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Cleft Palate Secondary to an Ingested Foreign Body: A Learning Experience
The Journal of Emergency Medicine, Vol. 43, No. 5, pp. e315–e317, 2012 Copyright Ó 2012 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
doi:10.1016/j.jemermed.2011.09.008
Clinical Communications: Pediatrics CLEFT PALATE SECONDARY TO AN INGESTED FOREIGN BODY: A LEARNING EXPERIENCE Sohit Paul Kanotra, MD,* Sonika Kanotra, MS,† and Jitendra Paul, MS‡ *Department of Otolaryngology, St. Luke’s Roosevelt Hospital Center, New York, New York, †Department of Ear, Nose, and Throat (ENT), Government Medical College, Jammu, India, and ‡Department of ENT, Acharya Shri Chander College of Medical Sciences Jammu, India Reprint Address: Sohit Paul Kanotra, MD, Department of Otolaryngology, St. Luke’s Roosevelt Hospital Center, 515 W 59th St., Apt 16P, New York, NY 10019
, Abstract—Background: Cleft palate has usually been described as a congenital anomaly. Acquired clefting of the palate is rare and is usually due to penetrating trauma. Objective: To report a case of cleft palate developing after ingestion of a coin due to prolonged impaction in the nasopharynx. Case Report: A 4½-year-old child presented with nasal regurgitation and nasal twang of voice. The parents reported a history of ingestion of a coin 2 years prior, which was undetectable on neck and chest X-ray study done at that time. Examination revealed a triangular cleft of soft palate. A diagnosis was made of an acquired cleft palate secondary to prolonged impaction of the coin in the nasopharynx. Under general anesthesia, the palatal defect was repaired in three layers. Conclusion: The case highlights the fact that ingested foreign bodies can get lodged in the nasopharynx and that nasopharynx X-ray study should always be done in cases of a disappearing foreign body in the aerodigestive tract. Ó 2012 Elsevier Inc.
foreign bodies can either have an uneventful gastrointestinal transition or can get impacted in some segment of gut. Less than 1% of the ingested foreign bodies produce serious morbidity including bowel obstruction, perforation, and erosion into adjacent organs (1). We present a case of an ingested foreign body that got impacted in the nasopharynx and presented as cleft palate. The case presents an interesting history and demonstrates the consequence of a missed foreign body. The importance of a thorough search for the foreign body—keeping in mind the nasopharynx as a potential site for lodgement of ingested foreign bodies—has been emphasized. CASE REPORT A 4½-year-old child presented with a history of nasal twang of voice and regurgitation of liquids through the nose for the past year. The parents reported a history of ingestion of a coin by the child when he was 2 years old. At that time he had been taken to an Ear, Nose and Throat specialist who had ordered X-ray studies of the neck and chest, but no foreign body was detected. The parents were reassured and the child discharged. However, after about 2 months the child started having nasal obstruction and occasional ear pain, which the pediatrician attributed to the presence of adenoids and treated with topical nasal decongestants and antibiotics. About a year and a half after this incident, the child suddenly
, Keywords—cleft palate; foreign body; coin; aerodigestive tract; pediatric
INTRODUCTION An ingested foreign body is a common pediatric emergency. A high level of suspicion is required for the diagnosis, as most times the ingestion of the foreign body has not been witnessed. Depending on their nature, ingested
RECEIVED: 11 May 2011; ACCEPTED: 20 September 2011 e315
e316
S. P. Kanotra et al.
coughed out a coin. After that, the present symptoms started. The parents gave a normal antenatal and postnatal history, with no feeding problems before this. Previous record of neonatal screening examination revealed no congenital abnormality. On examination the child had rhinolalia aperta and a triangular cleft of the soft palate slightly to the right of the uvula (Figure 1). The soft palate was mobile and the hard palate was normal. Rhinoscopy and otoscopy did not reveal any abnormality. A diagnosis was made of an acquired cleft palate secondary to prolonged impaction of the coin in the nasopharynx. Under general anesthesia, the palatal defect was repaired in three layers. At 6 months follow-up, the soft palate was intact and normally mobile, and the child had no evidence of rhinolalia aperta or any nasal regurgitation. DISCUSSION As a child explores its environment, it tends to put everything in the mouth, thus making foreign bodies of the upper aerodigestive tract a common pediatric emergency. Although almost anything can be ingested by a child, the most common foreign body in the pediatric age group is a coin. Ingested foreign bodies usually pass uneventfully through the gastrointestinal tract, rarely producing intestinal obstruction. Ingested foreign bodies can also reach the nasopharynx. Four basic reasons for the occurrence of such an event have been described. Firstly, accidental pushing of the foreign body into the nasopharynx while attempting to digitally remove the foreign body (2). Secondly, regurgitation of the foreign body due to vomiting or coughing (3). Thirdly, if the foreign body is put into the mouth in a lying-down position with the neck extended, making the nasopharynx dependent (4). Lastly, a large foreign body can migrate upwards and get lodged in the nasopharynx due to its inability to pass into the larynx or esophagus (5). In addition, animate foreign bodies like leeches can reach the nasopharynx through the nose, or a round worm can get lodged in the nasopharynx during vomiting (1). The nasopharynx can be considered one of the most common sites where foreign bodies remain undetected for long periods of time. A case of a plastic toy, lodged in the nasopharynx of an 8-year-old child for a period of 6½ years, has been described (6). Foreign bodies tend to remain for long periods, as the nasopharynx is a blind site that is not so easily amenable to visual inspection. Unlike foreign bodies in other parts of the aerodigestive tract, which often produce noticeable symptoms, foreign bodies in the nasopharynx can go unrecognized for significant periods of time. Inert foreign bodies are fairly asymptomatic, whereas in other cases they can cause chronic nasal symptoms. The usual symptoms of
Figure 1. Showing the cleft on the right side of uvula (arrow).
nasopharyngeal foreign bodies in children are indistinguishable from those of adenoid hypertrophy and include rhinorrhea, nasal obstruction, mouth breathing, and halitosis (6,7). Features similar to chronic rhinosinusitis are also seen. The feature of a nasopharyngeal foreign body that distinguishes it from a nasal foreign body is the bilaterality of the symptoms. Nasopharyngeal foreign bodies may later descend and cause sudden airway obstruction. Although nasopharyngeal foreign bodies have been described in patients with cleft palate, clefting of the palate secondary to a foreign body in the nasopharynx is an unknown entity (3). The patient in our case had, at the age of 2 years, ingested a coin that got lodged in his nasopharynx. This had been initially missed, as the nasopharynx was not evaluated. The coin had remained in the nasopharynx for a period of a year and a half, and by pressure necrosis, had resulted in clefting of the soft palate. Later on, when the cleft had sufficiently enlarged, the coin got dislodged and was coughed out. After this, the child developed symptoms of nasopharyngeal insufficiency. Before this case, cleft palate has never been reported as a complication of foreign body of the nasopharynx. This case highlights some important facts about nasopharyngeal foreign bodies. Firstly, the nasopharynx is a potential site for lodgement of ingested foreign bodies. Usually, coins are ingested and present as foreign bodies in the esophagus. However, they can get lodged in the nasopharynx and escape detection. Secondly, the foreign bodies tend to remain in the nasopharynx for prolonged periods. A nasopharyngeal foreign body usually presents
Cleft Palate Secondary to an Ingested Foreign Body
with chronic nasal symptoms, but can also lead to clefting of the palate, as happened in our patient. Thirdly, in cases of ingestion of a radiopaque foreign body, it is customary to obtain X-ray studies of the neck, chest, and abdomen to localize the foreign body. However, if the foreign body is not visualized in these areas, an X-ray study of the nasopharynx should always be done. In case of a nonradiopaque foreign body, a digital examination of the nasopharynx can also be performed to rule out the presence of foreign body. However, this can be frightening and annoying in children in whom endoscopic examination under general anesthesia is a better option. CONCLUSION Nasopharyngeal foreign body should be included in the differential diagnosis of unexplained acquired cleft palate. One must keep in mind the nasopharynx as a site of lodgement while investigating a case of disappearing foreign body in the aerodigestive tract. Apart from
e317
X-ray studies of the neck, chest, and abdomen, a lateral view of the nasopharynx should be done. In case of a non-radiopaque foreign body, nasopharyngoscopy should be performed.
REFERENCES 1. Uyemura MC. Foreign body ingestion in children. Am Fam Physician 2005;72:287–91. 2. Kanotra S, Lateef M, Showkat A. Nasopharyngeal foreign bodies. Asian J Ear Nose Throat 2007;3:21–5. 3. Walby AP. Foreign bodies in the ear or nose. In: Kerr AG, ed. Scott-Brown’s otolaryngology. 6th edn. Oxford, UK: ButterworthHeinemann; 1997:6/14/1–16. 4. Majumdar PK, Sinha AK, Mookherje PB. An unusual foreign body in the nasopharynx. Indian J Otolaryngol Head Neck Surg 1999;52:93. 5. Sharma SC, Bano S. An unusual foreign body in nasopharynx. Indian J Otolaryngol Head Neck Surg 1992;44:42–3. 6. Eghtedari F. Long lasting nasopharyngeal foreign body. Otolaryngol Head Neck Surg 2003;129:293–4. 7. Ogut F, Bereketoglu M, Bilgen C, Totan S. A metal ring that had been lodged in a child’s nasopharynx for 4 years. Ear Nose Throat J 2001; 80:520–2.
doi:10.1016/j.jemermed.2011.09.008
Clinical Communications: Pediatrics CLEFT PALATE SECONDARY TO AN INGESTED FOREIGN BODY: A LEARNING EXPERIENCE Sohit Paul Kanotra, MD,* Sonika Kanotra, MS,† and Jitendra Paul, MS‡ *Department of Otolaryngology, St. Luke’s Roosevelt Hospital Center, New York, New York, †Department of Ear, Nose, and Throat (ENT), Government Medical College, Jammu, India, and ‡Department of ENT, Acharya Shri Chander College of Medical Sciences Jammu, India Reprint Address: Sohit Paul Kanotra, MD, Department of Otolaryngology, St. Luke’s Roosevelt Hospital Center, 515 W 59th St., Apt 16P, New York, NY 10019
, Abstract—Background: Cleft palate has usually been described as a congenital anomaly. Acquired clefting of the palate is rare and is usually due to penetrating trauma. Objective: To report a case of cleft palate developing after ingestion of a coin due to prolonged impaction in the nasopharynx. Case Report: A 4½-year-old child presented with nasal regurgitation and nasal twang of voice. The parents reported a history of ingestion of a coin 2 years prior, which was undetectable on neck and chest X-ray study done at that time. Examination revealed a triangular cleft of soft palate. A diagnosis was made of an acquired cleft palate secondary to prolonged impaction of the coin in the nasopharynx. Under general anesthesia, the palatal defect was repaired in three layers. Conclusion: The case highlights the fact that ingested foreign bodies can get lodged in the nasopharynx and that nasopharynx X-ray study should always be done in cases of a disappearing foreign body in the aerodigestive tract. Ó 2012 Elsevier Inc.
foreign bodies can either have an uneventful gastrointestinal transition or can get impacted in some segment of gut. Less than 1% of the ingested foreign bodies produce serious morbidity including bowel obstruction, perforation, and erosion into adjacent organs (1). We present a case of an ingested foreign body that got impacted in the nasopharynx and presented as cleft palate. The case presents an interesting history and demonstrates the consequence of a missed foreign body. The importance of a thorough search for the foreign body—keeping in mind the nasopharynx as a potential site for lodgement of ingested foreign bodies—has been emphasized. CASE REPORT A 4½-year-old child presented with a history of nasal twang of voice and regurgitation of liquids through the nose for the past year. The parents reported a history of ingestion of a coin by the child when he was 2 years old. At that time he had been taken to an Ear, Nose and Throat specialist who had ordered X-ray studies of the neck and chest, but no foreign body was detected. The parents were reassured and the child discharged. However, after about 2 months the child started having nasal obstruction and occasional ear pain, which the pediatrician attributed to the presence of adenoids and treated with topical nasal decongestants and antibiotics. About a year and a half after this incident, the child suddenly
, Keywords—cleft palate; foreign body; coin; aerodigestive tract; pediatric
INTRODUCTION An ingested foreign body is a common pediatric emergency. A high level of suspicion is required for the diagnosis, as most times the ingestion of the foreign body has not been witnessed. Depending on their nature, ingested
RECEIVED: 11 May 2011; ACCEPTED: 20 September 2011 e315
e316
S. P. Kanotra et al.
coughed out a coin. After that, the present symptoms started. The parents gave a normal antenatal and postnatal history, with no feeding problems before this. Previous record of neonatal screening examination revealed no congenital abnormality. On examination the child had rhinolalia aperta and a triangular cleft of the soft palate slightly to the right of the uvula (Figure 1). The soft palate was mobile and the hard palate was normal. Rhinoscopy and otoscopy did not reveal any abnormality. A diagnosis was made of an acquired cleft palate secondary to prolonged impaction of the coin in the nasopharynx. Under general anesthesia, the palatal defect was repaired in three layers. At 6 months follow-up, the soft palate was intact and normally mobile, and the child had no evidence of rhinolalia aperta or any nasal regurgitation. DISCUSSION As a child explores its environment, it tends to put everything in the mouth, thus making foreign bodies of the upper aerodigestive tract a common pediatric emergency. Although almost anything can be ingested by a child, the most common foreign body in the pediatric age group is a coin. Ingested foreign bodies usually pass uneventfully through the gastrointestinal tract, rarely producing intestinal obstruction. Ingested foreign bodies can also reach the nasopharynx. Four basic reasons for the occurrence of such an event have been described. Firstly, accidental pushing of the foreign body into the nasopharynx while attempting to digitally remove the foreign body (2). Secondly, regurgitation of the foreign body due to vomiting or coughing (3). Thirdly, if the foreign body is put into the mouth in a lying-down position with the neck extended, making the nasopharynx dependent (4). Lastly, a large foreign body can migrate upwards and get lodged in the nasopharynx due to its inability to pass into the larynx or esophagus (5). In addition, animate foreign bodies like leeches can reach the nasopharynx through the nose, or a round worm can get lodged in the nasopharynx during vomiting (1). The nasopharynx can be considered one of the most common sites where foreign bodies remain undetected for long periods of time. A case of a plastic toy, lodged in the nasopharynx of an 8-year-old child for a period of 6½ years, has been described (6). Foreign bodies tend to remain for long periods, as the nasopharynx is a blind site that is not so easily amenable to visual inspection. Unlike foreign bodies in other parts of the aerodigestive tract, which often produce noticeable symptoms, foreign bodies in the nasopharynx can go unrecognized for significant periods of time. Inert foreign bodies are fairly asymptomatic, whereas in other cases they can cause chronic nasal symptoms. The usual symptoms of
Figure 1. Showing the cleft on the right side of uvula (arrow).
nasopharyngeal foreign bodies in children are indistinguishable from those of adenoid hypertrophy and include rhinorrhea, nasal obstruction, mouth breathing, and halitosis (6,7). Features similar to chronic rhinosinusitis are also seen. The feature of a nasopharyngeal foreign body that distinguishes it from a nasal foreign body is the bilaterality of the symptoms. Nasopharyngeal foreign bodies may later descend and cause sudden airway obstruction. Although nasopharyngeal foreign bodies have been described in patients with cleft palate, clefting of the palate secondary to a foreign body in the nasopharynx is an unknown entity (3). The patient in our case had, at the age of 2 years, ingested a coin that got lodged in his nasopharynx. This had been initially missed, as the nasopharynx was not evaluated. The coin had remained in the nasopharynx for a period of a year and a half, and by pressure necrosis, had resulted in clefting of the soft palate. Later on, when the cleft had sufficiently enlarged, the coin got dislodged and was coughed out. After this, the child developed symptoms of nasopharyngeal insufficiency. Before this case, cleft palate has never been reported as a complication of foreign body of the nasopharynx. This case highlights some important facts about nasopharyngeal foreign bodies. Firstly, the nasopharynx is a potential site for lodgement of ingested foreign bodies. Usually, coins are ingested and present as foreign bodies in the esophagus. However, they can get lodged in the nasopharynx and escape detection. Secondly, the foreign bodies tend to remain in the nasopharynx for prolonged periods. A nasopharyngeal foreign body usually presents
Cleft Palate Secondary to an Ingested Foreign Body
with chronic nasal symptoms, but can also lead to clefting of the palate, as happened in our patient. Thirdly, in cases of ingestion of a radiopaque foreign body, it is customary to obtain X-ray studies of the neck, chest, and abdomen to localize the foreign body. However, if the foreign body is not visualized in these areas, an X-ray study of the nasopharynx should always be done. In case of a nonradiopaque foreign body, a digital examination of the nasopharynx can also be performed to rule out the presence of foreign body. However, this can be frightening and annoying in children in whom endoscopic examination under general anesthesia is a better option. CONCLUSION Nasopharyngeal foreign body should be included in the differential diagnosis of unexplained acquired cleft palate. One must keep in mind the nasopharynx as a site of lodgement while investigating a case of disappearing foreign body in the aerodigestive tract. Apart from
e317
X-ray studies of the neck, chest, and abdomen, a lateral view of the nasopharynx should be done. In case of a non-radiopaque foreign body, nasopharyngoscopy should be performed.
REFERENCES 1. Uyemura MC. Foreign body ingestion in children. Am Fam Physician 2005;72:287–91. 2. Kanotra S, Lateef M, Showkat A. Nasopharyngeal foreign bodies. Asian J Ear Nose Throat 2007;3:21–5. 3. Walby AP. Foreign bodies in the ear or nose. In: Kerr AG, ed. Scott-Brown’s otolaryngology. 6th edn. Oxford, UK: ButterworthHeinemann; 1997:6/14/1–16. 4. Majumdar PK, Sinha AK, Mookherje PB. An unusual foreign body in the nasopharynx. Indian J Otolaryngol Head Neck Surg 1999;52:93. 5. Sharma SC, Bano S. An unusual foreign body in nasopharynx. Indian J Otolaryngol Head Neck Surg 1992;44:42–3. 6. Eghtedari F. Long lasting nasopharyngeal foreign body. Otolaryngol Head Neck Surg 2003;129:293–4. 7. Ogut F, Bereketoglu M, Bilgen C, Totan S. A metal ring that had been lodged in a child’s nasopharynx for 4 years. Ear Nose Throat J 2001; 80:520–2.