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Figure 1:  Thorny Foreign Body (Achyranthus aspera) on the Vocal Cord and After Removal
 

Authors:  Rupender K Ranga, M.S., S.P.S.*, Yadav, M.S.**, Jagat Singh, M.S.***, Rohtas Sehrawat, M.D.*

Institution:   * Bharat ENT & Endoscopy Hospital, Rohtak Gate- Bhiwani-127021. Haryana (India),
** Department of Otorhinolaryngology, Pt.BD Sharma PGIMS- Rohtak 124001 Haryana (India),
*** Department of Otorhinolaryngology, Pt.BD Sharma PGIMS- Rohtak 124001 Haryana (India).

Summary:

The vast majority of inhaled or ingested foreign bodies are results of carelessness. A thorny foreign body (Achyranthus asprea) got impacted on the vocal cord in a young girl which was removed by direct laryngoscopy using propofol as the sole anesthetic without intubation.  There was complete restoration of normal voice postoperatively. The
accidental inhalation or ingestion of a foreign body, however, is entirely preventable.

Introduction:

Foreign body impaction in adults on the vocal cord is not a common clinical entity; however, various foreign bodies are described in literature in children which at times may prove a serious and life threatening emergency.  The most common foreign bodies aspirated are small food items, such as nuts, raisins, sunflower seeds, improperly chewed pieces of meat and small, smooth items such as grapes, hot dogs and sausages.1 Boys are more likely than girls to inhale foreign bodies at 1-2 years of age.2  Children have a tendency to put anything and everything into the mouth to determine their taste and texture.

The human body has numerous defense mechanisms to keep the airway free and clear of extraneous matters. Protection of lungs is provided at three levels: aryepiglotic folds, false vocal cords and true vocal cords.  At all the levels, the mucosal folds meet in the midline, closing the larynx in three tiers, effectively sealing the trachea.  This mechanism prevents food from entering the trachea.3  The larynx and the cough reflex is an important defense mechanism which prevents entry of a foreign body into respiratory tract.  When a foreign body reaches the laryngeal inlet it triggers a cough reflex just by touching the laryngeal mucosa.  Enormous air pressure is built up against the vocal cord and released suddenly to force the foreign body out of the larynx.4  We report an unusual thorny foreign body in a young girl on the vocal cord without classical sign and symptoms of foreign body inhalation.

Case Report:

An 18 year old girl from  the countryside presented with hoarseness of 3 hours duration. When she went to the fields to collect fodder for cattle she accidently inhaled some object during inspiration.  She felt something in the throat followed by an episode of cough and pain in the neck region.  She didn’t have any respiratory distress.  On auscultation, air entry was equal on both sides.  There was no cyanosis or intercostal retractions.

 Indirect endoscopic examination revealed an irregular object on the right vocal cord with thick secretions (Fig. 1).  Soft tissue lateral x-ray was obtained which was inconclusive. Routine investigations were done for anesthetic fitness.  Direct laryngoscopy was done without intubation using intravenous propofol and the thorny foreign body was visualized, grasped with forceps and removed. There was immediate improvement in the voice of the girl after recovery from anesthesia.  Postoperative period was uneventful.  She was put on a 1000 mg augmentin tablet, 1 twice a day, tablet wysolone 40 mg once a day and voveran 50 mg, 1 three times a day.  On follow up, she had normal vocal cord movements and normal voice.

Discussion:

The most common cause of accidental death at home in children under 6 years of age is inhalation of a foreign body (National Safety Council of America, 1980).  Although cases of asymptomatic foreign bodies in the respiratory tract have been reported, the majority of foreign bodies pass through the glottis into the trachea or bronchus and get lodged there and not on the vocal cords.5  Literature reports many unusual foreign bodies in the respiratory tract which are likely to be trapped in the pharyngolaryngeal area are either sharp and pointed, sticking on the mucus membrane or irregular and soft being caught between the vocal cords due to laryngospasm.1,6

A foreign body present in the larynx is generally noted as a dire emergency, which needs immediate intervention.  Clinical diagnosis of such entities is easier as alarming obstructive symptoms like chocking, gagging, stridor, pain, hoarseness are present which may prove fatal.7

Achyranthus aspera (Bharunth) is a small erect common roadside herb and a common crop found in the plains and hills up to an elevation of 1500 meters.  Bharunth is an oval achne, enclosed in a hardened involucral bract of about 0.5 cm size with numerous bristles.8  The color varies from light yellow to brown (Fig. 1).  However, it’s impaction on the vocal cords is rarely seen.  Somewhat similar foreign bodies in upper airway, belonging to different species, i.e,. Canchrus biflorus and Xanthium strumarium have been reported, however, this foreign body is smaller and lighter.7,9  As the girl worked in the field, she had to hyperventilate due to physical exertion with open mouth and divided attention.  The foreign body which was floating in the air was aspirated during inspiration.  If coughing is forceful, it may be expelled out of the larynx.   On the other hand, if expiratory coughing is weak and the resistance offered by the aryepiglotic fold is enough, the foreign body is held on the vocal cords as probably was the case in our patient.  Foreign body was removed under general anesthesia using propofol with 2.5 mg/kg of body weight which is a short-acting agent with rapid onset of action of approximately 30 - 40 seconds.10  The effect of propofol persists for at least 5-10 minutes which is enough time to remove the foreign body.

Utmost care should be taken while removing these foreign bodies under anesthesia without intubation.  After removal, the foreign body should be inspected for missing bristles as one of these might have penetrated the mucosa and many could have remained impacted during removal.  The larynx should be inspected for missing bristles. But the dilemma is that one never knows how many bristles were already missing, when the foreign body was inhaled.8  Rarely, foreign bodies lodge in the esophagus without respiratory symptoms.11

References:

1) Eren S, Balci AE, Dikici B, Doblan M, Eren MN. Foreign body aspiration in children: experience of 1160 cases. n Trop Paediatr. 2003 Mar;23(1):31-7.   View Abstract

2) Brown TC, Clark CM. Inhaled foreign bodies in children. Med J Aust. 1983 Oct 1;2(7):322-6.  View Abstract

3) Mathieson L, Carding P. Physiology of larynx. In: Gleeson M, editor. Scott- Brown’s Otorhinolaryngology, Head and Neck Surgery. London: Hodder Arnold, 2008:2155- 69. 

4) Rothmann BF, Boeckman CR. Foreign bodies in the larynx and tracheobronchial tree in children. A review of 225 cases. Ann Otol Rhinol Laryngol. 1980 Sep-Oct;89(5 Pt 1):434-6.   View Abstract

5) Vaid L. Asymptomatic impacted foreign body of larynx.  Indian J Otolaryngol Head Neck Surg.  2003; 55(4):285- 87.  View Abstract

6) O'Neill JA Jr, Holcomb GW Jr, Neblett WW. Management of tracheobronchial and esophageal foreign bodies in childhood. J Pediatr Surg. 1983 Aug;18(4):475-9.  View Abstract

7) Kohli GS, Yadav SP, Sahni JK, Goel H, Jain L. Thorny foreign bodies of upper airway. Indian J Chest Dis Allied Sci. 1989 Apr-Jun;31(2):105-8.  View Abstract

8) Jain P, Yadav SP, Singh J. Hoarseness in a child--an unusual cause. Indian J Pediatr. 1995 Sep-Oct;62(5):629-30.   View Abstract

9) Soni NK, Chatterji P. Thorny foreign bodies of upper passage.  Indian J Otolaryngol 1978 30: 178.

10) ngley MS, Heel RC. Propofol. A review of its pharmacodynamic and pharmacokinetic properties and use as an intravenous anaesthetic. Drugs. 1988 Apr;35(4):334-72.  View Abstract

11) Kapila RK, Singal P, Gupta SK, Samdhani S, Sharma SD, Srivastava SP. Rare impacted foreign bodies of larynx. Indian J Otolaryngol Head Neck Surg.  2010 62(1):84- 87.   View Abstract

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