A rare case of coin impaction in larynx in an adult.

Impaction of foreign body in larynx is reported exclusively in paediatric population only. Moreover impaction of coin in larynx has never been reported previously. With this background, we report a rare case of coin impaction in larynx in a healthy adult.

Introduction

Foreign body (FB) impaction is seldom seen in adults,[1,2] although a prevalence of 2–5% is reported in medical literature for paediatric population.[3] This clinical record illustrates a rare case of impaction of coin in larynx in a healthy and conscious adult. The mode of entry, site of impaction and management were felt to be interesting, hitherto unreported in medical literature.

Case Report

A 45-year-old adult presented to the casualty department of Vardhman Mahavir Medical College & Safdarjung hospital, New Delhi with the chief complaint of hoarseness. History revealed that the patient had accidently swallowed a two rupee coin while casually fiddling with it and rolling it in the mouth. Apart from anxiety, general physical examination revealed nothing significant. Indirect laryngoscopy (IL) showed the said coin to be impacted at the laryngeal inlet. It would be prudent to note that patient had no signs and symptoms of airway compromise. X-rays confirmed the site of the coin (Figures 1, 2). The said coin was then removed in the operation theatre, with full anesthetic back-up under local anesthesia and sedation, by direct laryngoscopy and crocodile forceps (Figure 3). The coin was found impacted obliquely at the laryngeal inlet with one smooth edge jagged at the anterior commissure (Figure 4). Post-op IL revealed a slight bruise at the anterior commissure. Post operative period was uneventful with no untoward incident to report and the patient was kept in regular follow-up. A normal larynx was viewed at the end of 6 weeks by IL.

Figure 1

X-ray soft tissue neck showing impacted coin.

Figure 2

X-ray neck and chest pa view showing impacted coin.

Figure 3

Pictographic representation of impacted coin.

Figure 4

Removed coin.

Discussion

FB impaction in larynx in an adult is a rare phenomenon, as the sphinteric action of the larynx is well developed to protect the lower respiratory airway. Hence, most of the foreign bodies are seen in the hypopharynx or they go past the glottis into the bronchus. Impaction in adults is thus seen only in unconscious patients or those intoxicated with alcohol.[4] Moreover, FB lodges in the larynx if it is too large to pass through or if it is of an irregular shape with sharp edges that can catch on the laryngeal mucosa.[5] Contrary to these medical facts, it is interesting to note that a smooth and rounded coin got impacted in the larynx of our conscious patient. In addition, in the said case intubation, thereby general anaesthesia (GA) was avoided as there was risk of dislodgement of coin into the lower respiratory passages. As the patient was a healthy co-operative adult male with no respiratory distress whatsoever, we were able to remove the said coin under local anesthesia. It is however, pertinent to note that such cases should always be operated with good anesthetic back-up, for obvious reasons in the best interest of patient care.[6] In a literature search using Medline services/Pub med database using the medical subject function, authors could find no such case of coin impaction in the larynx as described here in. Though some pointed, sharp and irregular objects find mention in literature, but impaction of any smooth edged, well defined foreign body has not been reported in literature.[2,7,8] These sharp and irregular FB's were either iatrogenic or traumatic in impaction, and were removed under general anaesthesia.[7,8] The first author has also reported an alpin impaction in larynx resulting from casual fiddling, which was removed under local anesthesia.[2] We would thus emphasize that casual fiddling with any small object, even a coin is best avoided, as it can get accidently impacted in larynx in a healthy conscious adult.

In summary, the interesting mode of ingestion while fiddling, the unusual clinical presentation of impaction of the coin with no respiratory embarrassment in a conscious healthy adult and finally its endoscopic removal under local anesthesia make this clinical record unique, and prompted us to share our professional experience with the medical fraternity.