An Unhappy Shooting Star: A Laryngeal Foreign Body Masquerading as Croup

A previously healthy 16-month-old girl presented to the pediatric department for paroxysmal coughing and breathing difficulties. Her mother was not aware of the triggering event at home but heard the child begin coughing while playing out of sight. Her condition improved with dexamethasone and nebulized racemic epinephrine and was she diagnosed with croup. Thereafter, she was managed at home. She followed up the next day without incident. The patient was hospitalized 11 days later with the return of barking cough and new dysphonia. Neck radiography of the soft tissue demonstrated moderate subglottic narrowing with no foreign body. Nevertheless, her symptoms persisted despite antibiotics and dexamethasone. The patient was referred to our ENT department by a pediatrician due to suspected laryngotracheobronchitis or foreign body aspiration (FBA). Indirect laryngoscopy demonstrated a foreign body caught on the glottis opening with significant edema of the true vocal folds and laryngeal surface of the epiglottis. The patient was taken to the operating room for direct laryngoscopy and bronchoscopy. Granulation tissue was seen at the anterior commissure extending to the supraglottis (Figure 1), closely resembling a plastic star-shaped spangle (Figure 2). The foreign body was removed, and the patient was intubated overnight in the intensive care unit due to vocal cord edema. Airway obstruction immediate improved and she underwent extubation the next day. Repeat indirect laryngoscopy 10 days later confirmed complete resolution of the previously seen granulation tissue.

Figure 1.

Anterior commissure granulation tissue (white arrow) extending to the subglottis with embedded foreign body (black arrow).

Figure 2.

Plastic star-shaped spangle foreign body following removal.

A laryngeal foreign body typically presents with acute airway obstruction. Any foreign body in the larynx usually presents as a respiratory emergency. Initial symptoms such as gagging and choking may pass unnoticed, especially if the child is alone at the time of foreign body ingestion. If the foreign body is not quickly expelled with a cough or it is aspirated deeper into the airway, death will result. Therefore, foreign bodies caught in the larynx are extremely rare. Foreign bodies with sticky or thorny quality (irregularly shaped) may get lodged in the narrowest part of the larynx, the most common site of lodgment of such types of foreign bodies.^1,2 In the current case, I speculated that the star-shaped spangle saved the patient’s life because it was caught in the supraglottic region.

Correct medical history is crucial for the correct diagnosis of FBA, and lack of history may lead to negligence or misdiagnosis of FBA.^1-3 However, as the obtained medical history is often unclear, FBA should be suspected in all children who present with respiratory symptoms such as coughing and wheezing, and those who do not respond to conventional therapy against pneumonia or upper airway infections, even if the choking history is unclear. Although laryngeal FBA has been described in the literature,^1-5 to our knowledge, no better photographs of foreign body caught on the glottis due to irregular shape are available; thus, these images presented are extremely rare and educationally valuable.