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Removal of an Impacted Foreign Body from The Upper Airway with a Gastroscope in a Tertiary Hospital in South-West Nigeria -A Case Report

Authors:
  • Afe Babalola University Ado-Ekiti and Federal Teaching Hospital Ido-Ekiti, Ekiti State, Nigeria.
  • Federal Teaching Hospital, Ido - Ekiti, Nigeria.
  • Federal Teaching Hospital Ido-Ekiti/Afe Babalola University Ado-Ekiti

Abstract and Figures

Foreign body ingestion and food bolus impaction are encountered commonly in clinical practice and are a common endoscopic emergency. A wide variety of objects could be ingested which could get impacted, and the site of impaction is commonly the oesophagus but can also be the airway depending on the nature of the substance ingested, the age of the patient and the presence of a neurologic disorder. The predominant clinical features of a patient will depend on the site of impaction of the foreign body; the airway or the oesophagus. Endoscopy remains the gold standard for the diagnosis and management of foreign body ingestion of which there are different modalities and equipment types. For foreign body in the airway laryngoscopy, tracheoscopy and bronchoscopy are the modalities indicated and there are also different types of retrieval devices some of which include standard biopsy forceps, retrieval graspers, retrieval forceps and polypectomy snares. The management of foreign body ingestion cuts across different specialties including Pulmonology, Otorhinolaryngology, General surgery, Cardiothoracic surgery and Gastroenterology all of which are involved in various different endoscopic procedures and their endoscopy equipment have a lot of similarities and in certain instances they can be adapted to perform varying roles. Foreign bodies in the airway require urgent endoscopic removal because it can become rapidly life threatening with associated high morbidity and mortality, therefore the available equipment should be immediately deployed to save lives. We present a case of foreign body impaction in the upper airway (larynx) that was removed with a flexible video Gastroscope using a polypectomy snare.
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Volume 3 | Issue 1 | 1 of 5Gastroint Hepatol Dig Dis, 2020
Removal of an Impacted Foreign Body from The Upper Airway with a
Gastroscope in a Tertiary Hospital in South-West Nigeria – A Case Report
1Department of Internal Medicine, Federal Teaching Hospital
Ido-Ekiti and Afe Babalola University Ado-Ekiti, Nigeria.
2Department of Otorhinolaryngology, Federal Teaching
Hospital Ido-Ekiti and Afe Babalola University Ado-Ekiti,
Nigeria.
3Department of Internal Medicine, Federal Teaching Hospital
Ido-Ekiti, Nigeria.
4Department of Otorhinolaryngology, Federal Teaching
Hospital Ido-Ekiti, Nigeria.
*Correspondence:
Dr. Oguntoye Oluwatosin Oluwagbenga MBBS (Ibadan),
FWACP(Gastroenterol), Lecturer 1 and Consultant Physician
/ Gastroenterologist and Hepatologist, Department of Internal
Medicine, Federal Teaching Hospital Ido-Ekiti and Afe Babalola
University Ado-Ekiti, Ekiti State, Nigeria.
Received: 21 April 2020; Accepted: 02 May 2020
Oguntoye Oluwatosin Oluwagbenga1, Yusuf Musah1, Olowoyo Paul1, Aremu Shuaib Kayode2, Soje
Michael Osisiogu1, Oguntoye Oluwafunmilayo Adenike3, Raji Mustapha4, Oguntade Hameed Banjo3,
Ariyo Olumuyiwa Elijah3, Atolani Segun Alex3, Talabi Olukayode Abiola3 and Ogunmola Toba Osiron3
Gastroenterology, Hepatology & Digestive Disorders
ISSN 2639-9334Case Report
Citation: Oguntoye O Oluwagbenga, Yusuf Musah, Olowoyo Paul, et al. Removal of an Impacted Foreign Body from The Upper
Airway with a Gastroscope in a Tertiary Hospital in South-West Nigeria – A Case Report. Gastroint Hepatol Dig Dis. 2020; 3(1): 1-5.
ABSTRACT
Foreign body ingestion and food bolus impaction are encountered commonly in clinical practice and are a common
endoscopic emergency. A wide variety of objects could be ingested which could get impacted, and the site of
impaction is commonly the oesophagus but can also be the airway depending on the nature of the substance
ingested, the age of the patient and the presence of a neurologic disorder. The predominant clinical features of
a patient will depend on the site of impaction of the foreign body; the airway or the oesophagus. Endoscopy
remains the gold standard for the diagnosis and management of foreign body ingestion of which there are dierent
modalities and equipment types. For foreign body in the airway laryngoscopy, tracheoscopy and bronchoscopy
are the modalities indicated and there are also dierent types of retrieval devices some of which include standard
biopsy forceps, retrieval graspers, retrieval forceps and polypectomy snares. The management of foreign body
ingestion cuts across dierent specialties including Pulmonology, Otorhinolaryngology, General surgery,
Cardiothoracic surgery and Gastroenterology all of which are involved in various dierent endoscopic procedures
and their endoscopy equipment have a lot of similarities and in certain instances they can be adapted to perform
varying roles. Foreign bodies in the airway require urgent endoscopic removal because it can become rapidly life
threatening with associated high morbidity and mortality, therefore the available equipment should be immediately
deployed to save lives. We present a case of foreign body impaction in the upper airway (larynx) that was removed
with a exible video Gastroscope using a polypectomy snare.
Keywords
Airway, Foreign Body Removal, Gastroscope, Nigeria.
Introduction
Foreign body ingestion and food bolus impaction are encountered
commonly in clinical practice and are a common endoscopic
emergency [1]. The majority of foreign body ingestions occur
in the pediatric (75%) population but frequently occur among
adults (25%) also [2,3]. The site of impaction is commonly the
oesophagus but can also be the airway depending on the nature
of the substance ingested, the age of the patient and the presence
of a neurologic disorder [4]. The airway can be divided into the
upper airway, which includes the nasal cavity, the oral cavity, the
pharynx, and the larynx while the lower airway consists of the
tracheobronchial tree. Foreign bodies can lodge either in the upper
airway or the lower airway.
While a wide variety of objects could be ingested, the most
common foreign bodies in children are coins, marbles, button,
batteries, safety pins and bottle tops. In adults, common foreign
Volume 3 | Issue 1 | 2 of 5Gastroint Hepatol Dig Dis, 2020
bodies are meat bone, sh bone, dentures and metallic wires [4,5].
Patients usually present with history of accidental swallowing of
such objects, often while eating or during sleep or in association
with seizures, trauma, or in the presence of some degree of
neurologic or psychological dysfunction.
The clinical features depend on the site of impaction of the foreign
body. In the airway, patients may present with choking, gagging,
coughing, hoarseness of voice, breathlessness, stridor, chest
tightness, wheezing or cyanosis [6]. The predominant clinical
features can indicate the section of the airway that is aected.
For laryngotracheal foreign bodies they include dyspnea, cough,
and stridor, whereas those of bronchial foreign bodies include
cough, decreased air entry, wheezing, and dyspnea [7]. In the
oesophagus, patients may present with dysphagia, odynophagia,
hypersalivation, retrosternal fullness, regurgitation, hiccups or
retching [8,9].
If the diagnosis of foreign body in the upper airway is not
established immediately and the object removed, the foreign body
can get dislodged distally and retained in the bronchial tree leading
to recurrent pneumonias, bronchiectasis, recurrent hemoptysis,
pneumothorax, lung abscesses, pneumomediastinum, or other
complications [10].
Endoscopy remains the gold standard for the diagnosis and
management of foreign body ingestion of which there are dierent
modalities and equipment types ranging from exible to rigid
scopes which have their merits and demerits but exible endoscopes
are generally preferred partly because they can be used under local
anesthesia [11,12]. For foreign body in the airway laryngoscopy,
tracheoscopy and bronchoscopy are the modalities indicated while
for foreign body in the oesophagus, oesophagoscopy is indicated
with success rates greater than 95% and complication rates of
0%–5% [13].
The choice of retrieval device is determined by the size, location
and shape of the foreign body, by the endoscope length and
instrument channel, and by the endoscopist’s preference and
practice. Examples of retrieval devices include: standard biopsy
forceps, retrieval graspers, retrieval forceps, polypectomy snares,
multi-prong snares, endoscopic baskets, magnetic probes, retrieval
nets or bags, balloon catheters and cryoprobe [12,13].
Foreign bodies in the airway require urgent endoscopic removal
because it can become rapidly life threatening with high morbidity
and mortality. Foreign body aspiration accounts for 0.16–0.33%
of adult bronchoscopic procedures [14]. Most oesophageal foreign
bodies (80%–90%) pass spontaneously but 10%-20% of cases will
require endoscopic removal, while less than 1% will need surgery
for foreign body extraction or to treat complications [15,16].
Despite improvements in medical care and public awareness,
approximately 3000 deaths occur each year in the United States
from foreign body aspiration, with most deaths occurring before
hospital evaluation and treatment [12]. Use of the Heimlich
maneuver as a rst line intervention for foreign body in the upper
airway has improved the mortality rate of patients with complete
airway obstruction, but its use in patients with partial obstruction
may result in complete airway obstruction, therefore it is not
always benecial [12].
The management of foreign body ingestion cuts across dierent
specialties including Pulmonology, Otorhinolaryngology, General
surgery, Cardiothoracic surgery and Gastroenterology all of
which are involved in various dierent endoscopic procedures.
The principle of endoscopy is the same and the equipment used
by dierent specialties have a lot of similarities and in certain
instances they can be adapted to perform varying roles.
We present a case of foreign body impaction in the upper airway
(larynx) that was removed with a exible video Gastroscope using
a polypectomy snare at the Federal Teaching Hospital Ido-Ekiti,
Ekiti state in south-western Nigeria.
Case Presentation
Mr A.S., a 50-year old trader who was rushed to the emergency
room on account of sudden onset noisy breathing of two days
duration with associated diculty with breathing which became
worse a day prior to presentation. He was apparently well until two
days prior to presentation when while he was eating, he was said to
have complained that the bolus of meat he swallowed was stuck in
his throat and he immediately started having noisy breathing with
associated breathlessness. There was also associated hoarseness of
his voice.
There was no cough but he had a feeling of choking and a feeling
of a lump in his throat. No precordial pain, no palpitations, no
fainting spells but patient had diaphoresis. No recent prolonged
immobilization or recent long-distance travel, no calf pain or
swollen limbs and no pleuritic pain. He is a known patient with
systemic arterial hypertension with poor drug compliance who has
a history of previous Left hemispheric ischaemic stroke one year
ago but still had signicant residual neurologic decit (right-sided
hemiparesis) despite physiotherapy.
Prior to this incident of choking while eating, there was no complain
of worsening of the weakness in his right upper and lower limbs and
no weakness in the contralateral limbs, there was no headaches, no
sudden unilateral visual loss, no slurred speech, no deviation of the
mouth to one side, no observable facioparesis by the caregivers,
no convulsion, no altered sensorium or loss of consciousness, no
neck pain or neck stiness, no nausea or vomiting, no dizziness,
no vertigo and no tinnitus. No past history of similar choking
while eating, no past history of dysphagia or odynophagia and no
history of drooping of the eyelids (or ptosis), no diculty with
opening the mouth. No history of mouth lesions or ulcers and no
loose tooth. He has no dental prosthesis. No history of orthopnea
or paroxysmal nocturnal dyspnea and no pedal oedema.
He is not a known patient with diabetes mellitus, bronchial asthma
or chronic obstructive pulmonary disease. Not a known patient
Volume 3 | Issue 1 | 3 of 5Gastroint Hepatol Dig Dis, 2020
with seizure disorder. No past history of surgery. He is married in
a monogamous family setting and has four children. He does not
smoke cigarette nor drink alcohol. He has not been regular with
his anti-hypertensive medications and not on any other routine
medications. He has no known allergy.
Every attempt the patient made as well as that of his caregivers
to get the meat bolus out proved abortive. He was initially taken
to a primary health facility where he was placed on supplemental
oxygen but they also could not get the meat bolus out because
of lack of the necessary equipment and expertise. He was
subsequently referred to our health facility the following day for
further intervention and management.
At presentation in our emergency room he was conscious,
extremely breathless and in severe respiratory distress, having
grunting breathing, febrile (temperature was 38.1oC), diaphoretic,
centrally cyanosed and progressively getting exhausted. No neck
swelling or neck mass noted. The respiratory rate was 40cycles/
minute, Sp02 was 67%, and on auscultation of the chest, he had
widespread crackles bilaterally, no rhonchi. The pulse rate was
120 beats/minute, blood pressure was 170/100mmHg and the heart
sounds were S1 and S2 only; there was no murmur. There was
absent gag reex and a right cranial nerve 7 palsy; upper motor
neuron type. The muscle power was 2 in the right upper limb and
3 in the right lower limb. There was hypotonia and hyporeexia
in the right limbs but the ndings in the left upper and lower
limbs were essentially normal. There was no other remarkable
abnormality noted and abdominal examination was normal.
A provisional diagnosis of Upper airway obstruction by a foreign
body (meat bolus) was made in a known hypertensive patient with
residual neurologic decit from a previous left-sided ischaemic
stroke, to keep in view aspiration pneumonitis.
He was immediately placed on high ow (10L/min) 100%
intranasal Oxygen and the Sp02 gradually improved from 67%
to 88%. He could not be intubated and ventilated mechanically
by the anesthesiologists due to the suspected airway obstruction
by a foreign body. There was also no facility in our health
institution at the time for exible laryngoscopy or bronchoscopy
and the patient was not clinically t for a rigid laryngoscopy
by the otorhinolaryngologists under general anesthesia. The
Gastroenterology unit was therefore invited for a possible
endoscopic intervention. The patient was optimized and he
subsequently had an emergency endoscopy done. In view of the
clinical prole of the patient, no sedation or local anesthetic agent
was administered but an antimotility agent, intravenous Hyosine
Butyl Bromide 20mg stat, was administered to the patient before
the commencement of the endoscopy procedure. There was close
monitoring of the patient’s Sp02 and vital signs throughout the
procedure by an endoscopy nurse.
An Olympus CV-170 series (Olympus America Incorporated)
with a forward viewing exible video Gastroscope was used
for the procedure. The meat bolus was found abutting on the
epiglottis and almost completely occluding the larynx (Figures 1
and 2). The meat bolus was removed with a Polypectomy snare. It
measured about 6cm x 5cm x 2cm in dimension (Figure 3). There
was an immediate dramatic improvement in his symptomatology
thereafter. The noisy breathing stopped and the breathlessness
improved remarkably. The endoscope was re-inserted into the
pharynx for a proper assessment of the mucosa. The epiglottis
was inamed, there was also surrounding mucosal oedema and
hyperaemia; and some exudates seen at the site of impaction
(Figure 4). No endoscopic features to suggest a mucosa/wall tear,
perforation or any bleeding at the site of impaction.
Figure 1: Endoscopic image of a foreign body (meat bolus) in the larynx
causing signicant airway obstruction.
Figure 2: Another endoscopic view showing the foreign body (meat
bolus) occluding the larynx. A part of the epiglottis can also be seen.
Figure 3: The foreign body (meat bolus) specimen.
Volume 3 | Issue 1 | 4 of 5Gastroint Hepatol Dig Dis, 2020
Figure 4: Endoscopic image of the upper airway after the foreign body
(meat bolus) had been removed.
The procedure was fairly well tolerated and there were no
complications. He was continuously monitored while in the
recovery room and was subsequently transferred to the ward
when his vital signs were satisfactory. He was placed on nil per os
(NPO), intravenous uids (for hydration and calorie maintenance),
intravenous dexamethasone, ceftriaxone and metronidazole. He
was eventually, transferred to the Neurology/Stroke unit for further
management and neuro-rehabilitaion.
Conclusion
The management of foreign body ingestion requires an
interprofessional team with an interprofessional approach; this will
reduce the morbidity and mortality associated this condition. Most
patients will present to the emergency department and the triage
nurse or physician has to be aware of the symptoms and signs of
a foreign body in the airway or the oesophagus and immediately
invite the appropriate specialist.
Foreign bodies in the airway require urgent endoscopic removal
because it can become rapidly life threatening, therefore the
available equipment should be immediately deployed to save
lives. Gastroscopes are used for endoscopic visualization of
the upper gastrointestinal tract for diagnostic, screening and
therapeutic purposes. Our patient was managed by us at a time
when there was no exible laryngoscopy or bronchoscopy
facility in our health institution and the patient was not clinically
t for a rigid laryngoscopy by the otorhinolaryngologists under
general anesthesia. A minimally invasive procedure was required
at that time which was successfully achieved with the use of the
Gastroscope and a polypectomy snare.
Prior to discharge, patients should be evaluated for a possible
underlying psychological disorder such as mental retardation,
bulimia nervosa or pica; or a neurologic disorder such as stroke
or myasthenia gravis; and such patients should be referred to
the appropriate specialist for expert care in order to prevent a
recurrence. Patients should also be educated about measures to
prevent foreign body ingestion and food impaction such as good
eating habits; careful removal of bony components from sh and
meat; and care of dentures and metallic implants among others.
Acknowledgement
Special thanks to the Endoscopy Nurses, House Ocers and
Resident Doctors in the Gastroenterology unit of the Department
of Internal Medicine for their support in making this publication
a reality.
Funding
The authors bore the entire cost of the research and did not receive
any nancial support from any individual, institution, organization
or body towards this research work.
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... The incidence of swallowing foreign bodies or items irrespective of size, shape or constituency is high in children [1,2]. It could occur unintentionally especially while playing or when startled. ...
... The method of extraction of impacted foreign items and the expedition of this process depends on the following factors: size, type of foreign item, site of impaction, duration of impaction, associated complications and surgeon's preference [1,8]. The likelihood of oesophageal wall perforation is increased fourteen times if foreign item impaction lasts more than twenty-four hours [4]. ...
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Two hundred children aged 6 months to 12 years were admitted to the hospital with a foreign body in the airway. Food materials constituted 93% of all foreign bodies. A positive history of foreign body aspiration was obtained in 88% of the cases. The most common symptoms of laryngotracheal foreign bodies were dyspnea, cough, and stridor, whereas those of bronchial foreign bodies were cough, decreased air entry, wheezing, and dyspnea. Chest fluoroscopy contributed to the diagnosis in 90% of the cases of bronchial foreign bodies, but only 32% of those in the laryngotracheal area. Of the foreign bodies removed, 98 1/2% were done by laryngoscopy, tracheoscopy, and/or bronchoscopy. Complications were involved in 6% of the cases, including one death. History of recurrent intractable pneumonia should make one consider a foreign body in the airway. Removal of one foreign body does not exclude the existence of another. The condition may be fatal; thus immediate removal of the foreign body is mandatory.
Article
To compare the clinical and management aspects of tracheobronchial aspirated foreign body (AFB) removal in children and adults; to assess the influence of the operator's experience on the outcome of the procedure. A retrospective review of a 20-year experience (from 1976 to 1996). A 900-bed university hospital. Eighty-four children up to 8 years old (the child group) and 28 adult patients (the adult group). The peak incidence of foreign body aspiration occurred during the second year of life in the child group and during the sixth decade in the adult group. The symptoms at presentation were similar in both age groups, but the diagnosis was significantly delayed in the adults. The AFBs were lodged preferentially in the right bronchial tree only in the adults; a central location was predominant (but not at all exclusive) in the children. Atelectasis was more common in the adults, and air trapping was more common in the children. The most frequent procedure was rigid bronchoscopy; when a flexible bronchoscope was used, it was always in the adult patients. When the operator was less experienced, a failed first attempt at bronchoscopy and the need for a second procedure were significantly more frequent. At presentation, the symptoms seen with AFBs do not differ according to the age of the patient; however, the delay to diagnosis, the location of the AFBs, and the radiographic images differ between child and adult populations. The removal of AFBs in patients of all ages can be performed by the same operators. Because the outcome associated with these procedures improves when the operator is experienced, the removal of AFBs should be performed in medical centers that are capable of acquiring and maintaining the necessary expertise.