Tracheobronchial foreign body (FB) can be a life-threatening event that often requires immediate intervention. Its impaction in the larynx, however, is very uncommon, occurring in approximately 4% of all patients with FB aspiration. Laryngeal FB is especially encountered in older people.1
Clinical history helps in the diagnosis as adults can relate to the history more precisely than children. The clinical signs and symptoms may range from mild distortion of the voice to an airway emergency, the latter requiring lifesaving first aid, such as the Heimlich maneuver. Rima glottis is the narrowest part of the adult airway and it is a sagittal plane, common site for foreign body impaction. However, a foreign body having a sharp or irregular shape can get lodged in the larynx.1 Kansara and colleagues reported an unusual case of laryngeal foreign body presenting with sudden loss of voice of 6 days’ duration. There was no history of trauma or fever. Indirect laryngoscopy revealed a shiny material attached to left vocal cord.2 We would like to present 2 such unusual cases of foreign body aspiration in adults.
A 45-year-old man presented with a sudden onset of change in his voice without any respiratory difficulty after accidental ingestion of a coin. The patient was a bus conductor and was suffering from upper respiratory infection for 5 days and accidentally ingested the coin kept in his mouth following a bout of cough. On indirect laryngoscopy the coin was seen sitting vertically between the 2 vocal cords. The presence of the coin was also seen on the roentgenograms of the neck [anteroposterior (Fig. 1); and lateral views (Fig. 2)]. A direct laryngoscopy was performed under general anesthesia (GA) and the coin was found impacted in the sagittal plane between the vocal cords. It was disimpacted and successfully removed. Postoperative period was uneventful with immediate recovery of the symptoms.
A 42-year-old man presented with accidental inhalation of a crepe bandage holding a metallic pin, followed by hoarseness and foreign body sensation in the throat with mild difficulty in breathing. Indirect laryngoscopy and radiologic examination (Fig. 3) revealed a radiopaque foreign body in supraglottic and glottic larynx. Metallic pin was removed by direct laryngoscopy under GA. Postoperative period was uneventful.
Impaction of foreign body in the larynx is a rare condition, children are more susceptible but it is uncommon in adults.
Extremes of age group are most susceptible to foreign body aspiration because of: (A) the lack molars necessary for proper grinding of the food, (B) poor coordination of the swallowing and decreased laryngeal movements and glottic closure, and (C) inadequate cough reflex.3 Older children and adolescents may have an anatomic abnormality or a neurologic impairment, which may result in foreign body aspiration.4
Most commonly aspirated foreign bodies are organic materials such as nuts and seeds in children and food and bones in adults.5 Inhalation of metallic foreign body is very uncommon. Yadav et al6 in their study of 132 patients reported that only 6 (4.5%) cases had aspiration of a metallic foreign body. In both our cases, a metallic foreign body was found impacted in the larynx. Cultural and regional differences can lead to variations in foreign body aspiration. Specific adult lifestyle and profession may predispose to unusual types of aspiration.7,8 In our case 1, the patient was a bus conductor with a habit of keeping coins in his mouth, which made him susceptible to inhalation of coin. In the second case he inhaled a crepe bandage holding pin while wrapping the bandage around his hand with keeping pin in mouth.
The spectrum of presentation varies widely, ranging from sudden death due to respiratory obstruction to accidental finding during routine investigation. Lima9 in a review of 91 inhaled foreign bodies, found 11 to be true glottis, 5 of 11 had fatal outcome and transient hypoxic encephalopathy occurred in 3 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.10 However, both of our patients presented with only change in voice without difficulty in breathing with clear-cut history of aspiration that helped to establish the diagnosis early. In case 1, a coin was lying in sagittal plane causing partial obstruction. In addition, the foreign body was metallic in nature, which is less inflammatory than organic foreign bodies. Apart from difficulty in breathing the patient can also present with change of voice, dysphagia, sore throat, etc., which are more common complaints in older age group. The risk of aspiration is greater in the presence of upper respiratory infections (URI) because of forceful inspiration following a sudden bout of cough. This can cause any material in oral cavity to be aspirated into the airways. Our 2 cases had URI, which predisposed them to foreign body inhalation.
In the middle-age group foreign body of the larynx are uncommon. URI may be a predisposing factor of foreign body larynx. Sudden development of hoarseness of voice should raise a suspicion of a laryngeal foreign body. The nature of foreign body of the larynx is variable and may be associated with occupational environment and habits of the patient. Early diagnosis and intervention is the key in such cases as delay can lead to catastrophic complications and long-term sequelae.
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