Unusual Route of Impaction, Hypopharyngeal non Penetrating Steel Shrapnel Foreign Body

Foreign body ingestion is one of the most commonly encountered otorhinolaryngologic disorders, often requiring urgent decision making and management. In particular, it has been reported that children younger than 3 years exhibit the greatest risk of foreign body swallowing [1,2]. In adults foreign body ingestion occurs commonly, the majority of them pass spontaneously but some of them will impact at the hypopharyngeal level [3]. The result may be severe due to possible ulceration or even perforation with consequent life threatening complications [4,5]. Many studies of foreign body injuries have focused on the case of young patients [2,6]. However it is also important to determine the frequency and characteristics of foreign body injuries in other age groups in addition to young children. Previous studies have demonstrated that some fatal cases occur in elderly patients due to foreign body asphyxia [7].


Introduction
Foreign body ingestion is one of the most commonly encountered otorhinolaryngologic disorders, often requiring urgent decision making and management. In particular, it has been reported that children younger than 3 years exhibit the greatest risk of foreign body swallowing [1,2]. In adults foreign body ingestion occurs commonly, the majority of them pass spontaneously but some of them will impact at the hypopharyngeal level [3]. The result may be severe due to possible ulceration or even perforation with consequent life threatening complications [4,5]. Many studies of foreign body injuries have focused on the case of young patients [2,6].
However it is also important to determine the frequency and characteristics of foreign body injuries in other age groups in addition to young children. Previous studies have demonstrated that some fatal cases occur in elderly patients due to foreign body asphyxia [7].
The diagnosis and management of foreign bodies have mainly been based on the type and location of the foreign body.
Therefore, clinical information on the type and location of foreign bodies can expedite the management of these patients [7]. The workplace is a signifi cant contributor to fatal and non-fatal injuries worldwide and an insuffi ciently appreciated

Abstract
Foreign body injury is one of the most commonly encountered otorhinolaryngologic emergencies. The diagnosis and management of foreign bodies have mainly been based on the type and location of the foreign body. The workplace is a signifi cant contributor to fatal and non-fatal injuries worldwide and an insuffi ciently appreciated contributor to the total burden of health care costs. Steel workers sustain a higher occupational hazard of penetrating injuries anywhere in the body, including the head and neck. However, we found no reports in the literature about non-penetrating shrapnel foreign body injuries, particularly in the upper aero-digestive tract. This is a case report of a twenty-fi ve years old steelworker who presented to the emergency department in Al Wakra Hospital with a history of non-penetrating steel foreign body impaction in the throat which had been visualized by GlideScope and removed successfully with the assistance of Macintosh laryngoscope without complications. The purpose of this presentation is to highlight the unusual route taken by a shrapnel non-penetrating foreign body, through the open mouth to the hypopharynx. Also, probably this could be the fi rst such case to be reported. A note has, also, been added about its visualization and method of removal, comparing two different techniques.
contributor to the total burden of health care costs, like the occupational hazards of steel workers who manifest with penetrating injuries anywhere in the body [8]. However there are no reported non penetrating injuries of steel worker foreign body injuries particularly in the upper aerodigestive tract.
The aim of the presentation of this case report is to highlight the route of a non-penetrating steel foreign body in the hypopharynx in a steelworker, and probably this could be the fi rst reported case of this unusual route of entry. In the postoperative period, the patient was kept for continuous intravenous fl uids for the next 24 hours, with frequent checking of the neck for possible emphysema, then fl uid diet was started for the next coming hours and then the patient was discharged in good condition on the second postoperative day after psychiatric assessment to make sure that he is of normal mentality.

Discussion
Foreign body ingestion is more common in adults with mental developmental delay, psychiatric and neurological disorders or intoxication and in patients with dentures or dental bridges because of the decrease in tactile sensation during swallowing. The most commonly ingested foreign bodies are fi sh and chicken bones and there is an apparent predominance of certain types in specifi c groups of patients [9], e.g. coins and toys in children, razor blades and cutlery in prisoners [10]. Our case report highlights the peculiar route taken by the shrapnel foreign body, through the open oral cavity to the hypopharynx, a route we think have not been reported before. Also, it appears that the foreign body has taken a curved projectile rather than a straight pathway. This is suggested by the fact that no injuries were found in the oral cavity or oropharynx, apart from a small wound at the tip of the tongue. Medline search did not report this kind of foreign body route of entry, so we consider this is the fi rst reported case with such description.
GlideScopes represent a recent advancement over the Macintosh laryngoscope. It has increased endotracheal intubation success rate, and it is recommended mainly in the management of potential diffi cult airways in several patient populations [11].
The use of these devices to remove foreign bodies has been reported previously only in two adult patients affected by a non-impacted partial denture in the hypopharynx [12]. While desirable, it is not reported so far in the pediatric population.
Je, in a cadaver study, compared Macintosh laryngoscope and the GlideScope for extracting hypopharyngeal foreign bodies.
He stated that it is not possible to conclude that videoscopes are inferior to the Macintosh laryngoscope for foreign body extractions, and that the GlideScope might be necessary to aid the foreign body extraction in emergency situations [13]. In our case report, the GlideScope provided good indirect visualization and localization with magnifi cation of the foreign body but it didn't provide good access for removal. On the other hand, the Macintosh provided a direct visualization of the foreign body and easy removal and extraction.

Conclusion
We concluded that this report could be regarded as the fi rst case report of a non-penetrating steel foreign body with an   unusual per oral route of impaction in the hypopharynx. It, also, highlighted its visualization and a comparison between two techniques of its extraction.