granulation tissue was tightly attached to the foreign body. The adhesion zone was cut off using a CO2 laser and the foreign body was then removed. The remaining granulation tissue was excised and the wound surface was coagulated using a CO2 laser, as in Case 2. The foreign body was a thimble, corroded on the outside. The epiglottis had been transformed due to pressure from the thimble for almost 7 months. The infant underwent pedo-fibrolaryngoscopy on postoperative days 3 and 13, which showed gradual regression of tissue swelling around the epiglottis. On postoperative day 14, the patient was decannulated. However, dyspnea reappeared the next day, and a second tracheotomy was performed. This recurrence may have been due to the long-term pressure on the epiglottic, arytenoid and tracheal cartilages, leading to chondromalacia and hypochondroplasia, making the symptoms such as dyspnea more severe without the support of the metal thimble. She was later discharged with a tracheal cannula. Over the following 6 months, she gained 12kg in weight, and pedo-fibrolaryngoscopic examination showed that the larynx had almost returned to normal, and she was successfully decannulated. Discussion Aspiration of foreign bodies into the respiratory tract, especially in children, is a common emergency in clinics. It may lead to a wide range of clinical symptoms, from sudden acute respiratory distress to vague respiratory symptoms, presenting months or sometimes years after inhalation of the object [9]. Alternating complete and incomplete airway obstruction can occur. Patients may present weeks, months or even years, after the foreign body aspiration. If the incident is not witnessed, patients with atypical symptoms might be misdiagnosed and treatment therefore delayed. Detailed examination is helpful for detecting such cases and avoiding misdiagnoses. The ages at inhalation ranged from 7 months to 8 years in our cases. To the best of our knowledge, there have been few other reports of foreign bodies buried in the larynx for such long periods, with the consequent development of surrounding granulation tissue. Preoperative diagnostic examinations including pedo-fibrolaryngoscopy, electronic laryngoscopy, CT or laryngeal X-rays were helpful in diagnosing the presence of longstanding foreign bodies. Pedo-support laryngoscopy was useful for exposing the laryngeal and foreign bodies, and preoperative tracheotomy was recommended. General anesthesia was considered to be the safest option during surgery. Magnification of the foreign bodies using a microscope made the surgery much easier. The use of a CO2 laser also has advantages, including improved accuracy and safety, and efficient hemostasis. Use of these techniques allows the best therapeutic effects to be obtained with few injuries or complications. Prevention is the best strategy for dealing with these types of injuries, and more attention should therefore be paid to educating caregivers. References [1]. [1]Eren S, Balci AE, Dikici B, Doblan M, Eren MS. Foreign body aspiration in children: experience of 1160 cases. Ann. Trop. 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[13]. [13]Diop EM, Tall A, Diout R. Laryngeal foreign body: management in children in Senegal. Arch. Pediatr. 2000;7(1):10–15. a Department of Otolaryngology, Xijing Hospital, The Fourth Military Medical University, 17 West Chang Le Road, Xi’an, Shaanxi Province 710032, PR China b Department of Anaesthesiology, Xijing Hospital, The Fourth Military Medical University, 17 West Chang Le Road, Xi’an, Shaanxi Province 710032, PR China  Corresponding author. Tel.: +86 29 84776147; fax: +86 29 83218039.
PII: S1871-4048(09)00022-7 doi:10.1016/j.pedex.2009.03.004 © 2009 Elsevier Ireland Ltd. All rights reserved. | |
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