International Journal of Pediatric Otorhinolaryngology Extra
Volume 6, Issue 3 , Pages 122-124, September 2011

Glottic foreign body in a child with pre-existing vocal cord paralysis and reflux laryngitis: A challenging diagnostic paradigm

Pediatric Otolaryngology, ENT Clinic BC Children's Hospital, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada

Received 23 April 2010; accepted 9 May 2010. published online 21 June 2010.

Article Outline

Abstract 

Purpose: To illustrate the challenge and approach to diagnosing a laryngeal foreign body (FB) in a child with pre-existing laryngeal pathology. Methods: Case report. The diagnosis of laryngeal FB was initially missed in a 21-month old-infant. Two weeks later, the child experienced worsening in symptoms. Results: Flexible laryngoscopy revealed the presence of a plastic object in the subglottis, which was then removed under general anesthesia. Conclusions: For children with pre-existing laryngeal pathology, a sudden unexplained worsening of laryngeal symptoms, particularly dysphonia and biphasic stridor, should prompt the clinician to consider the possibility of a thin, sharp laryngeal FB.

Keywords: Foreign body aspiration, Vocal cord paralysis, Reflux laryngitis, Laryngeal foreign body, Dysphonia

 

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1. Introduction 

The literature contains numerous reports of foreign body aspiration (FBA) in children under the age of 5 years, causing significant morbidity and mortality [1], [2], [3], [4]. FBA occurs frequently in toddlers, as they begin to stand, reach for objects and explore the surrounding environment through the oral route [5]. Children even under 1 year of age may aspirate crunchy fruits or vegetables or other objects left within their grasp.

The rates of FBA are still alarmingly high in many areas of the world. At British Columbia's Children's Hospital in Vancouver, Canada, standard public education efforts have not reduced the incidence of FBA [6]. In Crete and Israel, personalized public education campaigns, aimed towards children and adults, have been more successful [7], [8], [9]. Therefore, efforts are being focused on developing web-based videos and educational material to be implemented through schools, to induce sustainable improvement in preventing FBA [6].

Before the development of rigid bronchoscopy in the early 1900s, the mortality rate associated with foreign body inhalation was close to 50%, compared to less than 1% now [10], [11]. The morbidity associated with late diagnosis and delayed management of FBA constitutes a significant burden to patients and to the medical health system [12]. The sequelae associated with late diagnosis and delayed management of FBA include: asphyxia, atelectasis, chronic cough, granulation tissue, recurrent pneumonia and bronchiectasis, as well as failure to thrive [5], [12], [13]. Laryngeal foreign bodies are less common than bronchial foreign bodies. In a child with no fever or baseline laryngeal pathology, the sudden onset of stridor and dysphonia should raise the suspicion for thin, sharp laryngeal FB, particularly in the presence of witnessed choking episode. In a child with underlying stridor or dysphonia and the absence of witnessed choking incident, diagnosing a partially obstructing laryngeal FB is more challenging. This case illustrates the challenging diagnosis of FBA in a syndromic child with previous chronic dysphonia and stridor, emphasizing the importance of the clinical suspicion and the choice of appropriate diagnostic tests to establish the diagnosis.

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2. Case 

21-Month-old male with Klippel-Feil Syndrome, reflux laryngitis and left vocal cord paralysis presented with a 2-week history of worsening mild biphasic stridor, after undergoing elective uncomplicated rigid laryngobronchoscopy to rule out a posterior laryngeal cleft. Past medical history was significant for multiple intubations and two previous cardiac surgeries to correct an aortic coarctation and a ventricular septal defect. A few days after the rigid endoscopy, the patient had sudden worsening of his baseline dysphonia and stridor and developed a barking cough. Over the next 2 weeks, the patient's dysphonia, biphasic stridor and barking cough continued to worsen, despite treatment with a 6-day course of oral corticosteroids for presumed viral croup. He was not in respiratory distress, but did have increased work of breathing. When his mother mentioned that he had, in the previous few months, several times swallowed art craft materials, the possibility of laryngeal foreign body was considered. Of note, no choking episode had been witnessed by the patient's family.

Flexible laryngoscopy revealed a shiny, plastic object between his vocal cords. The patient was brought to the operating room, placed under general anesthesia, and a baby Benjamin anterior commissure laryngoscope was inserted. Ventilation was maintained through the side-channel of the laryngoscope. A butterfly-shaped plastic sticker was carefully removed from the glottis and subglottis, using an optical alligator forceps (Fig. 1, Fig. 2). Further assessment of the airway revealed spherical areas of granulation tissue in the anterior glottis and subglottis (Fig. 1). The granulation tissue was conservatively de-bulked using the CO2 laser, coupled to the microscope, using Otrivin-soaked neurosurgical gauze for homeostasis. A Storz rigid bronchoscope was then inserted to examine the trachea and bronchi and remove a small amount of blood from the main bronchi. There were no other airway foreign bodies. The patient tolerated the procedure well, with no complications. Within a few days, his laryngeal symptoms improved to their usual baseline.

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  • Fig. 1. 

    A view of the laryngeal foreign body being removed using an alligator forceps (A) and subsequent view showing inflammation and granulation tissue at the anterior and posterior glottis (B).

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3. Discussion 

Most airway FBs lodge in the bronchi rather than in the larynx or trachea [14]. Laryngeal FBs tend to be either very large, causing complete obstruction, or thin and sharp, causing partial obstruction of the larynx [15], [16]. Radiography does not rule out radiolucent laryngeal FBs reliably [12], [17]. Furthermore, some of the clinical presenting features of laryngeal FBs (“croupy” cough and biphasic stridor) may lead to the misdiagnosis as viral croup [18]. In one reported case, a thin, sharp laryngeal FB was misdiagnosed and mistreated as viral croup and reflux laryngitis for 1 year, leading to massive laryngeal granulation tissue and the need for temporary tracheotomy [1].

One distinguishing sign of thin, sharp laryngeal FB's is the presence of dysphonia, far more severe than typical for viral croup [18]. While rigid laryngobronchoscopy is diagnostic and therapeutic for bronchial and tracheal FBs, transnasal flexible laryngoscopy is usually diagnostic of thin, sharp laryngeal FBs [19], [20], [21]. If obstructive granulation tissue remains after removal of a thin, sharp laryngeal FB, careful de-bulking of the granulation tissue with the CO2 laser may be needed.

In this case, the diagnosis of laryngeal FBA was challenging because of the patient's pre-existing stridor and dysphonia, due to chronic reflux laryngitis and vocal cord paralysis. As the patient did not have worsening laryngeal symptoms until a few days after the initial, uncomplicated, diagnostic rigid laryngobronchoscopy, the worsening symptoms were thought to be more likely from viral croup rather than post-endoscopy laryngeal edema. As no choking episode had been witnessed, a laryngeal FB was not initially considered. It was the progressive worsening of the child's stridor and dysphonia (despite oral corticosteroid therapy), plus the fact that he had a tendency to swallow art craft materials, that raised the suspicion for a laryngeal FBA and prompted flexible laryngoscopy. In conclusion, although a laryngeal foreign body is unusual in a child with pre-existing laryngeal pathology, it should be considered if the child's stridor and dysphonia become suddenly worse.

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PII: S1871-4048(10)00037-7

doi:10.1016/j.pedex.2010.05.003

International Journal of Pediatric Otorhinolaryngology Extra
Volume 6, Issue 3 , Pages 122-124, September 2011

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