Risk Factors for Lower Respiratory Tract Infection Associated With Tracheobronchial Foreign Body Aspiration in Children

OBJECTIVES

Tracheobronchial foreign body aspiration (TFBA) is a major cause of accidental death in children. Lower respiratory tract infection (LRTI) may be caused by TFBA, but there are few reports about LRTI associated with TFBA. This study collected TFBA cases in our hospital to analyze LRTI and determine its risk factors.

METHODS

A total of 194 children who underwent tracheobronchial foreign body (TFB) extraction in The Children's Hospital of Zhejiang University School of Medicine from June 2019 to April 2020 were enrolled. CT chest is routinely used in the workup of suspected airway FB at our institution to evaluate for patients, a FB was already highly suspected. The retention time was defined as from the time of TFB inhalation or presentation (if there was no history of TFBA) to the time of TFB removal. General characteristics including weight, clinical symptoms, operative records, cervicothoracic CT, retention time, type of TFB and postoperative hospitalization time were collected. Chi-square tests, rank sum tests and multivariate logistic regression analyses were performed.

RESULTS

The incidence of LRTI was 46.6%, 68.6%, and 68.6% when the retention time was within 24 hours, between 24 hours and up to 1 week and more than 1 week, respectively. Postoperative hospitalization time of LRTI group was significantly longer than that of non-LRTI group. Findings for cervicothoracic CT as pneumonia, emphysema, atelectasis meant more serious clinical manifestations and the retention time was longer in the LRTI group than in the non-LRTI group. There was a positive correlation between the retention time of a TFB and LRTI in multivariate logistic regression analysis.

CONCLUSIONS

The incidence of LRTI caused by TFBA is high. LRTI is association with longer postoperative hospitalization time. The TFB retention time is an independent risk factor for LRTI. If a patient presents with significant LRTI symptoms, a course of steroids and antibiotics maybe a safer approach rather than proceeding immediately with bronchoscopic removal.

First Reported Case of Lesser Sac Empyema Secondary to Foreign Body Perforation

This is the first reported case of lesser sac empyema secondary to a foreign body perforation in the posterior stomach. Although PubMed and Google Scholar search reports cases of lesser sac empyema alone and foreign body penetrations, there are currently no reported cases of a lesser sac abscess secondary to a foreign body. Patients with a lesser sac empyema present atypically with an insidious onset. The lesser sac should be examined in patients with peritonitis without a clear source. A 48-year-old female presented to the emergency department with acute onset epigastric pain. The patient was tender in the epigastrium and left upper quadrant with associated guarding. The patient had elevated white cell count and C-reactive protein, with a computed tomography scan identifying a foreign body posterior gastric wall perforation. The patient was managed with endoscopic drainage of the lesser sac empyema and surgical washout of the abdomen. Foreign bodies are investigated using different imaging modalities, with computed tomography being able to further evaluate the size, shape, and complications. Intra-abdominal collections can be managed through three different methods: percutaneous drainage, endoscopic drainage, and surgery. Patients with peritonitis would require a laparoscopic or open surgical washout of the abdomen and inspection of the lesser sac would be necessary if no obvious source is identified. Foreign body ingestion requires careful history taking and assessment. Patients with lesser sac empyema present atypically, and this can lead to delayed surgical referral and management. Contained intra-abdominal collections can be drained percutaneously or endoscopically.

Ultrasonography for Skin and Soft Tissue Infections, Noninfectious Cysts, Foreign Bodies, and Burns in the Critical Care Setting

There are multiple opportunities for the use of ultrasonography in the diagnosis of skin and soft tissue differentials. Ultrasonography is inexpensive, easily reproducible, and able to provide real-time data in situations where condition changes and progression are common. Not only does bedside ultrasonography provide the clinician an in-depth look beyond epidermal structures into body cavities, it remains a safe, nonionizing radiating, effective, cost-efficient, reliable, and accessible tool for the emergency management of life- and limb-threatening integumentary infections. Unnecessary invasive procedures are minimized, providing improved patient outcomes. Integumentary abnormalities secondary to trauma, surgery, and hospitalization are common among critical care patients. This article provides a brief overview and evidence-based recommendations for the use of ultrasonography in the critical care setting for integumentary system conditions, including common skin and soft tissue differentials, foreign bodies, and burn depth assessment.

Chest X-ray Foreign Objects Detection Using Artificial Intelligence

Diagnostic imaging has become an integral part of the healthcare system. In recent years, scientists around the world have been working on artificial intelligence-based tools that help in achieving better and faster diagnoses. Their accuracy is crucial for successful treatment, especially for imaging diagnostics. This study used a deep convolutional neural network to detect four categories of objects on digital chest X-ray images. The data were obtained from the publicly available National Institutes of Health (NIH) Chest X-ray (CXR) Dataset. In total, 112,120 CXRs from 30,805 patients were manually checked for foreign objects: vascular port, shoulder endoprosthesis, necklace, and implantable cardioverter-defibrillator (ICD). Then, they were annotated with the use of a computer program, and the necessary image preprocessing was performed, such as resizing, normalization, and cropping. The object detection model was trained using the You Only Look Once v8 architecture and the Ultralytics framework. The results showed not only that the obtained average precision of foreign object detection on the CXR was 0.815 but also that the model can be useful in detecting foreign objects on the CXR images. Models of this type may be used as a tool for specialists, in particular, with the growing popularity of radiology comes an increasing workload. We are optimistic that it could accelerate and facilitate the work to provide a faster diagnosis.

Elusive long-standing intraoral foreign body: A rare encounter

Foreign body ingestion/aspiration can occur during orthodontic procedures that may be of minimal risk or lead to acute medical and life-threatening emergencies. The present report describes a rare case of retained orthodontic wire fragment in the masticator space for nearly two decades identified as an incidental radiographic finding, highlighting the importance of optimum care in the dental clinic at all times be it surgical or nonsurgical intervention.

Toothpick perforates small bowel-mimicking diverticulitis

Bowel perforation is an emergency condition that requires critical thinking and readily intervention; nevertheless, on occasions, its presentation can be challenging to diagnose. Several etiologies could cause bowel perforation, including obstruction, mass, inflammation, ischemia, etc. On rare occasions, a foreign body could be the cause of perforation, which mandates a detailed history and focused review of the images when the patient's condition allows. We report a case of ileal perforation caused by an ingested wooden toothpick that was suspected on the CT images, which the patient has no memory of ingesting.

Endoscopic esophageal foreign body removal among children at Lubaga Hospital, Kampala, Uganda

Background

Diagnostic upper gastrointestinal endoscopy involves examination of the lining of the esophagus, stomach and part of the duodenum. Interventional endoscopy in addition to evaluating the upper gastrointestinal tract to make a diagnosis, also offers a treatment benefit. Traditionally, esophageal foreign bodies (FBs) in Uganda were removed using rigid endoscopy. We therefore report an emerging trend of using flexible endoscopy to remove these FBs.

Objective

To describe participant characteristics and endoscopic findings among children who underwent esophageal FB removal in Lubaga Hospital in Kampala.

Methods

This was a retrospective review of endoscopy reports for children who underwent endoscopic esophageal FB removal at Lubaga Hospital from December 2014 to March 2022.

Results

Overall, 61 symptomatic children underwent this procedure. The majority of the FBs were removed by flexible endoscopy (n=55, 90.16%). The mean age of the participants was 7.88 (SD=2.12) years old. The majority of the children were females (72.13%) and coins were the most ingested FBs (84%), others included steel crucifix, nails etc. The upper esophageal sphincter was the commonest site for FB impaction (74%).

Conclusion

We report high success rates of 90.16% for endoscopic removal of impacted esophageal foreign bodies among Ugandan children using the now widely available flexible endoscopy.

Meningoencephalomyelitis associated with foreign plant material in a dog: case report and brief literature review

Neurologic disease associated with migration of plant material is reported infrequently in dogs. Here we describe meningoencephalomyelitis associated with foreign plant material in a 2-y-old castrated male West Highland White Terrier dog with acute neck pain. Magnetic resonance imaging revealed spinal meningeal contrast enhancement. Although clinical signs improved after treatment with steroids, the dog was readmitted for further evaluation 3-mo later and was euthanized after generalized epileptic seizures. Autopsy findings consisted of coalescing, pus-filled, neuroparenchymal cavitations surrounded by hemorrhage in the left caudal colliculus and rostral left cerebellar hemisphere. Histologically, lesions consisted of necrosis and suppuration, which surrounded a 1 × 2-mm foreign body morphologically consistent with plant material and clusters of gram-positive bacterial cocci. Affected areas were surrounded by reactive astrocytes, fibrous connective tissue, and mixed inflammatory infiltrates. Areas of hemorrhage and infiltration by neutrophils and foamy macrophages with fibrinoid change of small capillaries were observed in the adjacent neuroparenchyma. The inflammation extended to the perivascular spaces in the leptomeninges (mesencephalon, cerebellum, and brainstem, and spinal cord) and spinal central canal. Anaerobic bacterial culture of frozen samples of cerebellum yielded heavy growth of Bacteroides pyogenes.

Managing the Destructive Foreign Body: Water Beads in the Ear (A Case Series) and Literature Review

OBJECTIVE

To characterize our experience with super-absorbent polymer beads placed in the external auditory canal to better understand the damage caused and subsequent management required.

METHODS

Retrospective chart review of pediatric patients at 2 separate tertiary referral centers.

RESULTS

Seven patients were identified as having placed super-absorbent polymer beads in the external auditory canal, 6 of whom required removal under general anesthesia. Three patients did not suffer otologic trauma or hearing loss (average foreign body duration <72 hours). Four patients experienced severe otologic complications (average foreign body duration >1 week), all of whom were treated with otologic drops prior to bead identification. Of this severe complication group, 3 patients had restored hearing after surgical intervention, while 1 patient suffered profound hearing loss secondary to labyrinthitis ossificans.

CONCLUSION

Early recognition of otologic foreign bodies is important, particularly if expansile water-bead is suspected. Depending on timeframe, water beads are highly destructive to the middle ear structures, and most patients will require surgical intervention.

Characteristics of Breast Charcoal Granuloma: A Delayed Complication Following Tattoo Localization

Rationale and Objective: To evaluate the characteristic clinical and imaging findings of charcoal granuloma and suggest features that may differentiate charcoal granuloma from breast cancer. Materials and Methods: This retrospective study included 18 patients with a histologically confirmed breast charcoal granuloma between 2005 and 2021 at a single institution. All patients had a history of breast surgery after ultrasound (US)-guided charcoal marking. Two radiologists analyzed the radiologic findings of charcoal granulomas, including the presence of a mass or calcification; the shape, margin and density of the masses on mammography; and the location, size, shape, margin, orientation, echogenicity, vascularity, presence of an echogenic halo, and posterior acoustic shadowing on US. In cases with available follow-up images, we also investigated whether the size and shape had changed. Results: The median interval between breast surgery and the diagnosis of charcoal granuloma was 2.3 years (range, 0.7-18.3 years). Thirteen lesions (72.2%) were detected on screening images. In 11 (61.1%) cases, the surgical incision was not made in the tattooed skin area. Mammography showed positive findings in 10/15 patients, and most lesions were isodense masses (70%). There were no cases with calcification. On US, all lesions were masses and showed a taller-than-wide orientation (61.1%), round or oval shape (55.6%), and iso- or hyperechogenicity (83.3%). Echogenic halo (27.8%) and posterior acoustic shadowing (16.7%) were uncommon. On Doppler US, only four cases (22.2%) showed increased vascularity. Most were classified as BI-RADS 3 (38.9%) or 4A (50.0%). After biopsy, 12 patients had follow-up mammography and US. The size of the lesion decreased in nine cases and remained unchanged in three cases. A decrease in the lesion size after biopsy showed a negative correlation with the interval between detection on imaging and biopsy (p = 0.04). Conclusion: Charcoal granuloma is most commonly found 2-3 years after surgery and occurs more frequently when the incision site is different from the tattooed skin area. US findings of tall and round or oval masses with iso- or hyperechogenicity without increased vascularity could help to differentiate them from malignancies.

A Predictive Model of Major Postoperative Respiratory Adverse Events in Pediatric Patients Undergoing Rigid Bronchoscopy for Exploration and Foreign Body Removal

Background: No nomogram has been established to predict the incidence of major postoperative respiratory adverse events (mPRAEs) in children undergoing rigid bronchoscopy for airway foreign bodies (AFB) removal and exploration of the airway, though some studies have confirmed the risk factors. Methods: 1214 pediatric patients (≤3 years old) undergoing rigid bronchoscopy for AFB from June 2014 to December 2020 were enrolled in this study. The primary outcome was the occurrence of mPRAEs, including laryngospasm and bronchospasm. Following that, a nomogram prediction model for the mPRAEs was developed. Results: The incidence of mPRAEs was 84 (6.9%) among 1214 subjects. American Society of Anesthesiologists physical status (ASA-PS), intraoperative desaturation (SpO2 < 90%), procedural duration and ventilatory approach were all independent risk factors of mPRAEs. The area under the receiver operating characteristic curve (AUC) value of the nomogram for predicting mPRAEs was 0.815 (95% CI: 0.770-0.861), and the average AUC for ten-fold cross-validation was 0.799. These nomograms were well calibrated by Hosmer-Lemshow (p = 0.607). Decision curve analysis showed that the nomogram prediction model is effective in clinical settings. Conclusions: Combining ASA-PS, intraoperative desaturation, procedural duration, and ventilatory approach, the nomogram model is adequate for predicting the risk of developing mPRAEs, followed by rigid bronchoscopy for AFB removal and exploration.

Partial Obstruction of the Endotracheal Tube by a Part of the Metallic Stylet; Case Report and Review of the Literature

Endotracheal intubation is common in the emergency department, intensive care units, and operating rooms. It involves the insertion of an endotracheal tube (ETT) through the mouth or nose into the trachea to maintain a patent airway and facilitate mechanical ventilation. Using a stylet during intubation can guide the ETT through the vocal cords. However, complications can arise when the stylet is not removed after successful intubation. Herewith, we reported a patient who was two years old and suffered from respiratory failure. However, in the first 12 hours, we observed a foreign body in the trachea, a small end of a metal stylet immediately removed by bronchoscope. This case demonstrates that multiple uses of a stylet, especially by a single user, can result in impaction of the stylet in the ETT during intubation, requiring force when the stylet is withdrawn after intubation, which can result in breakage, shearing, and retention of the stylet or plastic sheath in the lumen of the ETT.

Two Cases of Severe Complications Due to an Esophageal Fish Bone Foreign Body

Cases of foreign body ingestion are encountered relatively often in clinical settings; however, serious complications are rare. In such cases, mediastinal abscess due to esophageal perforation can become a life-threatening complication. We encountered two cases of severe complications due to an esophageal fish bone foreign body. The first case was a 40-year-old male with an intramural esophageal abscess due to a fish bone after eating fish five days before visiting the hospital. The patient underwent surgical treatment, but the esophageal abscess did not improve; so, the abscess was drained through endoscopic mucosal dissection, and the abscess improved. In the second case, a 64-year-old male, who had eaten fish three days before visiting the hospital, had esophageal perforation by a fish bone, and abscess formation in the mediastinum and the lesser sac in the abdominal cavity were observed. Although surgical treatment was performed, the intra-abdominal abscess formation was not controlled; so, percutaneous drainage (PCD) was inserted, and the abscess improved. Both patients were discharged without any complications. Here, we report two cases that were improved through surgical treatments and additional treatments such as endoscopic dissection and PCD.

Gossypiboma, the Hidden Enemy of an Emergency Cesarean Hysterectomy-Case Report and Review of the Literature

Gossypiboma or textiloma is a rare medical situation that can complicate the favorable evolution of a surgical case, with repercussions for the patient's prognosis. The diagnosis can be difficult due to various clinical symptoms, the time elapsed since the surgical intervention, and the imaging often not being precise in detecting textilomas. Due to the medicolegal implications, the reporting of this event is inconsistent. We present a rare case of a 28-year-old woman who presented with vague pain in the left iliac fossa 11 months after an emergency cesarean hysterectomy was performed. The preoperative imaging examination identified the presence of a subhepatic mass with dimensions of 10 × 8 cm2 and another formation in the right iliac fossa with dimensions of 11 × 9 cm2. Exploratory laparotomy found the presence of a large subhepatic gossypiboma, intimately adherent to the hepatic angle of the colon and omentum and a second one adherent to the sigmoid colon, small intestine, and parietal peritoneum. The particularity of this case is given by the simultaneous presence of two textilomas with inconclusive evolution, which can make the differential diagnosis difficult to achieve. For a better assessment of the risk of occurrence of this pathology and the identification of a correct prevention strategy, we performed an extensive search and a review of all the articles published in the PubMed database, identifying 57 articles. In conclusion, emergency surgery increases the risk of this complication, and, as a result, prevention can be achieved by following existing protocols in the operating room.

Pharyngeal Fish Hook Impaction: Case Report and Literature Review

Foreign bodies, particularly fish bones, in the hypopharynx and cervical esophagus are a common complaint. A swallowed foreign body can be embedded in the tonsil, the base of the tongue, the pyriform fossae, or any region of the upper esophagus. A 70-year-old woman presented with persistent left-sided pharyngeal pain with the sensation of a foreign body for 10 days. She felt a sudden sharp pain in her pharynx while eating a fish head 10 days before the presentation. On examination, an elderly woman was found in painful distress. Flexible fiberoptic laryngoscopy revealed a pool of saliva in the pyriform fossae and a diagnosis of a foreign body in the esophagus was suspected. She was planned for direct laryngoscopy, left (lateral/external) pharyngotomy, and removal of foreign bodies under fluoroscopic guidance of the C-arm. A metallic fish hook that hung over the greater left horn, buried in the neck muscles, was found during the surgery and was extracted. The patient did well postoperatively and was discharged from the clinic. Foreign bodies, particularly fish bones, in the hypopharynx and cervical esophagus are a common complaint, particularly in the African setting.

A Foreign Body Lodged in the Glottis of a Toddler for a Prolonged Time: Anatomical Considerations and Review of the Literature

Our scope is to present the unusual case of an impacted foreign body in a child's larynx for a prolonged period due to recurrent misdiagnosis and review the literature emphasizing the laryngeal foreign body. A toddler girl from a rural region was initially referred to a primary pediatric care center due to a sudden choking episode. The mother made an unsuccessful attempt to pull out a possible foreign body by blind finger sweeping. After 22 days of recurrent misdiagnosis and unsuccessful conservative therapies, the child developed hoarseness of voice and dyspnea during physical exertion. The patient underwent a flexible nasopharyngolaryngeal endoscopy, which observed a foreign body in the glottis, and an emergency microlaryngoscopy. Persistence of laryngeal symptoms in a child with a sudden choking episode should always raise the suspicion of a respiratory tract foreign body impaction. The most appropriate therapeutical approach is rigid bronchoscopy under general anesthesia.

A Right-Angled Thorn in the Bowel: A Curious Case of Small Bowel Perforation

We present a 45-year-old man with small bowel perforation resulting from the inadvertent ingestion of a right-angled thorn of the Gum Arabic plant (Vachellia nilotica). The diagnosis was made, and an emergency laparotomy was performed for suspected enteric peritonitis. The thorn was found projecting from the terminal ileum with a minimal intra-peritoneal fluid collection. The thorn was removed, and the perforation site was repaired primarily with absorbable sutures. The lack of a reliable history of foreign body ingestion makes it impossible to arrive at an accurate preoperative diagnosis in patients presenting with perforation peritonitis. Radiological investigations have a low sensitivity for detecting radiolucent vegetative foreign bodies as the cause of bowel perforations. Primary repair should be preferred over resection procedures in the management of foreign body-induced small bowel perforations.

Routine nasogastric tube placement in patients with small esophageal perforation after endoscopic foreign body removal may be unnecessary: a propensity score matching analysis

Background

Nasogastric tube (NGT) placement is part of the post-operative management of upper gastrointestinal perforation, but its routine use in esophageal perforation (EP) caused by foreign bodies remains unclear. The purpose of this research was to investigate the necessity for routine NGT placement in patients with EP after endoscopic foreign body removal.

Methods

A total of 323 patients diagnosed with EP caused by foreign bodies at the First Affiliated Hospital of Nanchang University between January 2012 and December 2021 were included in this retrospective study. Patients were divided into the NGT group and the non-NGT group according to whether or not NGT placement was performed. The perforation healing rate, post-operative adverse events, hospital stay, and death rate were analysed using a 1:1 propensity score matching model.

Results

Before matching, there were 263 patients in the NGT group and 60 patients in the non-NGT group. There were significant differences in the time to treatment, infection, albumin, and types of endoscopy between the two groups, while the length of hospital stay in the NGT group was significantly longer than that in the non-NGT group. After 1:1 propensity score matching, 48 pairs of patients were matched between the two groups. The perforation healing rate, post-operative adverse events, length of hospital stay, and death rate did not show significant differences between the two groups.

Conclusions

For patients with small EP caused by foreign bodies, routine NGT placement after endoscopic foreign body removal may be unnecessary.

Pediatric Magnet Ingestion with Delayed Presentation: Case Series from Tertiary Center in Saudi Arabia

Swallowing foreign bodies is common in young kids, especially those aged 6 months to 6 years. Magnet ingestion is a hazardous health issue that extremely jeopardizes the most vulnerable group, children, to risks of intestinal obstruction and worse, perforation. We, hereby, report 3 cases of magnet ingestion in the pediatric age group who had multiple beaded magnets stuck inside their GI tract over a variable period of 1 to 10 months before their presentation to the Emergency Department, King Fahad Medical City Riyadh, Saudi Arabia.

Case report: Foreign body aspiration requiring extracorporeal membrane oxygenation

Introduction

Foreign body aspiration is a common cause of respiratory distress in pediatrics, but the diagnosis can be challenging given aspirated objects are mostly radiolucent on chest radiographs and there is often no witnessed choking event. We present a case of a patient who was initially managed as severe status asthmaticus, requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for refractory hypercarbia and hypoxemia, but was later found to have bilateral bronchial foreign body aspiration. This case is unique in its severity of illness, diagnostic dilemma with findings suggesting a more common diagnosis of asthma, and use of ECMO as a bridge to diagnosis and recovery.

Patient case

A previously healthy 2-year-old boy presented during peak viral season with a 3-day history of fever, cough, coryza, and increased work of breathing over the prior 24 h. There was no reported history of choking or aspiration. He was diagnosed with asthma and treated with bronchodilator therapy. Physical examination revealed pulsus paradoxus, severe work of breathing with bilateral wheeze, and at times a silent chest. Chest radiographs showed bilateral lung hyperinflation. Following a brief period of stability on maximum bronchodilator therapies and bilevel positive pressure support, the patient had a rapid deterioration requiring endotracheal intubation, with subsequent cannulation to VA-ECMO. A diagnostic flexible bronchoscopy was performed and demonstrated bilateral foreign bodies, peanuts, in the right bronchus intermedius and the left mainstem bronchus. Removal of the foreign bodies was done by rigid bronchoscopy facilitating rapid wean from VA-ECMO and decannulation within 24 h of foreign body removal.

Conclusion

Foreign body aspiration should be suspected in all patients presenting with atypical history and physical examination findings, or in patients with suspected common diagnoses who do not progress as expected or deteriorate after a period of stability. Extracorporeal life support can be used as a bridge to diagnosis and recovery in patients with hemodynamic or respiratory instability.

Paediatric foreign body aspiration and endobronchial granuloma

Paediatric foreign body aspiration can result in pulmonary complications including the formation of endobronchial granuloma, which can be managed conservatively or via surgical or bronchoscopic intervention. This case highlights the importance of having a high index of suspicion for foreign body aspiration in patients with persistent symptoms or abnormal imaging.

Facilitating the removal of a foreign body in the tongue by intraoperative ultrasound guidance: A case report

The presence of soft tissue foreign bodies (FBs) presents a substantial concern due to their potential to induce both acute and chronic pain as well as tissue irritation. This case report documents the admission of a 25-year-old female with a history of bur fractures during endodontic treatment, accompanied by signs of infection. The clinical examination and radiographic assessment revealed an embedded foreign body within her tongue. The surgical procedure was informed by repeated ultrasound scans through the incision, facilitating precise targeting. Intraoperative ultrasound enables the accurate detection of submucosal foreign bodies in dynamic tissues like the tongue and facilitates focused and image-guided dissection, thereby decreasing surgical trauma to the delicate soft tissues.

Clinical Study of Labyrinthine Fistula in Cholesteatomatous Chronic Otitis Media: A Tertiary Care Hospital-Based Retrospective Study in a South Indian Population

INTRODUCTION

Among the extracranial complications of cholesteatoma, the most common is labyrinthine fistula (LF). The causes are still poorly understood for cholesteatoma-induced labyrinthine fistula. Some of the possible factors described in the literature are the patient's age, duration of the disease, growth pattern of cholesteatoma, and disease aggressiveness. These affect the site of development of labyrinthine fistula. Cholesteatoma and its complications pose a great burden on the economic and health sector of developing nations.

AIM AND OBJECTIVE

 The objective is to estimate the incidence of labyrinthine fistula in cholesteatomatous chronic otitis media (COM) and analyze the clinical presentation and post-surgical improvement in hearing and vertigo in the study cohort.

MATERIALS AND METHOD

The study was conducted in the Department of Otorhinolaryngology. It involved retrospective data collection of case records between 2018 and 2022. All patients diagnosed with chronic otitis media (COM) with cholesteatoma were reviewed retrospectively in a tertiary healthcare center. Of the 324 cases reviewed, 21 had an LF.

RESULTS

The incidence rate of LF in our study was 6.48%. Sixteen (76.1%) patients were male, and five (23.9%) were female. The youngest patient was a 10-year-old male, and the oldest was a 51-year-old female. The mean ± standard deviation (SD) age was 34.09 ± 10.05 years. The left ear (76.1%) was affected more than the right ear. All cases were from rural areas, and 16 (76.1%) of them were farmers. Ear discharge (85%) was the most common symptom, followed by hearing loss (76%) and then vertigo (47%). A very peculiar risk factor of self-cleansing the ear was noticed in all patients. Out of the 21 patients who underwent surgery, it was observed that the lateral semicircular canal (LSCC) was the commonest site of the fistula. According to the Dornhoffer and Milewski classification, type II LF was the commonest type. In one patient with a type III LF, a foreign body (a piece of a twig) was found intraoperatively near the LSCC fistula site. Two patients had multiple fistulae. Six patients had associated mastocutaneous fistula, and one had facial nerve paralysis. All patients, except one, were free of vertigo following surgery. Postoperatively, the bone conduction thresholds were similar to the pre-surgical values in 12 of 16 (74%) patients.

CONCLUSION

 The incidence of LF is still higher in developing countries, predominantly in rural populations, where the habit of self-cleansing the ear is a common practice. The common symptoms of COM with LF are ear discharge, hearing impairment, and vertigo. All the cases had a habit of frequent self-cleansing of the external ear as an important risk factor. Therefore, implementing awareness programs on maintaining aural hygiene in rural health centers may reduce the incidence of cholesteatomatous LF, thereby preserving hearing and vestibular functions and improving the quality of life. However, the above statement needs further validation with large multicenter studies.

An Adult Case of Pharyngeal Injury Caused by Toothbrush

Most toothbrush-induced oral injuries occur in children and are relatively shallow, involving the oral mucous membranes and musculature, but rarely deeper layers. Here, the management of an adult case of pharyngeal injury caused by a toothbrush is discussed. A man fell while brushing his teeth, and his toothbrush stuck in his throat. Contrast-enhanced computed tomography showed a toothbrush stuck in the left parapharyngeal space, reaching the subcutaneous tissue of the posterior neck. The toothbrush was surgically removed because blind removal could damage major cervical arterioles and nerves. In intraoral injuries caused by deep penetrating toothbrushes, there is a risk that the injury extends to the major arterioles and nerves of the neck. The need for imaging studies, methods of removal, and possible complications should all be considered before taking an appropriate removal action.

Ingesta-associated choledocholithiasis in horses: 2 cases and literature review

Equine ingesta-associated choledocholithiasis is a rare cause of morbidity and mortality. We describe here the clinical, gross, histologic, and microbiologic features of this condition in 2 horses and compare the features to 2 previous cases. Case 1 was a 4-y-old Thoroughbred mare with colic. Case 2 was an 18-y-old American Paint Horse mare with colic, chronic weight loss, and inappropriate mentation. Both had elevated biochemical markers of hepatocellular injury and cholestasis and were euthanized given a poor prognosis. Case 1 had a well-formed 5-cm choledocholith surrounding a piece of hay, and had chronic neutrophilic cholangiohepatitis, bridging fibrosis, and extrahepatic obstruction. Case 2 had an ill-formed choledocholith with occasional hay fragments, wood stick, and twigs, and had regionally extensive hepatocellular necrosis with mild neutrophilic cholangiohepatitis and bridging fibrosis. Enterococcus casseliflavus and Escherichia coli were isolated in both cases; Clostridium spp. were also isolated from case 2. All 4 reported cases had increased activity of cholestatic enzymes, hyperbilirubinemia, portal inflammation, and bridging fibrosis. Colic, pyrexia, leukocytosis with neutrophilia, and elevated hepatocellular enzyme activity were documented in 3 cases. Foreign material in all 4 cases was plant origin (choledochophytolithiasis), including hay (n = 2), sticks/twigs (n = 2), and grass awns (n = 1). Ingesta-associated choledocholithiasis may be considered as a cause of colic, pyrexia, and elevated cholestatic biomarkers in horses.