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Severe Sore Throat Caused by Impacted Laryngeal Foreign Body
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–2, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2015.05.030
Visual Diagnosis in Emergency Medicine
SEVERE SORE THROAT CAUSED BY IMPACTED LARYNGEAL FOREIGN BODY Hyun Jin Min, MD, PHD, Sei Young Lee, MD, PHD, Hoon Shik Yang, MD, PHD, and Kyung Soo Kim, MD, PHD Department of Otorhinolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Korea Reprint Address: Kyung Soo Kim, MD, PHD, Department of Otorhinolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, 224-1, Heukseok-dong, Dongjak-gu, Seoul 156-755, Korea
true vocal cords, and only a small airway space was preserved between the seed and the vocal cords. The foreign body was a cocklebur (Figure 1D), and it was removed by gentle manipulation using a direct laryngoscope under general anesthesia without intubation, keeping the tracheostomy set and bronchoscope ready nearby.
INTRODUCTION Foreign-body impaction in the laryngeal area can induce many emergent conditions, for example, respiratory insufficiency. Because foreign bodies lodged at the laryngeal area usually pass through the tracheobronchial tree, or are coughed out by sphincteric movement, impaction of a foreign body in the laryngeal area is relatively rare (1). However, foreign bodies can get lodged in the larynx when they are too large, sticky, or have irregular borders with sharp edges, such as eggshells, glass fragments, and plastics (2,3). Recently, we experienced an interesting case of cocklebur (Xanthium strumarium) impaction in the larynx, inducing severe pain but without respiratory insufficiency.
DISCUSSION Although various laryngeal foreign bodies can be observed, depending on cultural and regional diversity, to the authors’ knowledge this is the first case in the literature reporting a cocklebur (Xanthium strumarium) impaction in the larynx. Xanthium strumarium is a species of annual plants belonging to the Asteraceae family (4). Cocklebur is a reference to the cockle shell–like appearance of the pods and their ‘‘burry’’ nature (4). In many countries, different parts of the cocklebur, especially the fruit and root, are used as remedies. The cocklebur was found to possess useful medicinal properties, such as diuretic, hypoglycemic, anti-inflammatory, and antioxidant activities (4). In the present case, the patient had been drinking cocklebur tea, made by boiling the fruits of the cocklebur in water, for the purpose of stopping drinking alcohol. This report highlights some interesting points in diagnosing and treating the impacted foreign body in the larynx. First, the burs of Xanthium strumarium can become impacted into the laryngeal mucosa due to their prickly
CASE REPORT A 64-year-old woman presented to the emergency department (ED) with the complaint of severe sore throat and foreign-body sensation. The symptoms started 30 min before the visit, and happened just after drinking tea made by boiling the fruits of the cocklebur in water. She had no other concurrent medical disease, and did not take any medication. Vital signs were stable with no respiratory insufficiency. Fiberoptic laryngoscopy (Figure 1A) and nonenhanced lung high-resolution computed tomography (Figure 1B and 1C) were performed. A foreign body was found nearly covering the
RECEIVED: 1 April 2015; ACCEPTED: 21 May 2015 1
2
H. J. Min et al.
Figure 1. Impacted laryngeal foreign body: Xanthium strumarium. (A) Fiberoptic laryngoscopy showing the foreign body impacted on the true vocal cords. (B) Retrieved foreign body: Xanthium strumarium. (C, D) Axial computed tomography (CT) and coronal CT images showing the foreign body on the level of true vocal cords.
nature. Thus, it may be difficult to remove through forceful throat clearing alone. In addition, as in this case, endotracheal intubation may be impossible because the foreign body is located directly on the true vocal cords and there is a risk of dislodgment of the foreign body into the lower respiratory passages. Therefore, direct laryngoscopy should be applied during intermittent mask ventilation (intermittent apnea technique), which is the most common approach when the foreign body is lodged in the laryngeal area. If the patient has any ventilation problems, either jet ventilation or tracheotomy may be necessary for foreign-body retrieval. Second, the symptoms and prognosis associated with foreign-body aspiration depend on the following important factors: level of obstruction, degree of obstruction, and size and shape of the foreign object (5). Usually, foreign bodies lodged at the laryngeal area are lined in the anteroposterior direction along the rima glottis, which is the narrowest part of the laryngeal cavity. However, foreign bodies that lodge at this level, either at or just above the vocal cords, will allow a reasonable chance of adequate resuscitation with no respiratory insufficiency (6). Symptoms
include hoarse cry, stridor, neck pain, or acute respiratory distress. Larger objects are more difficult to remove and tend to produce more complete obstruction (5). Finally, regardless of history, physical examination, and x-ray studies, direct laryngoscopy is the single most important modality for the diagnosis of a laryngeal foreign body (6).
REFERENCES 1. Pandhi SC, Agarwal KK. Foreign body in subglottic region-an unusual site. Indian J Otolaryngol Head Neck Surg 1970;22:223–5. 2. Evans JNG. Scott-Brown’s diseases of ear, nose and throat. 6th edn, 6 vols. London: Butterworths; 1997:25/1–11. 3. Hada MS, Chadda V, Mishra P, Gupta P, Grover M. Unusual metallic foreign bodies in the larynx: two case reports. Indian J Pediatr 2012; 79:1100–2. 4. Rad JS, Alfatemi SM, Rad MS, Iriti M. In-vitro antioxidant and antibacterial activities of Xanthium strumarium L. extracts on methicillin-susceptible and methicillin-resistant Staphylococcus aureus. Anc Sci Life 2013;33:109–13. 5. Chrcanovic BR, de Souza LN. Tracheotomy for a foreign body in the larynx. Oral Maxillofac Surg 2009;13:55–8. 6. Atmaca S, Unal R, Ses¸en T, Kilic¸arslan H, Unal A. Laryngeal foreign body mistreated as recurrent laryngitis and croup for one year. Turk J Pediatr 2009;51:65–6.
http://dx.doi.org/10.1016/j.jemermed.2015.05.030
Visual Diagnosis in Emergency Medicine
SEVERE SORE THROAT CAUSED BY IMPACTED LARYNGEAL FOREIGN BODY Hyun Jin Min, MD, PHD, Sei Young Lee, MD, PHD, Hoon Shik Yang, MD, PHD, and Kyung Soo Kim, MD, PHD Department of Otorhinolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Korea Reprint Address: Kyung Soo Kim, MD, PHD, Department of Otorhinolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, 224-1, Heukseok-dong, Dongjak-gu, Seoul 156-755, Korea
true vocal cords, and only a small airway space was preserved between the seed and the vocal cords. The foreign body was a cocklebur (Figure 1D), and it was removed by gentle manipulation using a direct laryngoscope under general anesthesia without intubation, keeping the tracheostomy set and bronchoscope ready nearby.
INTRODUCTION Foreign-body impaction in the laryngeal area can induce many emergent conditions, for example, respiratory insufficiency. Because foreign bodies lodged at the laryngeal area usually pass through the tracheobronchial tree, or are coughed out by sphincteric movement, impaction of a foreign body in the laryngeal area is relatively rare (1). However, foreign bodies can get lodged in the larynx when they are too large, sticky, or have irregular borders with sharp edges, such as eggshells, glass fragments, and plastics (2,3). Recently, we experienced an interesting case of cocklebur (Xanthium strumarium) impaction in the larynx, inducing severe pain but without respiratory insufficiency.
DISCUSSION Although various laryngeal foreign bodies can be observed, depending on cultural and regional diversity, to the authors’ knowledge this is the first case in the literature reporting a cocklebur (Xanthium strumarium) impaction in the larynx. Xanthium strumarium is a species of annual plants belonging to the Asteraceae family (4). Cocklebur is a reference to the cockle shell–like appearance of the pods and their ‘‘burry’’ nature (4). In many countries, different parts of the cocklebur, especially the fruit and root, are used as remedies. The cocklebur was found to possess useful medicinal properties, such as diuretic, hypoglycemic, anti-inflammatory, and antioxidant activities (4). In the present case, the patient had been drinking cocklebur tea, made by boiling the fruits of the cocklebur in water, for the purpose of stopping drinking alcohol. This report highlights some interesting points in diagnosing and treating the impacted foreign body in the larynx. First, the burs of Xanthium strumarium can become impacted into the laryngeal mucosa due to their prickly
CASE REPORT A 64-year-old woman presented to the emergency department (ED) with the complaint of severe sore throat and foreign-body sensation. The symptoms started 30 min before the visit, and happened just after drinking tea made by boiling the fruits of the cocklebur in water. She had no other concurrent medical disease, and did not take any medication. Vital signs were stable with no respiratory insufficiency. Fiberoptic laryngoscopy (Figure 1A) and nonenhanced lung high-resolution computed tomography (Figure 1B and 1C) were performed. A foreign body was found nearly covering the
RECEIVED: 1 April 2015; ACCEPTED: 21 May 2015 1
2
H. J. Min et al.
Figure 1. Impacted laryngeal foreign body: Xanthium strumarium. (A) Fiberoptic laryngoscopy showing the foreign body impacted on the true vocal cords. (B) Retrieved foreign body: Xanthium strumarium. (C, D) Axial computed tomography (CT) and coronal CT images showing the foreign body on the level of true vocal cords.
nature. Thus, it may be difficult to remove through forceful throat clearing alone. In addition, as in this case, endotracheal intubation may be impossible because the foreign body is located directly on the true vocal cords and there is a risk of dislodgment of the foreign body into the lower respiratory passages. Therefore, direct laryngoscopy should be applied during intermittent mask ventilation (intermittent apnea technique), which is the most common approach when the foreign body is lodged in the laryngeal area. If the patient has any ventilation problems, either jet ventilation or tracheotomy may be necessary for foreign-body retrieval. Second, the symptoms and prognosis associated with foreign-body aspiration depend on the following important factors: level of obstruction, degree of obstruction, and size and shape of the foreign object (5). Usually, foreign bodies lodged at the laryngeal area are lined in the anteroposterior direction along the rima glottis, which is the narrowest part of the laryngeal cavity. However, foreign bodies that lodge at this level, either at or just above the vocal cords, will allow a reasonable chance of adequate resuscitation with no respiratory insufficiency (6). Symptoms
include hoarse cry, stridor, neck pain, or acute respiratory distress. Larger objects are more difficult to remove and tend to produce more complete obstruction (5). Finally, regardless of history, physical examination, and x-ray studies, direct laryngoscopy is the single most important modality for the diagnosis of a laryngeal foreign body (6).
REFERENCES 1. Pandhi SC, Agarwal KK. Foreign body in subglottic region-an unusual site. Indian J Otolaryngol Head Neck Surg 1970;22:223–5. 2. Evans JNG. Scott-Brown’s diseases of ear, nose and throat. 6th edn, 6 vols. London: Butterworths; 1997:25/1–11. 3. Hada MS, Chadda V, Mishra P, Gupta P, Grover M. Unusual metallic foreign bodies in the larynx: two case reports. Indian J Pediatr 2012; 79:1100–2. 4. Rad JS, Alfatemi SM, Rad MS, Iriti M. In-vitro antioxidant and antibacterial activities of Xanthium strumarium L. extracts on methicillin-susceptible and methicillin-resistant Staphylococcus aureus. Anc Sci Life 2013;33:109–13. 5. Chrcanovic BR, de Souza LN. Tracheotomy for a foreign body in the larynx. Oral Maxillofac Surg 2009;13:55–8. 6. Atmaca S, Unal R, Ses¸en T, Kilic¸arslan H, Unal A. Laryngeal foreign body mistreated as recurrent laryngitis and croup for one year. Turk J Pediatr 2009;51:65–6.