Anterior laryngofissure approach to an airway foreign body after migration into the paraglottic space

Airway foreign bodies (FBs) are often removed with endoscopic techniques. Although the vast majority of FBs can be removed endoscopically, this is not possible in all situations. With FBs that are either located beyond the reach of endoscopy or in the presence of significant granulation tissue, endoscopic removal may not be possible secondary to exceedingly high risk. Often in these situations, an open surgical procedure in the form of a tracheotomy or a limited thoracotomy with bronchotomy is advocated to successfully retrieve the FB. An FB aspiration to the larynx with subsequent paraglottic migration, however, is a rare occurrence and can be successfully managed, as described in the following case, with an anterior laryngofissure approach and assistance from intraoperative ultrasound guidance. A 16-year-old male presented to The Children’s Hospital emergency department with hoarseness, biphasic stridor, and increasing respiratory distress. Six weeks prior to presentation, the patient was involved in a motor vehicle collision, in which he was ejected from the vehicle. He was intubated on arrival to an outside hospital emergency department after the incident. The patient sustained injuries including abdominal trauma and facial trauma with dislodgement of the left lower central incisor tooth. A computed tomography (CT) study of the face revealed multiple broken teeth including an avulsed inferior left central incisor with bony fragments in the oral cavity (Fig. 1). The patient endorsed intact dentition prior to the accident. Both the dental and otolaryngology services at the outside hospital were consulted for tooth fracture and lip laceration, respectively. A review of the outside hospital records did not reveal specific documentation that the debris in the oral cavity seen on CT was removed, nor any further investigation performed. The imaging obtained at initial presentation included a chest x-ray, CT of the cervical spine, and maxillofacial CT. None of these studies showed an FB. He was extubated uneventfully on hospital day 2. The patient was discharged on hospital day 6 in satisfactory condition after treatment of his injuries. He continued with an uneventful recovery for the next 5 weeks. One week prior to presentation, however, he began developing odynophagia and dyspnea. On the day of admission, he had an acute worsening of symptoms. On presentation in the emergency department, he was found to have biphasic stridor and posturing in the sniffing position. CT imaging demonstrated a 7-mm calcified structure within the right endolaryngeal soft tissues (Fig. 2). An abscess measuring 3.4 1.5 2.3 cm surrounded the FB. The CT findings were significant for leftward displacement and compression of the adjacent airway.