Key points
- The obstructive foreign bodies of the pharynx have a pediatric
connotation
- Their occurrence is mainly accidental
- They present a high risk of asphyxiation
- They constitute major diagnostic and therapeutic emergencies
- Their post-therapeutic prognosis is generally favorable.
Introduction
Pharyngeal obstruction foreign bodies constitute an absolute relatively
rare emergency in ENT practice. 1,2 Of variable nature
and severity, they mainly affect young subjects in a context of mainly
accidental or recreational occurrence. Of spontaneous evolution, most
often serious, they sometimes pose a diagnostic problem because of the
young age of the patients concerned, but especially a problem of
therapeutic management in our context of classic delay of specialized
consultations and insufficiency of technical platform. Thus, we
investigated the epidemiology and diagnostic aspects of this pathology
in the ENT and reporting our therapeutic experience regarding the
reported cases.
Patients and method
Statement of Ethics
The local ethics committee approved the study protocol (No. 79, on
December 12, 2014). A written consent was obtained from all
participants.
Design and selection criteria
This was a cross-sectional prospective study in the ENT and
cervico-facial surgery department at the University Hospital for a
period of six (6) years from January 2015 to December 2020. We conducted
a census of all patients admitted and managed in the said department for
obstructive foreign bodies of the pharynx, during the study period and
having given their informed consent either directly or through their
legal guardian. The evaluation criteria were the history, identity
variables, clinical manifestations, paraclinical translations and
therapeutic and evolutionary aspects.
Statistical methods
The data collected were analyzed using Epi info 3.3.2 and Excel 2010
software.
Results
During a period of 6 years, 34 cases of Pharyngeal obstructive foreign
bodies were recorded, leading to an annual incidence of 5.7 cases. The
mean age was 8.7 ± 9.2 with extremes of 3 months to 39 years. The
dominant age group was ranged between 3 month and 3 years with a
frequency of 16 cases (47.1%). Men were mostly represented in 22 cases
(64.1%) against 12 cases of women (35.3%) with a man to female
ratio(M/F) of 1.8. The principal patient’s attendant was civil servants
in 6 cases (17.64%), farmers in 18 cases (52.94%) and informal sector
actors in 10 cases (29.41%). According to geographical origin, the
patients were from rural areas in 26 cases (76.47%) and residents of
the city of Bobo in 8 cases (23.53%).
Inpatient route was intra-hospital referral in 22 cases (64.7%),
inter-hospital transfer in 7 cases (20.59%) and direct admission in 5
cases (14.70%). The average time of diagnosis was 2.3 days with the
extremes of 3 hours and 7 days. The main clinical symptoms were
respiratory dyspnea in 18 cases (52.9%), dysphagia in 24 cases (70.6%)
and sialorrhea in 8 cases (23.5%). The occurrence of pharyngeal foreign
bodies was accidental in 32 cases (94.1%) and voluntary in 2 adult
cases (5.9%). The diagnosis was based on clinical findings in 14 cases
(41.2%), radiography in 24 cases (70.6%) and endoscopy in 22 cases
(64.7%). The topography of the foreign bodies (figure 1 ) was
hypopharyngeal in 28 cases (82.4%), oropharyngeal in 4 cases (11.8%)
and nasopharyngeal in 2 cases (5.9%). The type of foreign body was
variable, as shown in Table I. The foreign bodies encountered were
mainly toys (52.94%) and bottle caps (29.41%).
The average treatment time was 12.6 hours with extremes of 3 and 96
hours. The treatment was medico-instrumental in all cases. The
extraction mode used was endoscopic in 22 cases (64.7%) and chairside
in 12 cases (35.3%). The associated medical treatment consisted of
antibiotic therapy in 18 cases (52.9%), analgesic treatment in 22 cases
(64.70%) and observation in 14 cases (41.17%). The per-therapeutic
incidents encountered were an ulceration of the pharyngeal mucosa in 12
cases (35.3%) and a minimal parietal hemorrhage in 6 cases (17.7%).
The post-treatment evolution was favorable in 33 cases (97.1%) after a
follow-up of 8 months.
DISCUSSION
Pharyngeal obstructive foreign bodies are a relatively frequent
emergency in ENT and cervico-facial surgical practice.1,2 These are of much greater concern when they are
vulnating or obstructive because of their interference with the
physiological processes of swallowing and breathing. Relatively rare but
highly morbid, this obstructive pathology affects mostly young subjects
with a slight male predominance. 2,3 In our context,
the dominant age group was ranged between 3 month and 3 years with a
frequency of 16 cases (47.1%). This could be justified, on the one
hand, by the exploratory curiosity of young children, especially in
their oral stage of psychomotor evolution, and on the other hand, by the
greater turbulence characteristic of young boys. 4Also, the difficulty of monitoring children at this age, with the
beginning of the acquisition of kinetic autonomy and the frequency of
play activities that are linked to it could partly explain the frequency
of cases recorded at this period of life, with regard to the almost
accidental origin of this pathology.
As traumatic for the patients as it is distressing for those who
accompany them, this pathology rarely goes unnoticed and therefore
benefits from an urgent hospital admission, whether direct by medical
evacuation or mediated through an inter-hospital referral or an
intra-hospital transfer. 5,6 In our context, the main
modes of admission of patients were referral (64.7%) and intra-hospital
transfer (20.6%) with an average diagnosis time of 2 days. This delay
seems to us to be sufficiently late for a pathology considered to be
borderline urgent. Nevertheless, it could be justified not only by the
attempt to hide the pathology for fear of possible parental reprisals by
the patients themselves, but especially by the long evacuation times of
the patients from the peripheral services in our context of pyramidal
system of care based on successive evacuations.
The diagnosis of pharyngeal obstructive foreign bodies is based on a
clinical suspicion which deserves to be investigated, in front of any
pharyngeal syndrome of sudden onset. This syndrome can range from simple
sialorrhea to severe respiratory distress, including high mechanical
dysphagia. 7,8 In our series, the main circumstances
of discovery were respiratory dyspnea (52.9%), dysphagia (70.6%) and
sialorrhea (23.5%). They were related not only to the size but also to
the topography of the incriminated foreign body. Although the foreign
body was mostly hypopharyngeal in 82.4% cases, it was sometimes
oropharyngeal and exceptionally rhinopharyngeal. Thus, the classic
clinical profile of the patient concerned is that of the small child
found in a picture of agony or drooling of sudden onset on a playground.
The paraclinical exploration mainly based on the cervical radiography is
not less contributive for the diagnosis.9,10 Indeed,
in most cases, it allows not only to reinforce the positive diagnosis
through the demonstration of the radiopacity or the indirect signature
of the body involved, but also to obtain information on the possible
nature and appearance of the latter. 7,11 In our
context, they were mainly toys (52.9%) or objects used as toys, hence
the interest in regulating the marketing of recreational material for
small children, which for us should be neither too small to be
swallowed, nor too fragile to be removed.
In all cases, the diagnosis of certainty remains that of direct
pharyngoscopy, whether in the chair or on the operating table under
general anesthesia. 10 This allows direct
visualization of the foreign body, which is the most important step in
the therapeutic management of this pathology.
The pharyngeal obstructive foreign bodies constitute a major therapeutic
emergency rallying a necessity of the symptomatic and etiological
management in a concomitant and adequate way. Thus, if the preservation
of the vital functions is essential, it is the same for the extraction
of the foreign body, which constitutes the true treatment of this
pathology. This can be done by armchair oro-pharyngoscopy or by
pharyngoscopy under general anesthesia in the operating room, depending
on the complexity of the situation. In our series, extraction was
performed both in the chair in 35.3% cases and in the operating room
(64.7%) with the main criteria for therapeutic choice being the degree
of immediate respiratory emergency and the risk of inherent
per-extraction complications. In any case, the management of the
pharyngeal obstructive foreign bodies should not be improvised without
having tracheal intubation or better still emergency tracheostomy
equipment at hand. 12,13 This is in order to avoid any
risk of asphyxia, which can occur both per-induction and per-extraction.
The evolution of this pathology is variable and depends above all on the
efficiency of the management, which must not suffer any delay.3,10,13 In our context, it was marked by a pharyngeal
parietal trauma (52.95%) with mucosal ulceration and haemorrhage
related not only to the vulnating aspect of the incriminated foreign
bodies but also to the untimely non-adapted extraction attempts by
parents or untrained traditherapists. As for the prognosis, it is mainly
a function of the topography and the degree of obstruction as well as
the precocity of management. To this effect, if a partial pharyngeal
obstruction remains compatible with an acceptable vital and functional
prognosis, this is not the case of a complete hypo-pharyngeal
obstruction which is usually immediately fatal.7,8,12,13 In our series, the evolution was favorable
in 97.1% of the cases that reached the hospital; this should not
obscure the possible cases of pre-hospital death in the absence of
investigation in the general population. Therefore, it is of interest to
raise awareness for preventive purposes, parents for a rigorous
surveillance of children and public authorities for an effective
regulation of the marketing of children’s toys.