Sharp 3-Ended Metallic Foreign Body in an Infant Hypopharynx

Abstract

Foreign body ingestion is common in infants and children, but they can pose a difficult situation and a diagnostic problem if the foreign body is embedded in the soft tissues of the pharynx. To the best of our knowledge, this is the first case reported with such an unusually shaped foreign body having three sharp ends embedded at two different locations in the hypopharynx of a kid such small in age giving rise to respiratory as well as feeding problem. Secondly, a sharp foreign body penetrating arytenoid causing its swelling and inflammation, thus compromising the glottic opening and producing stridor is a rare phenomenon. We present a case of a 9 months old male infant who presented in ENT emergency with complaints of vomiting, refusal to accept solid as well as liquid feed for 5 days and sudden onset of abnormal grunting sounds on breathing for 1 day. Chest examination revealed intercostal retractions with decreased air entry bilaterally and conducted sounds in chest on auscultation. Abdomen examination revealed no abnormalities, and routine blood and urine investigations were also within normal limits. A metallic foreign body with three sharp ends was visualized in the neck X-ray, the retrieval of which by rigid hypopharyngoscopy relieved the symptoms.

Introduction

Foreign body ingestion is a common complaint in paediatric practice. Objects that are frequently ingested include coins, food products, buttons, plastic items, marbles, crayons, batteries, screws. A variety of sharp foreign bodies have also been described in literature including safety pins, bones, broken edges of toys, drawing pins and wires. Radiological investigation like chest X-ray and X-ray neck with anteroposterior and lateral view are most commonly done to diagnose them. Direct laryngoscopy is an option to remove objects lodged at or above the cricopharynx. Otherwise, rigid or flexible endoscopy may be performed when laryngoscopy is unsuccessful or for treatment of objects lodged below this area.

Case Presentation

We present a case of a 9 months old male infant who presented in the ENT emergency with complaints of vomiting, refusal to feed, drooling of saliva, frothing from mouth, and lethargy for 5 days and sudden onset of abnormal grunting sounds on breathing with intercostal retractions for 1 day. History was narrated by the parents who refused witnessing any foreign body ingestion. There were no loose stools or fever. Patient was afebrile to touch, abdomen was non tender. Examination of oropharynx showed no abnormality except for collection of saliva against a slightly inflamed posterior pharyngeal wall. The tonsils were normal. A chest and neck X-ray (AP and lateral view) were advised as well as paediatrician opinion was taken to rule out chest and abdomen infection. Routine blood and urine investigations were normal. X-ray neck (lateral view) revealed a metallic foreign body with 3 sharp ends in the hypopharyngeal region of neck at C3–C5 vertebral level (Fig. 1). Three sharp ends of the foreign body were easily seen in the anteroposterior view of chest (Fig. 2). The paediatrician proposed the etiology of symptoms as foreign body impaction and ruled out any major intervention from their side.

Fig. 1.

X-ray neck (lateral view) revealing a metallic foreign body in the hypopharyngeal region of neck at C3–C5 vertebral level

Fig. 2.

X-ray chest (anteroposterior view) revealing a metallic foreign body with three sharp ends clearly visible in the hypopharynx

The patient was admitted in the ward, and stat doses of intravenous antibiotics and steroids were given to the patient. The patient had been nil per oral for more than 8 h and hence was immediately shifted to emergency operation theatre for rigid hypopharyngoscopy and foreign body removal under general anaesthesia. After induction of general anaesthesia, a rigid hypopharyngoscope was introduced, and the foreign body was visualised in the post cricoid region with its one sharp end embedded in the right arytenoid and the other two sharp ends embedded in the adjacent posterior pharyngeal wall. Arytenoid was swollen and inflamed, and the posterior pharyngeal wall appeared congested. With a grasping forceps, the sharp ends were gently disimpacted from the right arytenoid and the posterior pharyngeal wall, and the foreign body along with the hypopharyngoscope was cautiously removed from the hypopharynx. The foreign body to our surprise was a “pant hook” of approximate size 1.5 × 1.5 cms (Fig. 3). The region of impaction of foreign body was examined and was found to be oedematous. There was slight bleeding at the site from where the foreign body was disimpacted from the posterior pharyngeal wall. Blood was suctioned to clear the field but perforation could not be ruled out as no clear cut rent was seen in the hypopharynx because the surrounding tissues were swollen. The patient was advised to be nil per oral till further orders, and was shifted to ward. The patient was started on intravenous fluids, antibiotics, and steroids, and was monitored for signs of perforation. Chest and neck X-ray were done 12 h later to look for any complication. The radiographs demonstrated absence of air in the prevertebral facial planes of neck, also there was no radiographic evidence of any retropharyngeal collection, pleural effusion, or mediastinal widening. Having shown no signs of perforation on radiographs, a check gastrograffin study was nevertheless done after 48 h of intervention to be sure before allowing the child orally. Gastrograffin scan showed no leak, and child was allowed to take oral feeds on 3rd postoperative day.

Fig. 3.

Retrieved metallic foreign body with three sharp ends, a “pant hook” of size approx. 1.5 × 1.5 cms

Patient started improving in ward and was free of presenting symptoms and intercostal retractions. He started accepting feeds, and tolerated them well. The patient was discharged on 4th postoperative day, and was asked to come for follow up after 7 days. After 7 days, the patient was absolutely asymptomatic.

Discussion

Foreign body ingestion is a common complaint in paediatric practice. Foreign body ingestion occurs commonly in children due to numerous reasons: they are naturally inclined towards oral exploration of their surrounding environment and are fond of playing with objects by oral perception, they masticate their food insufficiently due to sparse dentition, they have impaired sense of judgement of differentiating edible from inedible articles, and also being capricious, they are much engrossed in playing even while consuming food [1].

Objects that are frequently ingested include coins, food products, buttons, plastic items, marbles, crayons, batteries, screws. A variety of sharp foreign bodies have also been described in literature including safety pins, bones, broken edges of toys, drawing pins and wires. Although all foreign bodies should be attended to urgently but sharp foreign bodies warrant prompt attention as they can lead to various serious complications including perforation, erosion, and embedment of the foreign body in the hypopharyngeal or oesophageal wall. Sharp foreign bodies are notorious in getting impacted anywhere form the oral cavity to the cardio-oesophageal junction, the common sites being the tonsils, base of tongue, pyriform fossa and the cervical oesophagus [1, 2]. The ingested foreign bodies usually pass harmlessly through the gastrointestinal tract but a few become impacted at various levels [3].

In prelingual children the diagnosis of a pharyngeal foreign body gets difficult [4], particularly when the incident is not witnessed and the history is not forthcoming, as in our patient. A patient with a pharyngeal foreign body usually present with dysphagia, pain, and excessive salivation, refusal to eat or drink, drooling of saliva, stertor, or symptoms of respiratory tract infection [5]. Infants, young children, mentally impaired adults, and those with psychiatric illness may thus present with choking, refusal to eat, vomiting, drooling, wheezing, blood-stained saliva, or respiratory distress [3, 6]. Older children and non-impaired adults may identify the ingestion and localize the discomfort. However, the area of discomfort often does not necessarily correlate with the site of impaction. Oropharyngeal, hypopharyngeal or proximal oesophagus can get perforated by any sharp foreign body causing neck swelling, erythema, tenderness, or crepitus. These conditions require urgent attention, and prompt intervention [5].

The history, clinical examination, and radiographs collectively help in arriving at a diagnosis. Diagnosis is a lot easier when parents give history of foreign body ingestion. In the absence of a definitive history, diagnosis becomes difficult as even the mere choice of radiological investigation to be performed in infants becomes a hard task, in view of poor localization of symptoms and signs. However, radiological investigation like chest X-ray and X-ray neck with anteroposterior and lateral view are most commonly done, which are imperative because they confirm the location, size, shape, number of ingested foreign bodies, and also help to distinguish between tracheal and oesophageal foreign bodies as their symptoms can overlap [7]. Respiratory symptoms secondary to oesophageal foreign bodies are attributed to them being sharp and irregular, having a large size and a long duration of their impaction. Proximity of hypopharyngeal and cricopharyngeal area to the larynx and trachea is likely to cause respiratory symptoms due to tracheal compression [8, 9]. Cough and stridor may result from direct pressure on the membranous posterior tracheal wall by the foreign body itself or by secondary oesophageal dilatation, resulting in narrowing of the trachea. Long standing foreign bodies may lead to perioesophageal inflammation or may imbed in the wall of the oesophagus producing a foreign body granuloma resulting in compression of the trachea and consequently stridor. Vocal cord paralysis secondary to impacted oesophageal foreign body producing respiratory symptoms has also been reported in the literature [10, 11].

A sharp foreign body penetrating arytenoid causing its swelling and inflammation, thus compromising the glottic opening (more in its posterior part) and producing stridor in the infant is a rare phenomenon as described in our report.

Direct laryngoscopy is an option to remove objects lodged at or above the cricopharynx. Otherwise, rigid or flexible endoscopy may be performed when laryngoscopy is unsuccessful or for treatment of objects lodged below this area [12].

About 80–90 % of blunt or sharp foreign bodies can pass through the gastrointestinal tract spontaneously [13]. However in some instances, sharp or jagged foreign bodies may get impacted and lacerate the gastrointestinal wall partially or completely. Most commonly, such a laceration or perforation occurs at the anatomic narrowings of the oesophagus. These narrowing points are typically present at the cricopharynx, aortic arch, left main stem bronchus, and lower oesophageal sphincter. The signs and symptoms of early oesophageal perforation can be vague and non-specific. Therefore, a high index of suspicion is critical to avoid delays in establishing an accurate diagnosis. The clinical presentation depends on the cause, location of the injury, size of perforation, degree of contamination, length of time elapsed after injury [14].

Nesbitt and Sawyers reviewed oesophageal injuries from all causes during a 50 year period and found pain to be the most common symptom in 70 % cases followed by fever (51 %), dyspnoea (24 %), and crepitus (22 %) [15].

Dissection of air along the subcutaneous planes or into the mediastinum is a hallmark of oesophageal perforation. Patient with cervical oesophageal perforation presents with neck ache, and neck stiffness, but ache is typically less severe, and also subcutaneous emphysema is present over the neck after cervical oesophageal perforation and is easily detected by palpation in almost 60 % cases [16]. Radiographs studies are invaluable in establishing the diagnosis of oesophageal perforation. If cervical oesophageal perforation is suspected, a lateral neck X-ray may demonstrate air in the prevertebral facial planes before it is detected by chest radiographs [17]. Han et al. [18] reported that radiographic evidence of mediastinal emphysema requires at least 1 h after the initial injury to become discernable, whereas pleural effusion and mediastinal widening may take several hours to evolve. Panzini et al. [19] documented that 75 % of patients manifest abnormal radiographic findings on chest X-ray within 12 h of perforation, and pneumomediastinum was the most common radiographic finding.

Contrast oesophagography is the study of choice for suspected oesophageal perforation, and traditionally water-soluble contrast agents, such as gastrograffin (meglumine sodium) have been recommended over barium sulphate as the contrast of choice. There is a concern that extravasation of barium sulphate into the mediastinum can lead to an intense inflammatory response, resulting in fibrosing mediastinitis. In addition, the long term presence of barium in the mediastinum makes interpretation of future mediastinal imaging difficult, whereas gastrograffin is rapidly absorbed. However, due to the higher density and better mucosal adherence, barium allows the detection of even smaller oesophageal perforation [20].

Atypical symptoms pose a diagnostic difficulty in oesophageal foreign bodies. Clinical suspicion remains most important diagnostic tool favoured by radiological investigations. Rigid endoscopic examination is essential for diagnosis and successful management of sharp foreign bodies.