Glottic foreign bodies in infants: A series of four cases

doi:10.4236/crcm.2013.26092

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Vol.2, No.6, 341-344 (2013) Case Reports in Clinical Medicine

http://dx.doi.org/10.4236/crcm.2013.26092

Glottic foreign bodies in infants: A series of

four cases

Aayush Mittal1*, Rahul Bhargava2, Sunil Kumar2, Jatinder Kumar Sahni2

1Department of Otorhinolaryngology-Head & Neck Surgery, Hind Institute of Medical Sciences & Shekhar Hospital, Lucknow, India;

*Corresponding Author: aayush_mittal@yahoo.com

2Department of Otorhinolaryngology-Head & Neck Surgery, Lady Hardinge Medical College, New Delhi, India;

dr.rahul.bhargava@gmail.com, suku321@rediffmail.com, drjksahni@yahoo.co.in

Received 9 July 2013; revised 5 August 2013; accepted 12 August 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Foreign body in glottis especially in infants is

rare. Retrieval of foreign body is a rather simple

procedure but sharing of the airway with the

anaesthetist and impeding complication makes

it more challenging and dangerous. Making a

diagnosis of foreign body is most challenging in

delayed cases. Complete history and detailed phy-

sical examination along with high index of sus-

picion, in cases of persistent cough, fever, non-

resolving respiratory infection, are needed to

rule out airway especially laryngeal foreign body.

This series of 4 cases is being reported because

of the rarity of the glott is fore ign b od y in infants.

Keyw ords: Foreign Body; Bronchoscop y ; Infant;

Glottis

1. INTRODUCTION

Aspiration of foreign bodies in trachea-bronchial tree

is common. Most patients are younger than 4 years old

[1]. In literature, incidence of foreign body of the larynx

has been reported from 0.7% to 6.1% among all aero-di-

gestive foreign bodies [2-4]. Delay in diagnosis of the

foreign body in airway has the potential to make a diffi-

cult situation even more serious [5].

2. PATIENTS AND METHODS

We reviewed the data of 79 patients with suspected

history of foreign body aspiration who presented to the

ENT casualty and pediatric emergency during a period of

one year from August 2011 to August 2012.

3. RESULTS

In 6/79 (7.59%) patients foreign bodies were retrieved

from glottis, in among these 4/6 (66.67%) patients were

under the age group of one year. All the four patients

presented with the complaint of breathing difficulty of

two days to two months duration (Table 1). Two of them

had a history of choking and change in voice while two

of them had a history of coughing and cyanosis. One of

the patients was being treated for upper respiratory tract

infection in some peripheral hospital with antibiotics and

nebulisation for two months. Another patient was re-

ferred from the pediatric department for non-resolving

respiratory distress of more than one week, the child had

undergone fibreoptic laryngoscopy and was reported to

be normal.

On examination all children were having respiratory

distress of varying proportion however apparent suprast-

ernal and intercostal retractions with biphasic stridor was

present in 2 of the patients. Children were afebrile hav-

ing no cyanosis. No abnormal cry or palpatory thud was

noted over the trachea in any case. On auscultation bilat-

eral air entry was equal in all cases with conducted sound

in 2 cases. Rest of ENT examination as well as systemic

examination was unremarkable.

Routine haematological and urine examinations were

normal. X-ray of antero-posterior and lateral view of soft

tissue neck revealed foreign body in the larynx in only

three patients (Figure 1). Considering the possibility for-

eign body these children were subjected to microlaryn-

goscopy/bronchoscopy under general anesthesia on emer-

gency basis.

During the anesthesia, the children were induced using

inhalational sevoflurane only with oral mask. No endo-

tracheal tube was introduced throughout the procedure.

Under deep inhalational anesthesia, direct laryngoscopy

was done with videolaryngoscope and the foreign body

was visualised entrapped in the endolarynx (Figure 2),

which were removed using the appropriate forceps. The

retrieved foreign bodies included a triangular piece of

A. Mittal et al. / Case Reports in Clinical Medicine 2 (2013) 341-344

342

glass, foil of the strip of medicine, a piece of plastic toy,

buckle of belt (Figure 3). Check bronchoscopy was done

after the foreign body removal which was unremarkable

in all except in patient with long standing complaints

(Patient No 1) where raw areas on both cords at middle

third were observed. Subsequently, all children were ob-

served for overnight for any complication. Post-operative

period was uneventful and children were discharged on

Table 1. Demographic profile of cases of foreign body larynx.

S. No. Age/sex Symptoms Duration of symptoms Type of foreign body

Patient 1 11 m, male Breathing difficulty, change of voice, choking 2 months Triangular glass piece

Patient 2 8 m, male Breathing difficulty, change in voice 2 days Foil of strip of medicine

Patient 3 5 m, female Weak cry, breathing difficulty, cyanosis 5 days Piece of plastic toy

Patient 4 9 m, male Breathing difficulty, choking, cough Few hours Buckle of belt

Figure 1. X-Ray Soft tissue neck Lateral view showing the foreign body (FB).

(A) Triangular glass piece; (B) Buckle of belt.

Figure 2. Foreign body (FB) covering the entire glottic chink.

A. Mittal et al. / Case Reports in Clinical Medicine 2 (2013) 341-344 343

Figure 3. Retrieved foreign bodies. (A) Triangular glass piece; (B) Pieces of plastic toy; (C)

Foil of strip of medicine; (D) Buckle of belt.

next day without any medication.

4. DISCUSSION

Foreign body larynx is not a common occurrence.

Brkić [2], Lemberg [3], and Bittencourt [4] reported its

incidence from 0.7% to 6.1% amongst all aero-digestive

foreign bodies. It is prudent to diagnose aero-digestive

foreign bodies as early as possible to minimize potential

life-threatening complications in particular glottic for-

eign body. However, in many cases it is not easy to make

the diagnosis as classical symptoms of choking, wheez-

ing, and decreased breath sounds are absent [6]. The de-

lay in diagnosis is attributable to patients’ behaviour or

circumstances where aspiration was unwitnessed [7].

Once the anaesthesia along with muscle relaxants is

given, foreign body might fall down to subglottis or tra-

chea which is a more difficult area to deal with.

The present case series reviews the prevalence of for-

eign body entrapped in the glottis in children, their pres-

entation and duration of symptoms, and various types of

foreign bodies encountered during their retrieval.

Making a diagnosis of foreign body is most challeng-

ing in delayed cases [5]. Complete history and detailed

physical examination along with high index of suspicion,

in cases of persistent cough, fever, non-resolving respira-

tory infection, are needed to rule out airway especially

laryngeal foreign body. It also requires prior discussion

and delibuation with anaesthetist due to potential diffi-

culty and complication that might occur during the pro-

cedure so that everybody in operating room is mentally

prepared for the worst.

REFERENCES

[1] Holinger, L.D. (2007) Foreign bodies of the airway. In:

Kliegman, R.M., Behrman, R.E., Jenson, H.B. and Stan-

ton, B.F., Eds., Nelson Textbook of Pediatrics, 18th Edi-

tion, Saunders Elsevier, Philadelphia, 1769-1770.

[2] Brkić, F., Delibegović-Dedić, S. and Hajdarović, D.

(2001) Bronchoscopic removal of foreign bodies from

children in Bosnia and Herzegovina: Experience with 230

patients. International Journal of Pediatric Otorhinola-

ryngology, 60, 193-196.

doi:10.1016/S0165-5876(01)00531-6

[3] Lemberg, P.S., Darrow, D.H. and Holinger, L.D. (1996)

Aerodigestive tract foreign bodies in the older children

and adolescent. Annals of Otology, Rhinology, and Laryn-

gology, 105, 267-271.

[4] Bittencourt, P.F.S., Camargos, P.A.M., Scheinmann, P.

and de Blic, J. (2006) Foreign body aspiration: Clinical,

radiological findings and factors associated with its late

removal. International Journal of Pediatric Otorhino-

laryngology, 70, 879-884.

doi:10.1016/j.ijporl.2005.09.024

[5] Franzese, C.B. and Schweinfurth, J.M. (2002) Delayed

diagnosis of a pediatric airway foreign body: Case report

and review of the literature. Ear, Nose & Throat Journal,

81, 655-656.

A. Mittal et al. / Case Reports in Clinical Medicine 2 (2013) 341-344

344

[6] Reilly, J., Thompson, J., MacArthur, C., Pransky, S., Be-

ste, D., Smith, M., et al. (1997) Pediatric aerodigestive

foreign body injuries are complications related to timeli-

ness of diagnosis. Laryngoscope, 107, 17-20.

doi:10.1097/00005537-199701000-00006

[7] Esclamado, R.M. and Richardson, M.A. (1987) Laryn-

gotracheal foreign bodies in children, a comparison with

bronchial foreign bodies. American Journal of Diseases

of Children, 141, 259-262.