Hypopharyngeal Foreign Body in A 9-months-Old Male Baby

Fishbone is the commonest pharyngeal foreign body in Asia. However, uncommon types also were reported in the literature. A 9-months-old male infant presented with crying, dysphagia and excessive salivation. Plain X-ray of the cervical spine lateral view confirmed the diagnosis of a metallic foreign body in the hypopharynx. The foreign body was extracted under general anesthesia without complications. A high index of suspicion from the caregiver and early intervention from the dealing doctor are crucial to avoid unwanted complications of pharyngeal foreign bodies' impaction. In conclusion, we reported a rare hypopharyngeal foreign body (Sim Card Slotter of an old fashion mobile phone) in a 9-months-old boy.

Introduction haryngeal foreign bodies are common events affecting all age groups in particular children and infants, because they are during playing with various objects, the foreign bodies might enter the mouth and stuck mostly in oropharynx but may be in the hypopharynx, esophagus, and respiratory tract and presented as emergency cases. The foreign bodies are generally challenging to the dealing Otorhinolaryngologists 1 . There are various types of foreign bodies ingested but the most common type in Asia is fishbone. 2 Some uncommon hypopharyngeal foreign bodies like size tags was reported from a recent study in China. 3 In the presenting article, we reported a further case of an uncommon hypopharyngeal foreign object in a 9-months-old boy. Case report A 9-months-old male baby presented at 7 pm to the Emergency Department of Al-Ramadi Teaching Hospital with a history of suspicious foreign body swallowing. Her mother says that she hears her baby cry while he was playing. When she arrived for him, she observed that he was crying with excessive salivation and dysphagia. His parents took him immediately to the Emergency Unit of the Primary Hospital (Fallujah General Hospital) near their house.

Case report
After an initial assessment of the infant, the doctor on duty sent him for plain X-ray of the neck-lateral view, which showed square-shaped metallic foreign object in the hypopharynx Figure 1A. Owing to the lack of facilities to deal with such a case, the doctor referred him to our hospital in the same province. We sent him for another radiological film of the neck lateral view to confirm that the foreign body was not dislodged. We took an informed consent from his father about the necessity for securing the airway by tracheostomy at any time during the surgical operation. Under general anesthesia and by using Macintosh curved laryngoscope, the foreign body was retrieved by laryngeal forceps. The extracted foreign body was the Sim Card Slotter of an old fashion mobile phone Figure  1B. Close observation of the baby following the operation was done in the Ear, Nose, and Throat Ward for 48 hours. The postoperative follow-up passed smoothly and the baby was discharged with good swallowing and without any distress. The study was approved by the Department of Surgery, College of Medicine, University of Anbar. Informed consent from the parents was taken about the publication of the case.

Discussion
In daily Otolaryngology practice, adults with pharyngeal foreign objects can give exact history about the timing and type of foreign bodies lodgment, therefore, the diagnosis of foreign bodies impaction is easy and in time.
While the infants lack this ability to communicate resulting in a delay in the diagnosis unless the caregivers are aware of such events. 4 Moreover, due to the anatomical differences between the infant and adult make the problem more dangerous with unwanted complications especially compromised airway and even death. Therefore, great suspicion among parents or caregivers is of utmost importance to reach an accurate diagnosis and proper extraction of the foreign bodies and avoidance of sinister complications. Logically, the nature of the foreign bodies affecting the pharynx is the ones entering into the nature of human foods, and they differ from region to region. Also, children and infants, due to curiosity and playing with things around them, are more vulnerable to uncommon foreign bodies. In Asia, fishbone is the most common foreign body that affects the pharynx. However, there are some uncommon foreign bodies that have affected the pharynx, for example, pencil, barbecue blunder, whole fish, and size tag that has been recorded in prior studies. 3,[5][6][7] The presenting case reported another uncommon foreign body (the metallic Sim Card Slotter for an old fashion mobile phone) in an infant. The pharyngeal foreign bodies are usually lodged in the oropharynx and removed in the outpatient clinic. General anesthesia is required for the removal of foreign bodies in a sensitive or uncooperative subjects and those with hypopharyngeal foreign bodies. Moreover, the majority of sharp hypopharyngeal foreign bodies like fishbone is easily located and removed.
While in a rare situation they are embedded in the wall of the pharynx making their diagnosis is difficult even with the aid of fibro-optic nasolaryngoscopy or rigid esophagoscopy. Failure to discover these foreign bodies carry serious complications. 2 The study by Shu et al from Taiwan reported 2 cases of embedded fishbones in the hypopharyngeal wall and were removed by direct laryngoscopy with the aid of microscopy. 2 Foreign bodies of the pharynx in the pediatric population have more than 50% risk of dislodgment. Oropharyngeal foreign bodies are more likely to dislodge than the hypopharyngeal foreign bodies. The dislodgment is more in younger than older children. Despite the low complication rate of foreign bodies dislodgment, great care is needed to overcome the possible complications like local site infection, deep pharyngeal or neck abscess, and foreign object migration with its consequence risks. 8 In the presenting case, the persistence of the foreign object site was confirmed by another film of plain X-ray lateral view of the neck just before the time of surgical removal. Foreign bodies in the pharynx are one of the emergency conditions facing the Otolaryngologist. Immediate action is of utmost importance to prevent unwanted complications such as compromised airway due to increasing edema especially in infants and children, and local or deep spaces infections. Moreover, securing the airway at any time during the intervention is necessary by preparation the required conditions of the tracheotomy. Due to the foreign object size and site of the presenting case, we took an informed consent from his father about the need for tracheostomy at any time during the surgical extraction of the foreign body.