Foreign bodies of the pharynx: causes, symptoms, diagnosis, treatment

Foreign bodies of the pharynx belong to the category of damaging factors, since the result of their action on the pharyngeal wall may be abrasions, punctures of the mucosa and lesions of deeper layers of the pharynx. They are classified by the nature of their occurrence (exogenous, endogenous), by localization (nasopharynx, oropharynx, larynx), by origin (by negligence, intentional, accidental).

Pathogenesis and clinical picture. Pharynx is the main barrier to the path of foreign bodies, preventing their penetration into the respiratory and esophagus pathways. This is facilitated by a series of anatomical conditions and reflexes that lie in the way of foreign bodies. The main mechanism of protection against foreign bodies is the reflex spasm of pharyngeal pulp that occurs in response to the sensation of an alien body in the oropharynx or the laryngopharynx. Domestic foreign bodies are most often localized in the palatine tonsils, the posterior wall of the oropharynx, in lateral ridges, in the crevices between the palatine arch, in the epiglottis, lingual tonsils and pear-shaped sinuses. Most often these are small bones and objects that fall into the oral cavity with food or are deliberately kept by the lips (nails, pins, screws, etc.). Often, foreign bodies becomes a removable denture, dislocated during sleep. Introduced acute small foreign bodies cause considerable anxiety, because when swallowing, talking and even breathing they cause pain and often spasms of the pharyngeal musculature, depriving the patient not only of normal oral nutrition but also of sleep. Foreign bodies of the oropharynx are usually well visualized and easily removed. The situation is worse with thin fish bones, which are much worse. Also, foreign bodies of the laryngeal part of the pharynx and the laryngopharynx are poorly visualized, especially in the region of pear-shaped sinuses, between the root of the tongue and the epiglottis, in the region of the arytenoid folds. Pain with foreign bodies of the pharynx is especially pronounced with an empty pharynx. They can radiate into the ear, the larynx, cause perspiration and cough. At the site of the introduction of foreign bodies in the surrounding tissues, an inflammatory reaction may develop, sometimes a peritonsillar abscess, and with deep implantation - an extra-pharyngeal abscess. Localization of foreign bodies in the nasopharynx is a rare phenomenon. These foreign bodies occur for various reasons: during the extraction of the tooth or during manipulations in the nasal cavity, or during the ejection of foreign bodies from the throat part of the pharynx by a sharp coughing thrust. Most foreign bodies of the nasopharynx are observed in paralysis of the soft palate.

The most dangerous are the foreign bodies of the larynx of the pharynx. They cause so much pain that swallowing becomes impossible. And since with foreign bodies of the pharynx there is abundant salivation, the inability to swallow the saliva due to pain causes the secretion of it from the mouth cavity through the lips, which are macerated and inflamed. Voluminous foreign bodies of the laryngopharynx exert pressure on the larynx, causing a violation of external respiration. Especially dangerous are elastic foreign bodies, for example, meat, which tightly obturate the laryngopharynx as a result of spasm of its lower constrictors, leaving no slit (which is usually characteristic of solids) for air passage. There are numerous examples of the death of people precisely from the meat foreign bodies of the larynx.

A special category of foreign bodies of the pharynx are living objects (ascarids, leeches). The first (endogenous) are retrograde from the intestine, the latter - when drinking water from the pond. To endogenous foreign bodies are also the petrifications of palatine tonsils, which appear in the crypts by impregnation of calcium salts with their caseous contents (like petrificates of primary pulmonary tuberculosis in the basal lymph nodes), as well as by calcification of intramundinal abscesses.

The diagnosis is established based on anamnesis, endoscopic picture and (in the presence of indications for a radiopaque foreign body) radiographic examination. With a low-lying foreign body, direct hypopharyngoscopy is resorted, especially if the foreign body is located behind the cricoid cartilage. If a foreign body can not be detected, they are guided by a local inflammatory reaction: hyperemia, swelling, abrasion. In case of ineffective searches for a foreign body, anti-edematous treatment, analgesics and sedatives, as well as antibiotics, are prescribed. It happens that the foreign body before penetrating 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 carried out more freely without external drooling. When complaining about a feeling of discomfort and pain in the chest area, one should suspect the foreign body of the esophagus and take appropriate measures.

Treatment for foreign bodies is carried out by removing them. Curious is the attitude of VI Voyachek to the tactics of treatment of foreign bodies of the ENT organs, which is reflected by the author in the following classification of the variants of localization, foreign bodies and possible actions.

• Option 1. The foreign body is hard to reach, but does not pose an immediate danger to the patient. The removal of such foreign bodies can be delayed and performed by a specialist under appropriate conditions.
• Option 2. The foreign body is hard to reach and represents a certain danger for the patient, but not for the cattle. Removal of such a foreign body is shown in the shortest time in a specialized department.
• Option 3. The foreign body is easily accessible and does not present immediate danger to the patient. Such a foreign body can be removed by an ENT specialist in a polyclinic or a hospital without special haste, but within the next few hours.
• Variant 4. The foreign body is easily accessible and presents a certain danger for the patient, but not for life. Such a foreign body can be removed by an ENT specialist in a polyclinic or a hospital without special haste, but within the next few hours.

If the foreign body poses an immediate threat to life (obstructive asphyxia), then attempts to remove it are made at the scene of the accident before the arrival of the special ambulance crew present finger method. For this, the victim is put on the stomach and wound on the side wall of the oral cavity in the laryngopharynx with two fingers, bypasses the foreign body from the side wall, fetuses his fingers and raps him into the oral cavity. After removal of the foreign body, if necessary, they resort to mechanical ventilation and other resuscitation measures.

When gunshot foreign bodies neck and throat are often resorted to non-standard access to these bodies. So, Yu.K.Yanov and LNGlaznikov (1993) indicate that in some cases it is more expedient (safer and more accessible) to implement an approach to a foreign body through the contralateral cut. For example, a wounding object penetrating the neck in the posterior front direction at the level of the mastoid process behind the sternocleidomastoid muscle belongs, according to VI Voyachek's classification, to hard-to-reach foreign bodies, Its extraction by external access conceals the danger of damage to the facial and other nerves. After an 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, penetrated through the side surface of the neck, usually use the wound channel, while performing surgical treatment of the wound. In some cases, a special surgical metal detector is used to detect a metallic foreign body in the wound, or it is searched using an ultrasound scan. In the presence of these gunshot foreign bodies in the throat part of the pharynx and the impossibility of using the wound channel, one of the types of transverse pharyngotomy is used.

Foreign bodies accessible to visual inspection are removed with the help of nasal coronzanga or Brunings forceps. Stones of the tonsils are removed by the method of tonsillectomy. The greatest difficulties occur when removing a foreign body from the throat part of the pharynx. After the application anesthesia and the introduction of atropine to reduce salivation under visual control with the use of a laryngeal mirror, foreign bodies are removed with laryngeal forceps. With hard-to-reach foreign bodies located in pear-shaped sinuses or in retro-laryngeal space, direct laryngoscopy is used, which should be performed carefully with sufficiently deep local anesthesia to prevent spasm of the larynx. Dentures inserted in the larynx of the pharynx, especially when there was edema in this area, and if they can not be removed naturally, they are removed by one of the methods of pharyngotomy. Depending on the location of foreign bodies, a transverse sublingual nylon is used for supra-lingual, or transverse-lateral pharyngotomy.

The least traumatic and providing wide access to the throat part of the pharynx, in our opinion, is the transverse phantom pharyngotomy (first in Russia was made in 1889 by NV Sklifosofsky). The technique for carrying it out is as follows.

A skin incision length of 8-10 cm is made at the level of the lower edge of the hyoid bone. Cross directly at the bone of the sternum-tongue, shovel-sublingual and thyroid-secretory muscles, then the lining of the subterranean membrane. They pull the hyoid bone up and forward and, adhering to its back surface, penetrate into the pregothrane space. Dissect fatty tissue, mucous membrane and penetrate into the pharynx between the root of the tongue and the epiglottis. After the search and removal of the non-fire foreign body, the wound is sewn layer by layer. After removal of the fire foreign body, surgical processing of the gunshot wound is performed with preservation of drainage in it, and the wound produced during pharyngotomy is layer-by-layer sewn with leaving thin rubber graduates for 1-2 days. At the same time, antibiotics of a wide spectrum of action and decongestants and sedatives are prescribed. If there is a need for greater access to the laryngopharynx, the thyroid cartilage is pulled downwards, the hooks expand the wound and the epiglottis, sewn with a thread, is pulled out. If it is not possible to perform the operation under local infiltration anesthesia, a tracheotomy is performed and the operation is performed under intratracheal anesthesia. When the laryngopharynx is injured with damage to the larynx, the tracheostomy is retained until the patient is finally cured and breathing normalized through natural pathways.

Removal of foreign bodies from the nasopharynx should be done carefully with a reliable fixation of its removal tool to prevent its accidental entry into the lower parts of the pharynx, larynx and esophagus. In this case, the arcuate forceps are injected into the nasopharynx under the control of the second finger of the other hand, and the patient is on his back with a shaved head behind his head.

[1], [2], [3], [4], [5], [6], [7]