Pharyngeal foreign bodies: causes, symptoms, diagnosis, treatment

Foreign bodies in the pharynx are classified as damaging factors, since their effect on the pharyngeal wall can result in abrasions, punctures of the mucous membrane, and damage to deeper layers of the pharynx. They are classified by the nature of their occurrence (exogenous, endogenous), by localization (nasopharynx, oropharynx, laryngopharynx), by the conditions of origin (negligence, intentional, accidental).

Pathogenesis and clinical picture. The pharynx is the main barrier to foreign bodies, preventing them from penetrating the respiratory and esophageal tracts. This is facilitated by a number of anatomical conditions and reflexes that lie in the path of foreign bodies. The main mechanism of protection against foreign bodies is a reflex spasm of the pharyngeal sphincter, which occurs in response to the sensation of a foreign body in the oropharynx or laryngopharynx. Domestic foreign bodies are most often localized in the palatine tonsils, the posterior wall of the oropharynx, in the lateral ridges, in the gaps between the palatine arches, in the epiglottic fossa, the lingual tonsil and the pyriform sinuses. Most often, these are small bones and objects that have entered the oral cavity with food or are deliberately held by the lips (nails, pins, screws, etc.). Often foreign bodies become removable dentures, dislocated during sleep. The embedded sharp small foreign bodies cause significant discomfort, since they cause pain and often spasms of the pharyngeal muscles during swallowing, talking and even breathing movements, depriving the patient not only of normal oral nutrition, but also sleep. Foreign bodies of the oropharynx are usually well visualized and easily removed. The situation is worse with thin fish bones, which are much more difficult to detect. Foreign bodies of the laryngeal part of the pharynx and laryngopharynx are also poorly visualized, especially in the area of the piriform sinuses, between the root of the tongue and the epiglottis, in the area of the arytenoid folds. Pain from foreign bodies in the pharynx is especially pronounced with an empty throat. They can radiate to the ear, larynx, cause a sore throat and cough. At the site of foreign body penetration, an inflammatory reaction may develop in the surrounding tissues, sometimes a peritonsillar abscess, and with deep penetration - a retropharyngeal abscess. Localization of foreign bodies in the nasopharynx is a rare phenomenon. These foreign bodies occur for various reasons: during tooth extraction or during manipulations in the nasal cavity, or during the ejection of foreign bodies from the laryngeal part of the pharynx with a sharp cough push. More often, foreign bodies of the nasopharynx are observed with paralysis of the soft palate.

The greatest danger is posed by foreign bodies in the laryngopharynx. They cause such severe pain that the act of swallowing becomes impossible. And since foreign bodies in the pharynx cause profuse salivation, the inability to swallow saliva due to pain causes it to be released from the oral cavity through the lips, which become macerated and inflamed. Bulky foreign bodies in the laryngopharynx put pressure on the larynx, causing a disruption of external respiration. Particularly dangerous are elastic foreign bodies, such as meat ones, which tightly obstruct the laryngopharynx as a result of a spasm of its lower constrictors, leaving not the slightest gap (which is usually characteristic of solid bodies) for the passage of air. There are numerous examples of people dying from meat foreign bodies in the laryngopharynx.

A special category of foreign bodies in the pharynx are living objects (ascarids, leeches). The former (endogenous) enter retrograde from the intestines, the latter - when drinking water from a pond. Endogenous foreign bodies also include petrifications of the palatine tonsils, which arise in the crypts by impregnation with calcium salts of their caseous contents (similar to petrifications of primary pulmonary tuberculosis in the hilar lymph nodes), as well as by calcification of intra-tonsillar abscesses.

The diagnosis is established based on the anamnesis, endoscopic picture and (if there are indications of a radiopaque foreign body) X-ray examination. In case of a low-lying foreign body, direct hypopharyngoscopy is used, especially if the foreign body is located behind the cricoid cartilage. If the foreign body cannot be found, then the local inflammatory reaction is used as a guide: hyperemia, edema, abrasion. If the search for a foreign body is unsuccessful, anti-edema treatment, analgesics and sedatives, as well as antibiotics are prescribed. It happens that a foreign body, before penetrating further into the esophagus (stomach), causes damage to the mucous membrane of the pharynx, which causes pain, but the intensity of these sensations is not as pronounced as in the presence of a foreign body, and swallowing movements are performed more freely without external salivation. If there are complaints of discomfort and pain in the sternal region, a foreign body in the esophagus should be suspected and appropriate measures should be taken.

Treatment of foreign bodies is carried out by their removal. The attitude of V.I. Voyachek to the tactics of treatment of foreign bodies of ENT organs is curious, which is reflected by the author in the following classification of variants of localization of foreign bodies and possible actions with them.

• Option 1. The foreign body is difficult to access, but does not pose an immediate danger to the patient. Removal of such a foreign body can be delayed and performed by a specialist under appropriate conditions.
• Option 2. The foreign body is difficult to access and poses a certain danger to the patient, but not to the life. Removal of such a foreign body is indicated as soon as possible in a specialized department.
• Option 3. The foreign body is easily accessible and does not pose an immediate danger to the patient. Such a foreign body can be removed by an ENT specialist in a clinic or hospital without any particular rush, but within the next few hours.
• Option 4. The foreign body is easily accessible and poses a certain danger to the patient, but not to life. Such a foreign body can be removed by an ENT specialist in a clinic or hospital without any particular rush, but within the next few hours.

If a foreign body poses an immediate threat to life (obstructive asphyxia), then attempts to remove it are made at the scene of the incident before the arrival of a special ambulance team by those present using the digital method. To do this, the victim is placed on his stomach and two fingers are inserted along the side wall of the oral cavity into the laryngopharynx, they are used to bypass the foreign body from the side wall, insert the fingers behind it and scoop it out into the oral cavity. After removing the foreign body, if necessary, artificial ventilation and other resuscitation measures are used.

In case of gunshot foreign bodies of the neck and pharynx, non-standard approaches to these bodies are often used. Thus, Yu.K. Yanov and L.N. Glaznikov (1993) indicate that in a number of cases it is more expedient (safer and more accessible) to approach the foreign body through a contralateral incision. For example, a wounding object that has penetrated the neck in the posteroanterior direction at the level of the mastoid process behind the sternocleidomastoid muscle is classified, according to V.I. Voyachek's classification, as a hard-to-reach foreign body. Its removal by external access poses the risk of damaging the facial and other nerves. After appropriate X-ray examination and establishing the position of the foreign body, it can be removed through the oral cavity.

To remove gunshot foreign bodies that have penetrated through the lateral surface of the neck, a wound channel is usually used, simultaneously performing surgical treatment of the wound. In some cases, a special surgical metal detector is used to detect a metal foreign body in the wound or it is searched for using ultrasound scanning. If the above-mentioned gunshot foreign bodies are present in the laryngeal part of the pharynx and it is impossible to use the wound channel, one of the types of transverse pharyngotomy is used.

Foreign bodies accessible to visual control are removed using nasal forceps or Brunings forceps. Tonsil stones are removed by tonsillectomy. The greatest difficulties are encountered when removing a foreign body from the laryngeal part of the pharynx. After application anesthesia and administration of atropine to reduce salivation, foreign bodies are removed under visual control using a laryngeal mirror with laryngeal forceps. In the case of hard-to-reach foreign bodies located in the pyriform sinuses or in the retrolaryngeal space, direct laryngoscopy is used, which should be performed carefully under sufficiently deep local anesthesia to prevent laryngeal spasm. Dentures wedged in the laryngeal part of the pharynx, especially if there is edema in this area, and if they cannot be removed naturally, are removed using one of the pharyngotomy methods. Depending on the location of foreign bodies, transverse sublingual or supragingual or transverse-lateral pharyngotomy is used.

In our opinion, the least traumatic and providing wide access to the laryngeal part of the pharynx is the transverse sublingual pharyngotomy (first performed in Russia in 1889 by N.V. Sklifosovsky). The technique for performing it is as follows.

An 8-10 cm long skin incision is made at the level of the lower edge of the hyoid bone. The sternohyoid, omohyoid, and thyrohyoid muscles are cut directly at the bone, then the thyrohyoid membrane. The hyoid bone is pulled upward and forward and, holding onto its posterior surface, the preglottic space is penetrated. The fatty tissue and mucous membrane are dissected and the pharynx is penetrated between the root of the tongue and the epiglottis. After finding and removing a non-gunshot foreign body, the wound is sutured layer by layer. After removing a gunshot foreign body, the gunshot wound is surgically treated while maintaining drainage in it, and the wound made during pharyngotomy is sutured layer by layer with thin rubber drains left in it for 1-2 days. Broad-spectrum antibiotics, decongestants, and sedatives are simultaneously prescribed. If wider access to the laryngopharynx is required, the thyroid cartilage is pulled downwards, the wound is widened with hooks and the epiglottis, stitched with a thread, is pulled out. If it is impossible to perform the operation under local infiltration anesthesia, a tracheotomy is performed and the operation is carried out under intratracheal anesthesia. In case of laryngopharyngeal injury with damage to the larynx, the tracheostomy is preserved until the patient is completely cured and breathing through natural passages is normalized.

Removal of foreign bodies from the nasopharynx must be done carefully, with reliable fixation of the body with a removal instrument to prevent accidental entry into the lower parts of the pharynx, larynx and esophagus. In this case, arc-shaped forceps are inserted into the nasopharynx under the control of the second finger of the other hand, and the patient is on his back with his head hanging back.

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