Sir,
Aero-digestive foreign body aspiration is relatively a common occurrence in pediatric age group. In airway, right bronchus is the most common location for a foreign body while it is least common in larynx.[1] Children accidentally place them in aero-digestive tract during ingestion, inhalation, or manual insertion.[2] The clinical symptoms depend upon the size, material, and location of the object and can vary from mild symptoms of coughing, hoarseness, wheeze, stridor, complete obstruction, cyanosis, or even death. The object can be radiopaque or radiolucent; the size and exact location of which can be detected after appropriate imaging studies.
A 2-year-old boy presented to the pediatric emergency with complaints of hoarseness of voice and difficulty in breathing from last two days. The parents denied of any history of foreign body ingestion. On examination, his respiratory rate was 40/min, heart rate was 152/min along with the presence of inspiratory and expiratory wheeze and stridor. He was maintaining an oxygen saturation of 88% on room air and 95% on oxygen via oxymask. The neck X-ray showed presence of a linear structure at the level of subglottic region on antero-posterior (AP) view [Figure 1], but the same was not visible on lateral view, which created confusion about the actual presence of a foreign body. Rigid bronchoscopy was planned due to the high suspicion of foreign body in neck. After attaching the standard American Society of Anesthesiologist monitors and keeping emergency airway cart ready, anesthesia was deepened with inhalational agent Sevoflurane and the child was kept on spontaneous ventilation. Just a bit down the glottis, a glass like structure was visualized. When we tried to hold and remove the same, it broke into two more pieces. All of them were removed meticulously under vision. They were found to be pieces of thin transparent glass like plastic or plexiglass. The child was then intubated with a smaller endotracheal tube of size 3.5 mm and kept on overnight elective mechanical ventilation to avoid complications secondary to subglottic edema. The child was extubated upon satisfying extubation criteria and observed in high dependency unit for 24 hours before being discharged.
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Figure 1: Neck X-ray AP view showing linear image of foreign body
There are several causes of respiratory distress in children and without proper history; coming to a diagnosis is difficult for which radiological imaging is essential. In our case, where the finding of AP view was not corresponding to its lateral view, it raised suspicion in our mind that it can be due to the specific orientation of the object relative to X-ray beams, which created a radiopaque line in AP view while, no image in lateral view. It is now recognized that a glass foreign body can be easily visualized in conventional X-ray and computarized tomography (CT) scan;[3] however, plexiglass is actually a glass like plastic which may be undetectable in CT. Ultrasound and magnetic resonance imaging (MRI) are valuable tools if an object is occult on X-ray/CT.[3] Point-of-care ultrasound (POCUS) of the airway is a bedside investigation and can be performed easily, which shows plastic foreign body as a hyperechoic image.[3] POCUS obviates the need of shifting the sick patient for costly investigations like CT also avoiding radiation hazard and MRI which is time consuming and requires expertize.
The pediatric airway is funnel shaped with sub-glottis being the narrowest part of the airway. Lima has classified laryngeal foreign bodies into two types: one is bulky, irregular, round, or cylindrical which are large enough to cause complete airway obstruction and sudden death, the other type is thin, laminar, triangular which are less commonly associated with complete obstruction.[4] The laminar objects most commonly cause stridor or hoarseness similar to one seen in our case.[5] In any case the initial partial obstruction may get converted into complete obstruction, so timely and prompt approach is the key to prevent any catastrophe from occurring.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
References
1. Sahin A, Meteroglu F, Eren S, Celik Y. Inhalation of foreign bodies in children: Experience of 22 years J Trauma Acute Care Surg. 2013;74:658–63
2. Passali D, Gregori D, Lorenzoni G, Cocca S, Loglisci M, Passali FM, et al Foreign body injuries in children: A review Acta Otorhinolaryngol Ital. 2015;35:265–71
3. Voss JO, Maier C, Wüster J, Beck-Broichsitter B, Ebker T, Vater J, et al Imaging foreign bodies in head and neck trauma: A pictorial review Insights Imaging. 2021;12:20
4. Lima JA. Laryngeal foreign bodies in children: A persistent, life-threatening problem Laryngoscope. 1989;99:415–20
5. Hootnick JL, Schroeder JW Jr. Glass in the glottis: A pediatric case report Int J Pediatr Otorhinolaryngol Extra. 2015;10:4–7
