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

Foreign bodies of the larynx are much less common than foreign bodies of the trachea or foreign bodies of the bronchi, and make up, according to different authors, 4 to 14% of the number of foreign bodies of the upper respiratory tract.

Most of the foreign bodies trapped in the larynx overcome its space and get stuck in the right main bronchus, the angle of departure of which from the trachea is much less than the left main bronchus. In the larynx, mainly spiky foreign bodies (fish and thin chicken bones, needles, dentures, fragments of the walnut shell, metal objects) are retained. Often in the larynx leeches are fixed, which get into it when drinking water from natural bodies of water - the habitat of these annelids. The most common foreign bodies of the larynx are observed in children aged 5-7 years. Often, foreign bodies of the respiratory tract are observed in old people with weakened protective pharyngeal and terminal reflexes and in mentally ill persons.

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

Pathogenesis of foreign bodies of the larynx

Foreign bodies of the larynx can occur from the oral cavity during meals, from the nasal cavity and nasopharynx, where they fall during children's games and from where they aspirate into the larynx, and also retrograde with coughing of the trachea and bronchi or during vomiting from the stomach and esophagus. Foreign bodies of the larynx, related to iatrogenic, can arise during adenotomy and tonsillotomy (aspiration of the removed lymphadenoid tissue, a fragment of the surgical instrument). The most frequent mechanism of foreign bodies of the larynx is a sudden aspiration by foreign bodies, which occurs during eating with laughter, sneezing, talking, unexpected blow to the back of the head. Aspiration by foreign bodies can occur during sleep, in a state of intoxication or drowsiness, with distraction or fright. Foreign bodies of the larynx can be observed with some bulbar syndromes, prone to which the sensitivity of the pharynx and larynx is disturbed, with neuritis of the sensitive nerves of the larynx, etc.

Foreign bodies of the larynx mostly belong to the number of immobile, wedged. They get stuck in the larynx due to the large size, roughness of the edges or rough surface, and also due to the reflex (protective) spasm of the larynx constrictor. Due to the last reason, most foreign bodies get stuck with their main mass in the inter-head space above the glottis; one of the ends of this foreign body can be located in the ventricle of the larynx, and the other - in the region 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 at one end in the anterior commissure, the other in the back wall of the lining space or in the arytenal region. Foreign bodies, stuck in the throat of the pharynx, provoke a pronounced edema of the lining space, especially in children. Having penetrated into the depth of the edema, these foreign bodies are found with difficulty. According to N.Costinescu (1904), 50% of foreign bodies of the larynx, having tracheobronchial origin, are localized in the lining space.

Foreign bodies of the larynx, irritating and traumatizing its mucous membrane, cause the onset of edema and inflammation, the severity of which depends on the nature of the foreign body, the duration of its stay in the larynx and the attachment of a secondary infection. Sharp foreign bodies can perforate the larynx and penetrate into neighboring areas. These perforations are the entrance gates for secondary infection (perichondritis, perilaryngeal abscesses, mediastinitis, thrombosis of the external jugular vein). Long stay of foreign bodies in the larynx causes bedsores, contact ulcers, contact granulomas, secondary infection, and after their removal - this or that degree of cicatricial stenosis of the larynx.

Symptoms of foreign bodies of the larynx

Foreign bodies of considerable size (a piece of meat, adenoid growths, an aspirated tampon, etc.), characterized by a soft elastic consistency, with reflex spasm of the larynx, as a rule, completely cover the larynx, leaving no cracks and moves for at least minimal breathing, to death from asphyxiation. If the laryngeal obstruction is not complete, the foreign body provokes powerful means of protection, which not all play a positive role, for example protective spasm, while a strong paroxysmal cough, nausea and vomiting promote the expulsion of foreign bodies from both the larynx and the larynx. Very quickly, within a dozen seconds, there is a cyanosis of the face, on which the expression of extreme fright is imprinted. The victim begins to rush, his movements become disorderly, a hoarse voice and convulsive breathing movements are vain. Such a state can last 2-3 minutes, and if the foreign body is not ejaculated or somehow not removed, then the consciousness quickly leaves the patient, it falls into a coma and a state of clinical death. In time, unrestored respiration (within 7-9 min) leads to death from cardiac and respiratory activity. If it is possible to restore cardiac and respiratory activity through the indicated time interval or somewhat earlier, then there is a threat of partial or complete deactivation of cortical centers, at which a syndrome of decortication of different depth develops, as a result of which the patient passes to a vegetative lifestyle. If the foreign body wedges between the true vocal folds and prevents them from closing, and there remains space for a minimum passage of air, then sudden aphonia and some degree of dyspnea occur. The perforation of the larynx by a foreign body can lead to emphysema, especially with an expiratory impairment of breathing, when the perforation creates an obstacle to the expiration of the air.

Diagnosis of foreign bodies of the larynx

Diagnosis of foreign bodies of the larynx in acute cases does not cause difficulties; it is based on suddenness, external signs of sudden reflex irritation of sensitive laryngeal receptors, paroxysmal cough, dysphonia or aphonia, dyspnea or apnea. It is more difficult to diagnose chronic cases with delayed treatment of the injured to the doctor. Most often, such cases are observed with non-obstructive foreign bodies of the larynx, when respiration remains satisfactory, and various local complications (infected sore throat, edema, perichoiditis, etc.) begin to accompany the wedged foreign body.

[6], [7], [8], [9], [10]

Differential diagnosis of foreign bodies of the larynx

Often in acute cases of foreign bodies of the larynx, the emerging symptoms can simulate functional laryngeal spasm (eg, hysterical genesis), diptheria croup, lumbar lining, allergic edema. In older children and adults, indirect laryngoscopy is used, in which the foreign body is easily detected. In young children, direct laryngoscopy is more effective, which, in addition to diagnosis, pursues the therapeutic goal of removing the foreign body. Before laryngoscopy, an appropriate anesthesia must be made, including the use of diphenhydramine and atropine in injections, topical application or pulverization of dicaine or cocaine. Opioids are contraindicated due to their depressant effect on the respiratory center.

If the patient turns to the doctor with a significant delay, while complaining about the hoarseness of the voice, a periodic paroxysmal cough with expectoration of mucopurulent sputum, the sensation of a foreign body in the throat, dyspnea in physical work, often on the evening subfebrile condition, along with a significant number of all kinds diseases, it should be suspected and the presence of a chronic foreign body of the larynx. Such foreign body with prolonged (more than 5 days) stay in the larynx is covered with granulation tissue, swollen mucous membrane, mucopurulent discharge, which makes it difficult to detect it. In such cases, it is advisable to use a micro-laryngoscopy, which makes it possible to inspect all parts of the larynx that are inaccessible to ordinary straight and especially indirect laryngoscopy. When palpating with a metal probe, suspicious of the presence of a foreign body part of the larynx, it is possible to detect it in the folds of the swollen mucous membrane or in mucopurulent deposits among the granulation tissue and exfoliated mucosal flaps.

Differentiation of foreign bodies of the larynx follows from large foreign bodies of the esophagus in the cervical region, squeezing the larynx and causing disruption of breathing and voice formation. In these cases, radiography is assisted by X-rays of the esophagus with contrast. With regard to X-ray diagnostics of foreign bodies of the larynx, it is possible only with radiopaque foreign bodies and large fragments of bone tissue, however, it is mandatory in all cases, since it helps to diagnose secondary complications of foreign bodies (chondroperichoideritis, laryngeal phlegmon, mediastinitis, emphysema) .

In young children, the foreign bodies of the larynx should be differentiated from laryngospasm (false croup), lumbar lining, pertussis, diphtheria and laryngeal papillomatosis. In adults, the chronic foreign body of the larynx differentiates from hypertrophic laryngitis, cysts, tuberculosis, syphilis and laryngeal tumors.

[11], [12], [13]

Treatment of foreign bodies of the larynx

Foreign bodies of the larynx, even small ones, pose a danger to life, since the peculiarity of the larynx tissues and its reflexogenic zones are the rapid occurrence of the stalking edema and the almost instantaneous reflex laryngospasm. Therefore, in all cases of non-obstructive foreign bodies of the larynx, an immediate call of an "ambulance" or the delivery of an injured person with an improvised transport to the nearest medical institution in which there is an endoscopist or an ENT specialist is required. Removal of foreign bodies is performed only under the control of vision at the earliest possible time to prevent the occurrence of edema, which sharply complicates the extraction procedure and is fraught with traumatic complications in a number of cases (rupture of the mucosa, vestibular or vocal fold, subluxation of the periclamer pterygoid cartilage, etc.). Only in case of occurrence of asphyxiation, when foreign bodies are localized in the larynx to the arrival of a health worker, an attempt is made to remove it with the help of a finger, in which, however, it is possible to push a foreign body into the deeper parts of the larynx. Some authors recommend to make impacts with an edge of the palm but the occipital part of the neck for the dislocation of foreign bodies and its erasure. Probably, the mechanism of such removal consists in transferring the energy of the shock wave to the internal tissues of the neck in the direction of the foreign body and propulsing it into the oropharynx.

Asphyxia can be prevented by tracheotomy or intercricotireoidal laryngotomy, as a result of which the rescue breath is restored "at the tip of the scalpel." Removal of the wedged foreign body is performed after a tracheotomy, while the tracheostomy is used for intubation anesthesia. The position of the victim and the procedure for direct laryngoscopy are described above. In young children, direct laryngoscopy and removal of a foreign body are performed without local anesthesia, fraught with reflex stopping of respiration, and under premedication with phenobarbital acting as an anticonvulsant and chloral hydrate.

The most difficult to remove are foreign bodies, wedged into the ventricles of the larynx, pear-shaped sinuses and lining space. Removal of such foreign bodies is performed after a tracheotomy, and the tracheotomy can serve to push a foreign body upward or to remove it from the tracheostomy. When removing foreign bodies of the larynx, a reflex stop of the respiration may occur, to which the medical staff should be ready, having at their disposal the means necessary for restoring the respiratory function (oxygen, carbogen, respiratory analeptics - lobelia, cytiton, etc.).

In the case of chronic foreign bodies of the larynx, thyreotomy with a pre-tracheotomy is indicated, especially in the presence of granulations, pressure ulcers and ulcers or phenomena of chondroperichondritis, perforation of the larynx. This surgical intervention has two goals - removing foreign bodies and sanitizing manipulations to eliminate secondary complications.

In all cases, foreign bodies of the larynx show the appointment of broad-spectrum antibiotics for the prevention of secondary complications, as well as sedative, analgesic and in some cases tranquilizing agents.

What prediction do foreign bodies of the larynx have?

Foreign bodies of the larynx have a serious prognosis, especially in young children, which are more located to severe asphyxia and rapid lethal outcome. In general, the prognosis depends on the degree of obstruction of the larynx and the timeliness of providing effective medical care.