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CASE REPORTS
“LIVE FISH” IN THE THROAT AN UNUSUAL FOREIGN BODY
ROHAN R WALVEKAR*, HARITOSH VELANKAR**, PRAMOD SHIRALKAR*, KA
PRADHAN***
INTRODUCTION
the city of Hyderabad, Andhra Pradesh in India, on the auspicious day of Mrigashira Karthi which falls between June 6 - 8th, the Bathini Goud family push down the throats of takers, a live murrel as a part of sacred treatment for asthma. The takers of this once secret, 156 year old traditional cure for asthma include asthmatics - young, old, toddlers and invalids. This is more commonly known as Bathini fish medicine or Hyderabad fish therapy. (Life Positive, November 1999)
Fish bones rather than live fish are very common foreign bodies seen usually in the adult age group and have been reported often for their varied presentation and complications. We report the ingestion of a whole live fish in a 6 month old male child presenting with respiratory distress, occasional cyanosis and oral bleeding - making it a very unusual foreign body of the throat.
CASE REPORT
A 6 month old male child was brought to the casualty ward frantically by his mother and relatives with respiratory distress and oral bleeding. On further questioning a history of an accidental ingestion of a whole live fish was obtained. It was learnt that while one of the younger brothers was showing the live fish to the child it slipped and was swallowed by the child. On examination, there was active bleeding from the oral cavity and the patient was uncomfortable and crying. There were intermittent episodes of apnoea and occasional cyanosis which seemed to be relieved on crying. The patient was immediately taken to the operating room for an emergency foreign body removal under anaesthesia. On passing the direct laryngoscope, we were astonished to find the presence of a 6- 7 cm size fish placed head down in the right pyriform fossa. The tail and body of the fish which was visible seemed to flop down covering the laryngeal inlet, a plausible cause for the intermittent episodes of respiratory distress. With the help of a Magill’s forceps the fish was removed ( Fig 1). The fish was partially chewed because of which the fish bones had traumatized the oropharyngeal mucosa leading to the bleeding which was later controlled by a pressure pack for a few minutes. Once the offending foreign body was removed, a check examination was done to rule out any solitary fish bone or remnants of the fish. The rest of the intra-operative and post-operative period was uneventful and the patient was discharged the next day. Six months after the event the child has been completely symptom free and has no complications.
DISCUSSION
A foreign body is defined as “an object or a substance foreign to the location”. In otolaryngology we have come across a variety of foreign bodies affecting the upper aerodigestive tract. They are classified as exogenous, substances from outside the body and endogenous and also traumatic and atraumatic. It is known that the incidence of the foreign bodies are more common in the younger age groups and more so in boys compared to girls.1
In 80% of the cases commonest site for impaction
Fig. 1 : Foreign body - Fish removed from the Right Pyriform
Fossa
of foreign bodies is the cricopharynx. The children most commonly present with acute symptoms of coughing, choking, dysphagia and vomiting. Usually there is a clear history of foreign body ingestion. Uncommonly the presenting complaints are obscure with history of chronic respiratory problems, haematemesis, anorexia without a clear history of ingestion of a foreign body.4 The aetiology for such laryngopharyngeal foreign bodies include failure of normal protective mechanisms e.g. cough reflex, physical factors e.g. posture, hasty eating and drinking habits and various surgical, medical, dental and psychopathic factors. However, a study of over 4710 cases has shown nearly all foreign bodies are preventable if we follow the dictum.” If one puts into his mouth nothing but food, foreign bodies would be rare”.2 A variety of laryngopharyngeal foreign bodies have been described. Fish bone are very common presenting usually in an older group of children (>10 years) and associated with complications like retropharyngeal abscesses. The overall incidence of complications associated with foreign bodies of the pharynx, larynx and oesophagus is about 7.6 %.3 Our case report is unusual as it is the accidental ingestion of a whole fish and the peculiar symptoms the patient came with that can be explained on the
Fig. 2 : Figure explaining the symptom of intermittent respiratory distress - cyanosis relieved with onset of a crying spell.
basis of the lie and nature of the foreign body. The active oral bleeding was caused by the lacerations caused by the sharp bones of a partially damaged fish. This was evident on seeing the fish after removal as some of the axial bones were projecting out of the body of the fish. The lie of the fish in the upper oesophagus was responsible for the respiratory symptoms. The fish was placed head first in the right pyriform fossa. The body and tail were found to be encroaching upon the small infant laryngeal inlet giving rise to the respiratory distress which was relieved intermittently by the crying which caused a thrust of air that pushed the fish body parts away from the laryngeal inlet relieving the respiratory distress. The child would then stop crying and the tail would flop over the laryngeal inlet and lead to breathing difficulty and an occasional cyanosis
(Fig. 2). An emergency laryngoscopic examination and removal of foreign body was necessary to evaluate these alarming symptoms and ensure complete removal of the foreign body.
REFERENCES
1. Evans JNG. Foreign bodies in the Larynx and Trachea. Scott- Brown’s Otolaryngology 1997, 6th Edition: 6/25/1 - 10.
2. Jackson C, Jackson CL. Foreign bodies in the air and food passages. Bronchooesophagology 1964: 13-4.
3. Singh B, Kantu M, Har-El, Lucente FE. Complications associated with 327 foreign bodies of the pharynx, larynx and esophagus. Ann Otol Rhinol Laryngol 1997; 106 (4) : 30-4.
4. Spitz L. Diseases of the Oesophagus. Scott-Brown’s Otolaryngology 1997, 6th Edition: 6/29/10 - 12.
