Laryngeal foreign bodies: causes, symptoms, diagnosis, treatment

Foreign bodies in the larynx are much less common than foreign bodies in the trachea or foreign bodies in the bronchi, and, according to various authors, account for 4 to 14% of all foreign bodies in the upper respiratory tract.

Most of the foreign bodies that enter the larynx overcome its space and get stuck in the right main bronchus, the angle of departure of which from the trachea is significantly smaller than that of the left main bronchus. The larynx mainly retains pointed foreign bodies (fish and thin chicken bones, needles, dentures, walnut shell fragments, metal objects). Leeches are often found in the larynx, which get into it when drinking water from natural reservoirs - the habitat of these annelids. Foreign bodies of the larynx are most often observed in children aged 5-7 years. Foreign bodies of the respiratory tract are often observed in old people with weakened protective pharyngeal and closing reflexes and in mentally ill individuals.

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Pathogenesis of foreign bodies in the larynx

Foreign bodies of the larynx may originate from the oral cavity during eating, from the nasal cavity and nasopharynx, where they get during children's games and from where they are aspirated into the larynx, as well as retrogradely during coughing from the trachea and bronchi or during vomiting from the stomach and esophagus. Foreign bodies of the larynx, related to iatrogenic, may occur during adenotomy and tonsillotomy (aspiration of removed lymphadenoid tissue, a fragment of a surgical instrument). The most common mechanism of foreign bodies of the larynx is sudden aspiration of foreign bodies, which occurs during eating, laughing, sneezing, talking, an unexpected blow to the back of the head. Aspiration of foreign bodies may occur during sleep, in a state of intoxication or drowsiness, when distracted or frightened. Foreign bodies in the larynx can be observed in some bulbar syndromes, in which the sensitivity of the pharynx and larynx is impaired, in neuritis of the sensory nerves of the larynx, etc.

Foreign bodies of the larynx are mostly immobile, wedged. They get stuck in the larynx due to their large size, uneven edges or rough surface, and also because of a reflex (protective) spasm of the laryngeal constrictors. Due to the latter reason, most foreign bodies get stuck with their main mass in the interarytenoid space above the glottis; one end of this foreign body may be in the ventricle of the larynx, and the other - in the area of the posterior wall of the larynx or in the area of the anterior commissure. In other cases, the foreign body is located in the sagittal plane between the vocal folds, fixed with one end in the anterior commissure, the other - in the posterior wall of the subglottic space or in the arytenoid region. Foreign bodies stuck in the laryngeal part of the pharynx provoke pronounced edema of the lining space, especially in children. Having penetrated deep into the edema, these foreign bodies are difficult to detect. According to N. Costinescu (1904), 50% of foreign bodies of the larynx, having a tracheobronchial origin, are localized in the lining space.

Foreign bodies in the larynx, irritating and injuring its mucous membrane, cause swelling and inflammation, the severity of which depends on the nature of the foreign body, the duration of its presence in the larynx and the addition of a secondary infection. Sharp foreign bodies can perforate the larynx and penetrate into adjacent areas. These perforations are the entry points for secondary infection (perichondritis, perilaryngeal abscesses, mediastinitis, thrombosis of the external jugular vein). Long-term presence of foreign bodies in the larynx causes bedsores, contact ulcers, contact granulomas, secondary infection, and after their removal - one or another degree of cicatricial stenosis of the larynx.

Symptoms of foreign bodies in the larynx

Foreign bodies of significant size (a piece of meat, adenoid growths, aspirated tampon, etc.), characterized by a soft elastic consistency, with a reflex spasm of the larynx, as a rule, completely block the larynx, leaving no gaps or passages for even minimal breathing, very often lead to death from asphyxia. If the obstruction of the larynx is not complete, then the foreign body provokes powerful means of protection, not all of which play a positive role, for example, a protective spasm, while a strong paroxysmal cough, nausea and vomiting contribute to the expulsion of foreign bodies from both the laryngopharynx and the larynx. Very quickly, within ten seconds, cyanosis of the face appears, on which an expression of extreme fear is imprinted. The victim begins to rush about, his movements become disordered, a hoarse voice and convulsive respiratory movements are futile. This condition can last for 2-3 minutes, and if the foreign body is not ejected or removed in any way, the patient quickly loses consciousness, falls into a comatose state and clinical death. Breathing that is not restored in time (within 7-9 minutes) leads to death from cardiac and respiratory arrest. If cardiac and respiratory activity can be restored after the specified period of time or a little earlier, there is a risk of partial or complete shutdown of the cortical centers, which leads to decortication syndrome of varying depth, as a result of which the patient switches to a vegetative lifestyle. If a foreign body wedges between the true vocal folds and prevents them from closing, and there is space for minimal air passage, then sudden aphonia and one or another degree of dyspnea occur. Perforation of the larynx by a foreign body can lead to emphysema, especially in the case of expiratory respiratory failure, when an obstruction to the exhalation of air occurs above the perforation.

Diagnosis of foreign bodies in the larynx

Diagnosis of foreign bodies in the larynx in acute cases is not difficult; it is based on suddenness, external signs of sudden reflex irritation of the sensitive receptors of the larynx, paroxysmal cough, dysphonia or aphonia, dyspnea or apnea. Chronic cases are more difficult to diagnose when the victims seek medical attention late. Most often, such cases are observed with non-obstructive foreign bodies of the larynx, when breathing remains satisfactory, and the wedged foreign body begins to be accompanied by various local complications (infected bedsore, edema, perichoidritis, etc.).

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Differential diagnostics of foreign bodies of the larynx

In acute cases of foreign bodies in the larynx, the symptoms that arise can often simulate functional spasm of the larynx (e.g., hysterical genesis), diphtheritic croup, subglottic laryngitis, allergic edema. Indirect laryngoscopy is used in older children and adults, in which the foreign body is easily detected. Direct laryngoscopy is more effective in younger children, which, in addition to diagnostics, also has a therapeutic purpose - removal of the foreign body. Before laryngoscopy, appropriate anesthesia is required, including the use of diphenhydramine and atropine injections, local application or spraying of dicaine or cocaine. Opiates are contraindicated due to their depressant effect on the respiratory center.

If a patient consults a doctor with a significant delay, presenting complaints of hoarseness of voice, periodic paroxysmal cough with expectoration of mucopurulent sputum, sensation of a foreign body in the throat, shortness of breath during physical work, often evening subfebrile temperature, along with a significant number of all kinds of diseases, one should also suspect the presence of a chronic foreign body in the larynx. Such a foreign body, with a long (more than 5 days) presence in the larynx, is covered with granulation tissue, edematous mucous membrane, mucopurulent discharge, which significantly complicates its detection. In such cases, it is advisable to use microlaryngoscopy, which allows examining all parts of the larynx inaccessible to conventional direct and especially indirect laryngoscopy. When palpating a part of the larynx that is suspected of containing a foreign body with a metal probe, it may be detected in the folds of the edematous mucous membrane or in mucopurulent deposits among granulation tissue and exfoliated flaps of the mucous membrane.

Foreign bodies of the larynx should be differentiated from large foreign bodies of the esophagus in the cervical region, compressing the larynx and causing respiratory and voice production disorders. In these cases, esophageal radiography with contrast helps with diagnosis. As for X-ray diagnostics of foreign bodies of the larynx, it is possible only with radiopaque foreign bodies and large fragments of bone tissue, but it is mandatory in all cases, since it helps diagnose secondary complications of foreign bodies (chondroperichoiditis, phlegmon of the larynx, mediastinal emphysema, mediastinitis).

In young children, foreign bodies in the larynx should be differentiated from laryngospasm (false croup), subglottic laryngitis, whooping cough, diphtheria, and laryngeal papillomatosis. In adults, chronic foreign bodies in the larynx are differentiated from hypertrophic laryngitis, cysts, tuberculosis, syphilis, and laryngeal tumors.

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Treatment of foreign bodies in the larynx

Foreign bodies in the larynx, even small ones, are life-threatening, since the peculiarity of the laryngeal tissues and its reflexogenic zones is the rapid development of obstructive edema and almost instantaneous reflex laryngospasm. Therefore, in all cases of non-obstructive foreign bodies in the larynx, an ambulance should be called immediately or the victim should be transported by improvised transport to the nearest medical facility with an endoscopist or ENT specialist. Removal of foreign bodies is performed only under visual control at the earliest possible stage in order to prevent the development of edema, which greatly complicates the extraction procedure and is fraught in some cases with traumatic complications (rupture of the mucous membrane, vestibular or vocal fold, subluxation of the cricoarytenoid cartilage, etc.). Only in the case of asphyxia due to the localization of foreign bodies in the laryngopharynx before the arrival of a health worker is it permissible to attempt to remove it with a finger, in which case, however, it is possible to push the foreign body into the deeper parts of the larynx. Some authors recommend striking the occipital part of the neck with the edge of the palm to dislocate and expel foreign bodies. Probably, the mechanism of such removal consists in the transfer of shock wave energy to the internal tissues of the neck in the direction of the foreign body and its propulsion into the oropharynx.

Asphyxia can be prevented by tracheotomy or intercricothyroidal laryngotomy, as a result of which life-saving breathing is restored "at the tip of a scalpel". Removal of a wedged foreign body is performed after tracheotomy, and the tracheostomy is used for intubation anesthesia. The position of the victim and the procedure for direct laryngoscopy are described above. In small children, direct laryngoscopy and removal of a foreign body are performed without local anesthesia, which is fraught with reflex respiratory arrest, but under premedication with phenobarbital, which acts as an anticonvulsant, and chloral hydrate.

The most difficult to remove are foreign bodies wedged into the laryngeal ventricles, pyriform sinuses and subglottic space. Removal of such foreign bodies is performed after tracheotomy, and the tracheotomy opening can be used to push the foreign body upward or remove it through a tracheostomy. When removing foreign bodies from the larynx, reflex respiratory arrest may occur, for which medical personnel must be prepared, having at their disposal the means necessary to restore respiratory function (oxygen, carbogen, respiratory analeptics - lobelia, cytitone, etc.).

In case of old foreign bodies in the larynx, thyrotomy with preliminary tracheotomy is indicated, especially in the presence of granulations, bedsores and ulcers or signs of chondroperichondritis, perforation of the larynx. This surgical intervention pursues two goals - removal of foreign bodies and sanitizing manipulations to eliminate secondary complications.

In all cases of foreign bodies in the larynx, broad-spectrum antibiotics are indicated to prevent secondary complications, as well as sedatives, analgesics, and in some cases tranquilizers.

What is the prognosis for foreign bodies in the larynx?

Foreign bodies in the larynx have a serious prognosis, especially in young children, who are more prone to severe asphyxia and rapid death. In general, the prognosis depends on the degree of laryngeal obstruction and the timeliness of effective medical care.