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Case Report
The Open Access Journal of Science and Technology
Vol. 2 (2014), Article ID 101074, 4 pages
doi:10.11131/2014/101074

Inhaled Live Fish—A Case Report

Peter Appiah-Thompson1, Kofi Ngyedu2, Felix Mintah3, and Kafui Akakpo4

1Ear, Nose and Throat Unit, Central Regional Hospital, Post Office Box CT 1363 Cape Coast, Ghana

2Maxillofacial Unit, Central Regional Hospital, Post Office Box CT 1363, Cape Coast, Ghana

3Department of Surgery, Central Regional Hospital, Post Office Box CT 1363, Cape Coast, Ghana

4Pathology Department, Central Regional Hospital Post Office Box CT 1363, Cape Coast, Ghana

Received 30 December 2013; Accepted 21 March 2014

Academic Editor: Mohannad Al-Qudah

Copyright © 2014 Peter Appiah-Thompson et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Foreign body inhalation is an emergency condition as it can cause sudden upper airway obstruction. It is rare in adults. They produce signs and symptoms initially which may progressively resolve and thus may be difficult to diagnose. Here, we report a rare case of inhalation of a live fish by a young fisherman. X-rays showed subcutaneous and mediastinal emphysema. Emergency tracheostomy was performed under local anesthesia. Patient, however, died the following day after the subcutaneous emphysema had spread all over the body. Bronchoscopy could not be done as the facility was not available at our centre. Postmortem showed parts of the fish at the carina of the trachea and both bronchi.

1. Introduction

Foreign body inhalation is quite common. For instance, inhalation/ingestion of food or objects is the 5th leading cause of death in the United States. This mostly occurs in children who play with toy parts, seeds, etc. [1]. Children are vulnerable because of exploration of their environment by putting objects into their mouths, inadequate dentition, and immature swallowing coordination. In some instances older siblings have put foreign bodies in the mouths of their siblings [2].

Adult foreign body inhalation is rather rare and may be found in the mentally deranged or the unconscious patient whose capacity for protecting the airway is disrupted.

The foreign bodies inhaled may be organic or inorganic, where as the inorganic foreign bodies remain the same and so may not completely block the airway the inorganic objects absorb water and swell up with time. The foreign body may also change position with time, thus either improving the patient's condition or worsening it [3]. The inhalation of a live organism is, however, rare and data on such cases are scanty [4,5]. This is the objective of this report.

2. Case Report

A 20-year old fisherman presented to the Accident & Emergency Unit of a Regional Hospital (a secondary referral centre) in Ghana in severe stridor with an enlarged neck following the ingestion' of a live Tilapia fish three hours prior to presentation.

This young man had tried to stabilize a fish he had caught with his teeth while preventing another fish on the ground from slipping off back into the sea. He lost his control on the fish in between his teeth resulting in the inhalation of the live fish. He was sent immediately to a primary healthcare facility where analgesics were given and then referred immediately to our centre.

At presentation, his main difficulties were breathlessness and progressive enlargement of the neck and anterior chest. He also had dysphagia and odynophagia with a mild hoarseness of his voice.

On examination, a young anxious patient in obvious stridor was found. He was sweating, afebrile, anicteric, not pale, and not dehydrated. His pulse was 124 beats per minute, regular and of good volume. His blood pressure was also 180/80. He had flaring alae nasae, and respiratory rate was 28cycles/min. Air entry was reduced slightly bilaterally. Breath sounds were vesicular with transmitted sounds. There were crepitations palpable all over the neck, left face, anterior chest, and left upper limb. Oxygen saturation with oxygen support was 85-88%.

An impression of acute upper airway obstruction secondary to inhaled live fish with subcutaneous emphysema (hypopharyngeal/tracheal perforation) was made. An emergency tracheostomy was done and patient's condition immediately improved. The stridor reduced and the oxygen saturation with oxygen support now was 92-96%.

F1
Figure 1: Picture of patient's neck showing tracheostomy and subcutaneous emphysema.

X-ray of the soft tissue lateral neck showed widened retropharyngeal space with airtrapping. Anteroposterior view X-ray of the neck also showed air trapped in the cervical fascial spaces and superior mediastinum.

F2
Figure 2: X-ray of the soft tissue lateral neck showing widened retropharyngeal space.
F3
Figure 3: X-ray of neck (anteroposterior view) showing air trapping in the cervical fascial spaces.

Patient's relatives, however, could not afford an immediate referral to a tertiary centre; thus, he was admitted to the Intensive Care Unit of our centre.

His condition remained stable until 22 hours after admission when the oxygen saturation with oxygen support started reducing with subcutaneous emphysema spreading to every part of the body. He subsequently died after failed attempts at resuscitation.

Postmortem done showed parts of fish at the bifurcation of the trachea with the head in the left main bronchus and tail in the right bronchus. No obvious perforation was noted in the trachea.

F4
Figure 4: Picture of the airway showing parts of the fish in the trachea and bronchi.

3. Discussion

These inhaled foreign bodies can lodge anywhere from the larynx through the trachea and bronchi to the bronchioles and alveoli depending on the size [1].

The clinical features, thus, depend on the location of the object. These may include stridor, intermittent cough, dyspnea, wheezing, hemoptysis, choking, suprasternal, and subcostal recessions [6].

Various complications are also possible after foreign body inhalation. These may include lung collapse (atelectasis), pneumomediastinum, subcutaneous emphysema, pneumonia, lung and mediastinal abscesses, and death, likely to result in these complications as was seen in our patient [2].

X-rays of the neck (anteroposterior and lateral views) and chest (both on inspiration and expiration) are mostly used to help make the diagnosis [3,6].

Whenever there is an injury to the neck as occurred in this case, management plan is largely guided by the findings on flexible fiberoptic endoscopy. In the event that significant airway edema or hematoma of the larynx is found, then CT scan of the neck becomes imperative to give an idea of the laryngotracheal framework and thus inform the need for operative intervention [7].

Resolution of symptoms follows if the foreign body can be retrieved from the airway [4]. The foreign body is removed by bronchoscopy in most cases. Bronchoscopy helps both for diagnostic and therapeutic purposes. Having both rigid and flexible bronchoscopy is advantageous as larger foreign bodies cannot be removed by the flexible scope [8,9]. Unfortunately this was not possible at our centre since bronchoscopy is only done at the three teaching hospitals in Ghana.

In case bronchoscopy fails, thoracotomy with bronchotomy is indicated which has to be done by thoracic surgeons who only work in Accra, the capital of Ghana. Flexible nasolaryngoscopes and CT scans are not yet available at our centre.

In the case of laryngeal foreign bodies tracheostomy may be needed to relieve acute upper airway obstruction and the foreign body removed by direct laryngoscopy [3].

The economic situation of our patients greatly influences how much help by way of treatment can be given [10]. In the case we have reported, the best possible care could not be given the client since his relatives could not afford to have him referred to a tertiary centre.

4. Consent

Written informed consent was obtained from the relatives of this patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

5. Competing Interests

The authors declare that they do not have any competing interests.

They wish to thank the nurses who helped with the care of this patient.

They also wish to express their gratitude to the secretaries who typed this article.

References

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  2. E. Yaniv and J. Weinberg, Pneumomediastinum with subcutaneous emphysema as a complication of foreign body in the bronchus, International Journal of Pediatric Otorhinolaryngology, 7, no. 1, 75–77, (1984). PubMed Abstract | Publisher Full Text | Google Scholar
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Case Report
The Open Access Journal of Science and Technology
Vol. 2 (2014), Article ID 101074, 4 pages
doi:10.11131/2014/101074

Inhaled Live Fish—A Case Report

Peter Appiah-Thompson1, Kofi Ngyedu2, Felix Mintah3, and Kafui Akakpo4

1Ear, Nose and Throat Unit, Central Regional Hospital, Post Office Box CT 1363 Cape Coast, Ghana

2Maxillofacial Unit, Central Regional Hospital, Post Office Box CT 1363, Cape Coast, Ghana

3Department of Surgery, Central Regional Hospital, Post Office Box CT 1363, Cape Coast, Ghana

4Pathology Department, Central Regional Hospital Post Office Box CT 1363, Cape Coast, Ghana

Received 30 December 2013; Accepted 21 March 2014

Academic Editor: Mohannad Al-Qudah

Copyright © 2014 Peter Appiah-Thompson et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Foreign body inhalation is an emergency condition as it can cause sudden upper airway obstruction. It is rare in adults. They produce signs and symptoms initially which may progressively resolve and thus may be difficult to diagnose. Here, we report a rare case of inhalation of a live fish by a young fisherman. X-rays showed subcutaneous and mediastinal emphysema. Emergency tracheostomy was performed under local anesthesia. Patient, however, died the following day after the subcutaneous emphysema had spread all over the body. Bronchoscopy could not be done as the facility was not available at our centre. Postmortem showed parts of the fish at the carina of the trachea and both bronchi.