Aspirated foreign body in a laryngectomized patient: Case report and literature review.

Abstract

The presence of a permanent tracheal stoma in a laryngectomized adult is a predisposing factor for foreign-body aspiration, as are conditions that impair normal protective airway mechanisms. Such an aspiration can cause significant morbidity if it is not properly managed. The use of rigid bronchoscopy to remove an aspirated object can be difficult in these patients, and a high percentage of them require thoracotomy, especially for the removal of sharp objects. An emphasis on patient education regarding the handling of objects around the stoma in laryngectomized adults is key to preventing aspiration and its complications.

Introduction

Foreign-body aspiration into the tracheobronchial tree is not as common in adults as it is in children, except for adults who have predisposing factors--primarily an impairment of their protective airway mechanisms. [1,2] The presence of a permanent tracheal stoma appears to be one such predisposing condition because of the direct communication of the stoma with the surrounding external environment. However, there is a paucity of information in the literature concerning aspirated foreign bodies in patients with a permanent stoma. In view of the estimated 11,700 new cases of laryngeal cancer that occur every year in the United States--a significant percentage of which require laryngectomy and stoma placement--it seems appropriate to draw attention to this potentially life-threatening complication in this subgroup of patients.

Case report

A 61-year-old laryngectomized man came to the emergency room soon after he had aspirated a brush that he had been using to clean his tracheal stoma. The patient had undergone a total laryngectomy and neck dissection 3 months earlier. He denied any shortness of breath, cough, or chest pain. On physical examination, the man was not in any obvious acute respiratory distress, although he did exhibit diminished breath sounds over the left lung base. Admission chest x-rays revealed that the brush had settled in the left lower lobe bronchus (figure 1).

The patient was taken to the operating room, where an initial attempt to remove the object by flexible bronchoscopy and different grasping forceps was unsuccessful. Next, the patient was administered general anesthesia, and his neck was hyperextended and held in position by the anesthesiologist. A rigid bronchoscope was inserted via the stoma and directed into the left main stem bronchus. The brush, which was firmly wedged in the lower lobe bronchus, was extracted with an alligator forceps (figure 2). The patient was discharged the next day following an uneventful hospital course.

Discussion

Among adults, aspiration of foreign bodies occurs more often in those who have certain conditions that impair the natural protective airway mechanisms. Limper and Prakash identified several of these predisposing conditions, including primary neurologic disorders, a loss of consciousness from trauma, and the use of sedatives or alcohol. [2] In their series, 25 of 60 such patients (41.7%) had at least one of these impairments of their protective airway mechanisms. Although only three cases of aspiration in patients with a permanent postlaryngectomy tracheal stoma have been previously reported in the literature, [3-5] we believe that the presence of such a stoma should be added to the list of risk factors for foreign-body aspiration in adults.

Rigid bronchoscopy has been the gold standard for the removal of aspirated foreign bodies, particularly in children, because it allows the surgeon to maintain an airway for ventilation during the procedure and to use a wider variety of extraction instruments. Even so, some authors have advocated the use of flexible bronchoscopy to extract foreign bodies in adults. [6,7] Depending on the nature and location of the foreign body, flexible bronchoscopy might be attempted initially, especially if the bronchoscopist has no experience with the rigid bronchoscope. Yet despite its ease of use, flexible bronchoscopy is not nearly as successful as rigid bronchoscopy. For example, Limper and Prakash found that flexible bronchoscopy was successful in removing an aspirated foreign body in only 14 of 23 patients (60.9%), while rigid bronchoscopy was successful in 43 of 44 patients (97.7%), including six of seven who had previously failed flexible bronchoscopy. [2] In the three previously published case reports of aspirated foreign bodies in laryngectomized patients, bronchoscopic retrieval was successful in only one--a patient who had aspirated a button. [3] The other two patients required thoracotomy after bronchoscopy had failed (one patient had inhaled a piece of wire he used to clean his stoma, [4] and the other had aspirated a safety pin that he had used to fasten the cloth bib covering his stoma to his shirt [5]).

In laryngectomized patients, the stoma often precludes the passage of a rigid bronchoscope transorally. Passage of the scope through the stoma itself can also be difficult in these patients because of interference from the chin, even when the neck is hyperextended. Hyperextension can be especially problematic in patients who have a short neck and in elderly patients with cervical arthritis. Our patient had a prominent chin, so hyperextension was facilitated by the anesthesiologist. The anesthesiologist supported the neck with his hands as he hyperextended it, which made it possible for the surgeon to introduce the rigid bronchoscope through the stoma, although with some difficulty. We were therefore able to avoid the need for thoracotomy.

In an attempt to classify the indications for surgical removal of foreign bodies in the airway, Marks et al reviewed 50 published papers in the English-language literature. [8] In all, complete data were available on 6,393 patients. Of this group, 161 (2.5%) required thoracotomy (102 bronchotomies and 59 lung resections). Only two of these 161 patients died following thoracotomy (mortality: 1.2%). On the other hand, 5,622 of these patients had undergone a successful bronchoscopic retrieval of a foreign body (mortality: 0.6%).

Marks et al pointed Out a statement made by Chevalier Jackson during a speech before the American Broncho-Esophalogical Association in 1921. Jackson had said that there was no indication whatsoever for the open surgical removal of an airway foreign body. Time has proven that this statement is no longer true. There are several situations in which the morbidity and mortality associated with thoracotomy are much less than those associated with repeatedly unsuccessful attempts to remove an object bronchoscopically, especially in light of the development of modem surgical and anesthetic techniques and improvements in postoperative care. Marks et al concluded that open surgical removal should be considered in at least five situations: (1) when a large object in the subglottis or trachea might be better removed by tracheotomy, (2) when grass heads result in irreversible lung damage that requires pulmonary resection, (3) when a foreign body is embedded in the lung periphery, (4) when double-pointed objects are lodged in the tracheobronchial tree of a small child, and (5) whenever the risk of endoscopic removal might exceed that of open surgery.

Some of these indications are especially applicable to laryngectomized patients because of the previously mentioned potential difficulties associated with passing a rigid bronchoscope. This is particularly true for patients who have aspirated a sharp object.

Patients with a permanent tracheal stoma following total laryngectomy need to fully understand that the stoma is now part of their airway. The stoma provides a direct and easy access to their lower tracheobronchial tree, and it increases the risk of foreign-body aspiration. Patients should also know that the negative intrapleural pressure gradient that is generated during deep breathing or paroxysms of coughing might cause a vacuum effect, which can also facilitate the aspiration of an object held loosely around the stoma. In short, patient education is key to preventing foreign-body aspiration.

References

(1.) Abdulmajid OA, Ebeid AM, Motaweh MM, Kleibo IS. Aspirated foreign bodies in the tracheobronchial tree: Report of 250 cases. Thorax 1976;31:635-40.

(2.) Limper AH, Prakash UB. Tracheobronchial foreign bodies in adults. Ann Intern Med 1990;l12:604-9.

(3.) Rehurek L. Unusual complications caused by a foreign body in the tracheobronchial tree. Laryngoscope 1975;85:l767-9.

(4.) Cannon CR. Small tracheal stoma: An unusual cause of aspiration. South Med J 1982;75:512-3.

(5.) Finkelstein DM, Noyek AM, Friedberg J, Goldberg M. Inhalation of a safety pin by a laryngectomized patient: A case report. J Otolaryngol 1989;18;189-92.

(6.) Lan RS, Lee CH, Chiang YC, Wang WJ. Use of fiberoptic bronchoscopy to retrieve bronchial foreign bodies in adults. Am Rev Respir Dis 1989;140:l734-7.

(7.) Cunanan OS. The flexible fiberoptic bronchoscope in foreign body removal. Experience in 300 cases. Chest 1978;73(5 Suppl):725-6.

(8.) Marks SC, Marsh BR, Dudgeon DL. Indications for open surgical removal of airway foreign bodies. Ann Otol Rhinol Laryngol 1993;102:690-4