Office Removal of a Subglottic Bread Clip

Objective. The presence of an upper airway foreign body is an emergent, potentially life-threatening situation that requires careful but rapid evaluation and management. Organic or nonorganic material may typically be found in the pyriform sinuses or tongue base or may be aspirated directly into the tracheobronchial tree. We present here an unusual case report of a patient who accidentally ingested a plastic bread clip that was lodged in his subglottis for 15 months and report successful removal in the office under local anesthesia. Methods. Mucosal anesthesia was achieved with inhaled 4% lidocaine spray. Flexible laryngoscopic removal of the foreign body was then successfully accomplished. Results. The patient’s symptoms resolved completely following removal, with no sequelae. Conclusions. Office removal of airway foreign bodies is feasible and can be safely done with adequate topical anesthesia, but great caution and emergency planning must be exercised. 1. History and Presentation A 34-year-old man was referred for laryngeal foreign body. His symptoms began 15 months prior to presentation when he felt his airway obstruct for a few seconds while eating a fish oil capsule. He developed hoarseness and globus sensation and sought consultation with an otolaryngologist at another institution. His evaluation apparently did not include laryngoscopy, and the patient was given a diagnosis of laryngopharyngeal reflux that was empirically treated with proton pump inhibitors. The patient noted that his voice actually improved over time, but the globus sensation persisted. He was not evaluated again until over a year later, when he was seen by a second outside otolaryngologist. This time, flexible laryngoscopy was done, and he was diagnosed with a laryngeal foreign body, possibly a bay leaf. On our initial office examination, a firm, linear foreign body was seen vertically bisecting the subglottis approximately 5？mm below the vocal folds, wedged between the anterior and posterior wall (Figure 1(a)). It was rigid and no movement was noted with phonation or respiration. It did not affect glottic closure, and there was no stridor or airway distress. There was no apparent granulation tissue or infection. Given these findings, approaches to removal of the foreign body was discussed with the patient. Direct laryngoscopy with microscopic removal under general anesthesia was considered, but he favored attempting awake removal with topical anesthesia only. He was consented for office removal. Figure 1: (a) Identification of bread clip wedged into subglottic airway. (b)