Laryngoscopic removal of unusual metallic foreign body of the subglottic region of the larynx.

Foreign bodies of the respiratory tract are frequently encountered emergencies in children. A male child of 4 years was brought to our hospital by anxious parents with a history of loss of speech. No information could be gathered from the frightened child and his parents regarding the incidence to elucidate the cause of loss of speech. On examination, the breathing was normal and vital signs did not reveal any abnormality. Roentgenogram of the neck showed a foreign body of metallic density located at the glottis region. The child was immediately taken up for emergency bronchoscopic removal of the foreign body under general anesthesia. A laryngoscopic view revealed this as a piece of safety razor blade lying between the cords and hanging into the subglottis of the larynx. Immediately, this foreign body was successfully removed with the Magill's Forceps by the anesthesiologist. Lack of anesthesia and surgical complications encouraged us to present this case on the basis of our experience.

INTRODUCTION

A rare case of unusual metallic foreign body of subglottic region, which was a piece of razor blade, is presented.In literature we could not found such foreign body of respiratory tract. Foreign body ingestion and impaction in the aerodigestive tract are common problems in children between 1 and 3 years of age. Delay in the removal of foreign body leads to morbidity and mortality. The most common foreign bodies in children is coins, but marbles, button, batteries, safety pin and bottle tops have also been reported. Foods such as nuts and seeds are common airway foreign body in children, while in adults, common foreign bodies are bones, dentures and metallic wires. The diagnosis and treatment requires awareness and suspicion of signs and symptoms of foreign body aspiration. A foreign body swallowed into the esophagus presents with dysphasia while foreign body aspiration into the respiratory tract presents with cough, dyspnoea and stridor. The removal of respiratory tract foreign body generally leads to rapid recovery.

We are presenting the anesthetic management of an unusual metallic foreign body of the respiratory tract.

CASE REPORT

A male child of 4 years was brought to our hospital by anxious parents with a history of loss of speech. No information could be gathered from the frightened child and his parents to elucidate the cause of loss of speech. On examination, his vitals were stable and he was breathing normally. Chest roentgenogram was normal but neck roentgenogram showed a foreign body of metallic density with linear pattern in the A-P view [Figure 1] and squarish pattern with two ridges in the lateral view [Figure 2], located at the glottis region. Emergency bronchoscopic removal of the foreign body of the respiratory tract under general anesthesia was planned. Preoperative assessment was performed and monitors for pulse-oximetry, arterial blood pressure and EtCO2 were attached. Emergency airway cart was alerted including cooks airway catheter, all types of laryngeal mask airways, track light, fibreoptic bronchoscope, 14 gauge needle for needle crico-thyroidectomy with percutaneous tracheostomy and surgical tracheostomy set. A crystalloid intravenous infusion of Isolyte-P was started. After premedication with glycopyrrolate (0.01 mg/kg), anesthesia was induced with sevoflurane and oxygen. After achieving adequate depth of anesthesia, direct laryngoscopy was performed without muscle relaxant, which revealed this foreign body as a piece of safety razor blade, lying between the vocal cords and hanging in the subglottic region. Immediately, this blade was successfully removed with Magill's Forceps by the anesthesiologist. Recovery and the postoperative period was uneventful. The child was discharged with complete recovery of his voice.

Figure 1

A-P view of the neck showing a metallic linear opacity in the glottic region

Figure 2

Lateral view of the neck showing a piece of blade in the glottic region of the larynx

DISCUSSION

Foreign body aspiration or ingestion is a common problem in children as they explore their environment with their mouth. The lack of posterior dentition and immaturity of the swallowing mechanism make lodgement of food in the esophagus common,[1] which is potentially life-threatening if not properly and promptly managed. The severity of the symptoms depends on the site, size, composition and duration of foreign body present in the aerodigestive tract. Smooth foreign body may cause airway obstruction while sharp foreign body can penetrate the esophageal wall. The clinical presentation is usually with acute dysphasia, choking, gagging, drooling and regurgitation. The bronchial foreign bodies lead to respiratory embarrassment, dyspnoea, tachypnoea, strider, spasmodic cough, change in voice and cyanosis.[2]

Diagnosis is difficult due to unclear history, lack of characteristic clinical features and absence of conclusive radiological findings. Lannigan et al. in 1987 have reported impaction of lamb bone in the subglottis of a smoker without any respiratory compromise.[3] Kieth et al. also reported inhalation of a button at the carina in a postlaryngectomy patient without any respiratory difficulty.[4] Carelessness of the parents, mental infirmity under the influence of drug addiction and alcohol and rapid eating are some of the factors responsible for foreign body inhalation/ingestion.[5]

General anesthesia is preferred for endoscopic removal of foreign body of the respiratory tract.[6] The problems of full stomach and sharing of airway must be taken into account to maintain the airway for adequate ventilation and oxygenation in children. During preoperative assessment, the main focus should be on location of foreign body and degree of airway obstruction. The neck and chest roentgenograms are helpful in determining the location of the foreign body and pulmonary pathology. If a significant hyperinflation of one lung or lobe exists, nitrous oxide should be avoided to limit pulmonary inflation and potential rupture.[7] Unless the foreign body is visible in the airway, the trachea should be intubated with one size smaller endotracheal tube without muscle relaxant.

As foreign body was at glottis region intubation and cook airway catheter could not be planned. Positive pressure ventilation could have pushed the razor blade piece down towards trachea. So only the 14 gauge needle cricothyroidetomy was the plan ‘B’ for airway management in this patient, if needed followed by percutaneous tracheostomy.

In this case, he was induced with oxygen and sevoflurane after glycopyrrolate premedication to decrease secretions and obtund autonomic reflexes of airway instrumentation. During direct laryngoscopy, the foreign body, i.e. the piece of safety razor blade, was visible in the airway, lying between the vocal cords and hanging in the subglottic region of the larynx, which was promptly taken out with a Magill's Forceps.

In a stable child, an intravenous induction with either sodium thiopental, ketamine or propofol may be used.[89] Ketamine induction is preferred due to intact cough reflexes, with cardiovascular stability and consciousness returned quickly. Muscle relaxation, if needed, can be achieved by succinylcholine by bolus or intermittent doses or short-acting nondepolarizing muscle relaxants (rocuronium or atracurium) to avoid excessive neuromuscular blockade at the end of brief bronchoscopy. Muscle relaxation necessitates controlled ventilation but prevents coughing and trauma and facilitates removal of foreign bodies through the vocal cords.For removal of aspirated foreign bodies, the rigid bronchoscope is undoubtedly the equipment of choice. The rigid instrument affords a much better exposure of the foreign body and much greater range of size and variety of forceps. Unlike the flexible bronchoscope, the patient can be ventilated through the rigid bronchoscope. Flexible bronchoscopy is performed only to confirm, localize and visualize the foreign body. Its use for extracting the foreign bodies should be limited to objects too small to cause total airway obstruction and those that can be grasped without shattering or dislodgement. Different ventilator techniques can be used during rigid bronchoscopy. Short-acting anesthetic agents should be used for rapid and complete recovery. Oxygen and anesthetic gases can be delivered through the side arm of the bronchoscope by intermittent ventilation or uninterrupted ventilation can be delivered by a Sander's system using the Venturi principle.[10]

In cases of laryngeal foreign bodies, elective tracheotomy should be performed to secure the airway. Large laryngeal and tracheal foreign bodies can be delivered through tracheotomy.

CONCLUSION

Foreign bodies of the respiratory tract are common emergencies of children, and its treatment is bronchoscopic removal under general anesthesia with the aim to maintain adequate oxygenation and prevention of aspiration with rapid return of upper airway reflexes. The vigilance, alertness and experience of the anesthesiologist could bring the patient's voice back to normal.