Introduction

Foreign bodies of the airway are a fairly

common condition, both in adults and

children. In children, aspiration or

ingestion of organic foreign bodies is a

common occurrence due to in-complete

development of dentition and their nature

of putting objects in mouth. Ingestion and

aspiration of foreign bodies can also occur

in adults due to impaired consciousness,

under the influence of alcohol or

carelessness. Rarely, metallic objects can

enter the neck through a puncture wound

and penetrate the airway. Blacksmiths,

workers in steel and metal factories are

under the risk of this occupational hazard.

We describe an unusual penetrating

foreign body in the larynx, which

presented without any airway complaints

and was removed endoscopically, without

resorting to neck exploration or a

tracheostomy.

Case Report A 20 year old male blacksmith suffered an injury to the neck by a metal splinter while working. The

metal splinter got lodged inside his neck. The patient

underwent a surgery for exploration of the neck at

another hospital where the splinter could not be

retrieved. The patient was referred to our institute

after ten days, with the complaint of pain in neck.

On examination, the patient was alert,

conscious and well oriented. He complained of pain

while breathing, but had no evidence of respiratory

distress or stridor. The use of accessory muscles of

respiration and suprasternal / subcostal retractions

was absent. Oxygen saturation was well maintained.

There was an external sutured wound on the neck

due to the previous exploration (Fig. 1).

Fig. 1: External wound due to previous exploration

A CT scan of the neck of the patient showed a

metal foreign body, which had pierced the larynx, and

was lying partially in the lumen, just below the vocal

*Senior Registrar, **Professor & Head, ***Assistant Professor, Dept. of ENT & Head-Neck Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai - 400 022.

Abstract

Diagnosis and management of airway foreign bodies is a challenge to

otorhinolaryngologists. Laryngeal foreign bodies can very often have a catastrophic

course. Surgical exploration of the neck has been routinely described for a

penetrating foreign body lodged in the larynx. There are very few cases reported of

endoscopic removal of such a foreign body. We describe a case wherein a metal

splinter was lodged in the larynx following penetrating trauma to the neck. We

performed a CT scan to localise the foreign body following which it was removed by

an endoscopic approach.

A Penetrating Neck Foreign Body Presenting in the Airway: a Diagnostic and Therapeutic Challenge

Tanvi A Lohiya*, Renuka A Bradoo**, Kshitij D Shah***

Bombay Hospital Journal, Vol. 57, No. 3, 2015 329

cords (Figs. 2 a, b and c)

Fig. 2a

Fig. 2b

Fig. 2c

Figs. 2 a, b, c: CT scan of Neck - axial, coronal and

sagittal - showing the foreign body

The patient was hospitalised and a rigid

bronchoscopy under general anaesthesia was

planned. Consent for an external approach was also

taken in the event that the foreign body could not be

extracted endoscopically.

The patient was intubated, the larynx exposed

using a 0 degree telescope with a McIntosh

laryngoscope. A metal splinter was seen lying

partially in the lumen of the subglottis just below the thtrue vocal cords. Almost 3/4 of the splinter, which

had entered externally and pierced the larynx, was thlying in the lumen while 1/ 4 was imbedded in the

wall. It was covered with slough and secretions (Figs.

3 a & b). A crocodile forceps was inserted along-side

the telescope, the splinter grasped and first

Fig. 3a: Endoscopic view of the foreign body (*)

Fig. 3b: Endoscopic view of removal with a forceps

delivered into the lumen of the larynx. It was then

trailed out under the direct vision of the telescope.

The patient was extubated and observed for

pneumothorax, pneumomediast inum and

subcutaneous emphysema.

The patient was given intravenous ceftriaxone (1

gm bd) for three more days and observed for

complications for one week and then discharged from

care.

Discussion

The management of a foreign body in

the airway has always been a challenge to

Otorhinolaryngologists. The presentation

of a foreign body depends upon the size,

shape, site, nature of foreign body, and the

degree of obstruction leading to a great

Bombay Hospital Journal, Vol. 57, No. 3, 2015330

1,2,3,4variability in symptoms. Complication

rates for bronchoscopy and the

laryngotracheal foreign body itself

increase with the duration of the foreign

body in situ.

The symptomatology of laryngeal

foreign bodies depends on whether it

produces complete or incomplete airway 5obstruction. In complete airway

obstruction, the presentation is with

catastrophic respiratory distress leading

t o a p n o e a , c y a n o s i s , l o s s o f

consciousness, and sudden death if

foreign body is not dislodged. However,

incomplete laryngeal obstruction may

present with less severe symptoms and

possible misdiagnosis or delay in

diagnosis.

A laryngeal foreign body causing

complete obstruction may not allow

enough time for detailed evaluation and

assessment of the patient, or X-ray. The

patient may be in acute respiratory

distress requiring a tracheostomy to

maintain airway, or a cricothyrotomy

depending on the urgency. In case of a

laryngeal foreign body causing incomplete

obstruction, detailed history and

evaluation is necessary. An X-ray neck AP

and lateral view can give important clues

to the diagnosis.

Penetrating foreign bodies in the neck

can be even more difficult to diagnose,

localise and subsequently treat. We think

it is very important to localise the foreign

body in the neck before planning a surgical

exploration. An exploration of the neck can

very often become 'a needle in a haystack'

exercise without proper localisation of the

foreign body. A multiplanar CT scan of the

neck is the best modality to accurately

localise a penetrating neck foreign body. It

also serves to diagnose any concomitant

pathology like an abscess formation in

relation to the foreign object as well as any

damage to the great vessels or the airway.

In case of a penetrating foreign body,

neck exploration has been described to

find the foreign body and remove it.

However, if the foreign body penetrates the

airway, then rigid bronchoscopy under

direct vision remains the gold standard for

the removal of such foreign bodies from the 6,7laryngotracheobronchial tree. The need

for this procedure can be on much of an

urgent basis as compared to a neck

exploration and the risk of this procedure

are much higher too. The anaesthetic

technique most favoured for rigid

bronchoscopic removal of laryn-

gotracheal foreign bodies is controlled

ventilation with intermittent apnoea

technique combined with intravenous 8drugs and paralysis.

T h e a d v e n t o f v e n t i l a t i n g

bronchoscopes and improvement in the

illumination and visualisation provided by

Hopkins telescope guided optical forceps

and the advances in anaesthesia have

reduced the mortality and greatly

facilitated the task of the endoscopist by

allowing simultaneous visualisation and

manipulation of the foreign bodies.

Flexible bronchoscopy compliments rigid

bronchoscopy and makes removal of

foreign bodies even safer and more 9,10complete.

Bronchoscopic extraction of foreign

bodies should however be performed with

surgical backup as surgical intervention

Bombay Hospital Journal, Vol. 57, No. 3, 2015 331

may occasionally be necessary. Efforts to

retrieve the foreign body should be well

coordinated and require close cooperation

between the surgical and anaesthetic

teams.

Conclusion

Penetrating neck foreign bodies can

often be tricky to localise. A CT scan is

paramount to accurately localise these

foreign bodies in order to avoid surgical

misadventures. The fact that these foreign

bodies can migrate to various organs

needs to be borne in mind. In case that the

foreign body migrates into the airway,

early treatment is imperative to prevent

morbidity and often mortality as well as to

prevent the complications of recurrent

acute respiratory distress, recurrent

pneumonia and pulmonary abscess. The

use of telescopes and bronchoscopes for

removal of a foreign body from the airway

decreases morbidity to the patient and has

become the go ld s t andard f o r

treatment.

References1. Mathiasen RA, Cruz RM. Asymptomatic near-

total Airway obstruction by a Cylindrical

Tracheal foreign body. Laryngoscope. 2005;

115:274-7.

2. Bloom DC, Christenson TE, Manning SC,

Eksteen EC, Perkins JA, Inglis AF, et al. Plastic

laryngeal foreign bodies in children: A diagnostic

challenge. Int J PediatrOtorhinolaryngol. 2005;

69:657-62.

3. Robinson PJ. Laryngeal foreign bodies in

children: First stop before the right main

bronchus. J Paediatr Child Health. 2003; 39:

477-9.

4. Zaytoun GM, Rouadi PW, Bali DH. Endoscopic

management of foreign bodies in the

tracheobronchial tree: Predictive factors for

complications. Otolaryngol Head Neck Surg.

2000; 123:311-6.

5. Jain S, Kashikar S, Deshmukh P, Gosavi S,

Kaushal A. Impacted laryngeal foreign body in a

child: a diagnostic and therapeutic challenge.

Ann Med Health Sci Res. 2013 Jul;3(3):464-6.

doi: 10.4103/2141-9248.117937. PubMed

PMID:24116337; PubMed Central PMCID:

PMC3793463.

6. Kaur K, Sonkhya N, Bapna AS. Foreign bodies in

the Tracheobronchial Tree: a prospective study

of fifty cases. Ind J Otolaryng and Head and Neck

Surgery. 2002; 54(1): 30-34.

7. Rodrigues JA. Bronchoscopic techniques for

removal of foreign bodies in children?s

airways. Paediatr Pulmonol. 2012; 47(1):

59-62.

8. Fidkowski CW, Zheng H, Firth PG. The

anesthetic considerations of tracheobronchial

foreign bodies in children: A literature review of

12,979 cases. Anesth Analg. 2010;111:1016-25.

9. Korlacki W, Koreka k, Dzielicki J. Foreign body

aspiration in children: diagnostic and

therapeutic role of bronchoscopy. Pediatr Surg

Int. 2011; 27(8): 833-7.

10. Surka AE, Chin R, Comforti J. Bronchoscopic

Myths and Legends; Airway Foreign

Bodies.Clinical Myths and Evidence-based

Medicine. 2006; 13(3): 209-211.

Bombay Hospital Journal, Vol. 57, No. 3, 2015332

Drug-eluting stents-SORTed

In The Lancet, Bent Raungaard and colleagues report the 12-month results of SORT OUT VI, which compared two drug-eluting stents, the durable-polymer coated zotarolimus-eluting Resolute Integrity stent and the biodegradable-polymer-coated biolimus-eluting Biomatrix Flex stent.

Large, adequately powered, long-term studies are needed to capture the natural history of the processes initiated by stent deployment and to investigate whether there are important differences between drug-eluting stents. Assessment of the primary endpoint at 2 or 3 years might be most useful clinically, with prespecified overall follow-up of 5 years or longer to allow time for possible benefits, such as reduced shear stress or vessel-wall inflammation, to manifest themselves clinically.

Mark W I Webster, John A Ormiston, The Lancet, 2015, Vol 385, 1487-1489

Page 1Page 2Page 3Page 4