An impacted fish bone in the subglottis manifesting as protracted stridor: photodocumentation.

A 1-year-old boy presented with a 2-day history of stridor and cough and associated low-grade fever. His condition was initially treated as acute laryngotracheitis, and he was given salbutamol (albuterol) and budesonide by nebulizer. An antibiotic was also prescribed to cover for possible bacterial tracheitis.

Despite drug therapy, the patient continued to experience fluctuating stridor. When his symptoms became severe, he was transferred to the pediatric intensive care unit for close monitoring; he also received a dose of epinephrine by nebulizer. At 12 days after admission, his symptoms had still not resolved, so an ENT evaluation was sought. Direct laryngoscopy under general anesthesia detected a complete fish vertebra (figure, A). The bone was impacted in the subglottis and surrounded by edematous mucosa. A small ulcer was also noted on the anterior surface of the right arytenoid cartilage. The vertebra was removed intact with a foreign-body--removal forceps (figure, B).

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Following the procedure, the child was put on intravenous dexamethasone and an antibiotic; he was later switched to oral preparations. His stridor diminished rapidly, and he was discharged the next day symptom-free.

Foreign-body inhalation is primarily a disease of toddlers. Patients usually present with a choking episode or short bouts of dry cough. In more severe cases, breathing difficulties, fever, and prolonged coughs may develop. Although radiologic imaging is helpful, it may be negative if the foreign body is radiolucent. A careful history and a high index of suspicion are more important to the diagnosis.

For patients with unexplained stridor, the presence of a foreign body in the airway should be ruled out. The subglottic area is the narrowest part of the larynx, and an undetected foreign body could cause edema and ultimately result in a fatal outcome.

Good cooperation between the surgeon and anesthetist is necessary during examination under anesthesia. Meticulous removal technique is required to avoid a laceration or perforation of the airway.

In the case described here, the presence of the subglottic fish bone was masked by the fluctuating stridor, which did not respond to bronchodilators and antibiotics. The delay in mechanical intervention resulted in significant subglottic edema, which further reduced the patency of the airway that was already compromised by the fish bone.

We believe this is the first photodocumented case of a fish bone in the subglottic area to be published in the literature.

Omar Rahmat, MS; Wye Keat Lira, FRCS; Narayanan Prepageran, FRCS

From the Department of Otolaryngology, University Malaya Medical Center, Kuala Lumpur.