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PREVENTION 3 Haake DA, Zakowski PC, Haake DL, et al. Early treatment with acyclovir for varicella pneumonia in otherwise healthy The US National Center for Infectious Dis- Rev adults: retrospective controlled study and review. Infect J Accid Emerg Med: first published as 10.1136/emj.16.2.150 on 1 March 1999. Downloaded from eases received reports of three adult deaths due Dis 1990;12:788-98. 4 Wallace MR, Bowler WA, Murray NB, et al. Treatment of to chickenpox in the first three months of 1997, adult varicella with oral acyclovir. A randomised, placebo- including two cases of pneumonia in previously controlled trial. Ann Intern Med 1992;117:358-63. 5 Joseph CA, Noah ND. Epidemiology of chickenpox in Eng- healthy non-pregnant adults.28 Three control land and Wales, 1976-85. BMJ 1988;296:673-6. strategies were recommended, including uni- 6 Fairley CK, Miller E. Varicella-zoster virus epidemiology-a changing scene ?JIlnfect Dis 1996;174(suppl 3):S314-19. versal vaccination against varicella in children 7 Mermelstein RH, Freireich AW. Varicella pneumonia. Ann aged over 12 months and non-immune adults, Intern Med 1961;55:456-63. 8 Knyvett AF. The pulmonary lesions of chickenpox. QJ'Med after antibody testing in doubtful cases. The 1966;139:313-23. vaccine was developed in Japan in 1972 and has 9 Ellis ME, Neal KR, Webb AK. Is smoking a risk factor for been available in North America since March pneumonia in adults with chickenpox ? BMJ 1987;294: 1002-3. 1995. It is a live, attenuated virus preparation 10 Rose RM, Wasserman AS, Wyser WY, et al. Deficient and therefore is unsuitable for immunosu- response ofpulmonary macrophages from healthy smokers to antiviral lymphokines in vitro.3JInfect Dis 1986;154:61 1- pressed persons and pregnant women. Uptake 18. of the vaccine has been poor even in designated 11 Waring JJ, Neubuerger K, Geever EF. Severe form of chick- enpox in adults. Arch Intern Med 1942;69:348-408. US surveillance sites because of perceptions 12 Nillson A, Ortqvist A. Severe varicella pneumonia in adults that chickenpox is mild and usually uncompli- in Stockholm county 1980-1989. Scand J Infect Dis 1996;28: 121-3. cated and unjustified concerns over the efficacy 13 Davidson RN, Lynn W, Savage P, et al. Chickenpox and duration of immunity afforded by vaccina- pneumonia: experience with antiviral treatment. Thorax 1988;43:627-30. tion. Other reasons advanced to account for 14 Weber DM, Pellecchia JA. Varicella pneumonia. Study of poor "hit rates" are the stringent storage and prevalence in adult men. JAMA 1965;192:572-3. 15 Baren JM, Henneman PL, Lewis RJ. Primary varicella in handling regulations and matters of cost. adults: pneumonia, pregnancy and hospital admission. Ann Varicella is not included in currently available Emerg Med 1996;28: 165-9. vaccination schedules in the UK. 16 Jackson MA, Burry VF, Olson LC. Complications of varicella requiring hospitalization in previously healthy The second strategy concerns varicella children. Pediatr Infect Dis J 1992;11:441-5. zoster immune globulin (VZIG). It is available 17 Potgeiter PD, Hammond JMJ. Intensive care management ofvaricella pneumonia. Respir Med 1997;91:207-12. for post-exposure prophylaxis in susceptible 18 Weinstein L, Meade R. Respiratory manifestations of chick- individuals including pregnant women and enpox. Arch Intern Med 1956;98:91-9. 19 Picken G, Booth AJ, Williams MV. The pulmonary lesions immunosuppressed persons and may be pre- of chickenpox pneumonia revisited. Br J Radiol 1994;67: scribed, on the advice of specialists in infec- 659-60. 20 Lee WA, Kolla S, Schreiner RJ, et al. Prolonged extracorpor- tious , to non-immune health care eal life support (ECLS) for varicella pneumonia. Crit Care workers who may present to the Med 1997;25:977-82. 21 Whited RE. A prospective study oflaryngotracheal sequelae department after occupational exposure to a in long-term intubation. Laryngoscope 1984;94:367-77. case of chickenpox. VZIG should be given as 22 Sugerman HJ, Wolfe L, Pasquale MD, et al. Multicenter, randomized, prospective trial of early tracheostomy. J soon as possible but it may be effective up to 96 Trauma 1997;43:741-7. hours after exposure. 23 Gershon AA. Steroid therapy and varicella. J Pediatr Finally, it was recommended that all adult 1972;81:1034. 24 Smego RA, Asperills MO. Acyclovir for varicella pneumonia cases of chickenpox should be treated with oral during pregnancy. Obstet Gynecol 1991;78: 1112-16. 25 Bean B. Antiviral therapy: new drugs and their uses. Postgrad acicolvir, preferably within 24 hours of the http://emj.bmj.com/ Med 1986;80:1 13-19 development of the rash. 26 Laskin OL. Acyclovir: pharmacology and clinical experi- ence. Arch Intern Med 1984;144:387-8. 1 Gershon AA, Steinberg SP, Gelb L. Clinical reinfection with 27 Broussard RC, Payne DK, George RB. Treatment with acy- varicella-zoster virus. J Infect Dis 1984;149:137-42. clovir of varicella pneumonia in pregnancy. Chest 1991;99: 2 Miller E, Marshall R, Vurdien J. Epidemiology, outcome 1045-7. and control of varicella-zoster infection. Rev Med Microbiol 28 Anonymous. Varicella-related deaths among adults- 1 993;4:222-30. United States, 1997.JAAMA 1997;277:1754-5. on September 29, 2021 by guest. Protected copyright. Management of laryngeal foreign bodies in children

School ofMedical Sciences, University Hari Shankar Sharma, Sanjay Sharma Sains Malaysia, 16150 Kota Bharu, Kelantan, Malaysia: Department of Abstract aspiration with subglottic impaction in Otorhinolaryngology H S Sharma Foreign body aspiration is one ofthe lead- very young children (under 2 years of age) ing causes of accidental death in children. are described. In both the cases subglottic Department of Food items are the most common items impaction occurred consequent to at- Anaesthesiology aspirated in infants and toddlers, whereas tempted removal of foreign body by blind S Sharma older children are more likely to aspirate finger sweeping. The clinical presentation, Correspondence to: non-food items. Laryngeal impaction of a investigations, and management of these Dr Hari Shankar Sharma, foreign body is very rare as most aspirated rare cases are discussed. Lecturer (e-mail: foreign bodies pass through the laryngeal (T Accid Emerg Med 1999;16: 150-153) [email protected]). inlet and get lodged lower down in the air- Accepted 31 October 1998 way. Two rare cases of foreign body Keywords: foreign body; aspiration; larynx; children Laryngealforeign bodies in children 151

Aspiration of a foreign body occurs either with objects that have been put into the mouth and accidentally displaced posteriorly or with J Accid Emerg Med: first published as 10.1136/emj.16.2.150 on 1 March 1999. Downloaded from objects that are unexpectedly encountered in food. In 1994, 3000 patients died from suffocation by ingested objects in the US mak- ing this the sixth leading cause of accidental death.' As most aspirated foreign bodies enter the bronchus after negotiating the glottis, the subglottic impaction of aspirated foreign body is rare. However, the diagnosis becomes a chal- lenge when an object crosses the glottis and lodges in the subglottic region. Two cases of subglottic impaction of foreign bodies are discussed. Case reports CASE 1 A 1 year old boy choked after putting a small fish bone into his mouth. His mother, who wit- nessed the incident, tried to remove the fish bone by putting her finger into the child's mouth, but was unsuccessful. The child then had a bout of coughing with blood tinged spu- Figure 1 Soft tissue radiograph ofchest and the neck tum and developed stridor. The child was showing radio-opaque shadow of thefish bone at subglottic taken to a general practitioner for complaints region in case 1. ofnoisy and vomiting and oral ampi- cillin was prescribed. Three days later the child was referred to the casualty department of our university hospital with the same complaints. On examination, the child was afebrile and had minimal inspiratory stridor but no cyanosis. He refused oral feeds and had pooling of saliva and milk in the oral cavity. He also had occasional vomiting. The respiratory rate was 22 breaths/min. There was no suprasternal or substernal recession. On auscultation there was I , . equal air entry in both the lungs with a rough mmr-T 10 20 30 inspiratory sound which was maximally heard Figure 2 Subglotticforeign bodies:fish bone (case 1) and broken tip ofplastic ball pen (case 2).

over the trachea, but there was no palpatory http://emj.bmj.com/ tracheal thud (the impact of a moving tracheal foreign body hitting against the wall of the tra- gently withdrawn and the left vocal cord was chea is felt by placing one finger on the retracted extremely laterally with the tip of the trachea). A radiograph of the soft tissue of the bronchoscope. The foreign body appeared like neck showed a radio-opaque shadow in the a "torn vocal cord" on end-on view through the subglottic region (fig 1). An emergency endos- bronchoscope. The fish bone, which was copy was planned. deeply embedded in the subglottic region, was Underall essential monitoring (electrocardio- removed with difficulty using forceps (fig 2). on September 29, 2021 by guest. Protected copyright. graphy, non-invasive blood , and Check bronchoscopy showed oedema of the oximeter), anaesthesia was induced with oxy- subglottic region. The child was subsequently gen, nitrous oxide, and halothane. All prepara- extubated and transferred to the intensive care tions were made to carry out tracheostomy or unit for observation. Postoperatively the child cricothyrotomy, if necessary. Once the child was treated with intravenous ampicillin and was under anaesthesia direct laryngoscopy was dexamethasone. Recovery was uneventful and done. No foreign body was found despite a the child was discharged from the ward after thorough direct laryngoscopic examination, three days. At follow up two weeks later, he was therefore rigid bronchoscopy (using a 3.5 mm asymptomatic and well. Storz bronchoscope) was used. 0.1 mg and suxamethonium 10 mg were given to CASE 2 facilitate introduction of the bronchoscope. A 14 month old girl was brought to the Ventilation was maintained by low frequency casualty department; she had been playing manual jet ventilation (Sander's jet injector). with plastic toys, was knocked down by her sis- Adequate depth of anaesthesia was maintained ter, and had then choked. The mother, who with entrainment of -halaothane mix- witnessed the incident, suspected foreign body ture delivered through the breathing circuit aspiration and explored the baby's mouth with (modified Ayer's T piece) connected to the a finger. She felt a sharp foreign body but was ventilation port of the bronchoscope. Muscle unable to remove it. This manipulation re- relaxation was maintained with atracurium. sulted in blood stained vomiting followed by The sagittally impacted foreign body was stridor. On examination the child had mild revealed only when the bronchoscope was inspiratory and expiratory stridor but no 152 Sharma, Sharma

cyanosis. The respiratory rate was 30 breaths/ the age of 4 years.'4 In our patients parents min. Auscultation of the chest showed bilateral instinctively attempted removal by blind finger conducted sounds. The child was taking food sweeping, which probably pushed the thin and J Accid Emerg Med: first published as 10.1136/emj.16.2.150 on 1 March 1999. Downloaded from orally. Radiography of the chest and soft tissue sharp foreign body deep into the subglottic neck were normal. Under general anaesthesia region. Therefore, blind finger sweeping should (low frequency manual jet ventilation through never be done in infants and small children as a small catheter placed in the trachea) direct this manoeuvre can cause trauma and induce laryngoscopy did not show a foreign body. A and what is initially a partial airway rigid bronchoscopy (using 3.5 mm broncho- obstruction may then become complete.'5 scope) revealed a greenish foreign body (a Finger sweeping is rarely useful in adult plastic tip of a ball pen) lying impacted at sub- victims to remove foreign bodies lying glottic region; this was removed with forceps in the oral cavity or oropharynx before starting after dislodging and rotating it to the sagittal resuscitation. Instead, a properly performed plane (fig 2). The anaesthetic technique used Heimlich manoeuvre (with a combination of was the same as in the first case. A repeat bron- and back blows to relieve choscopy showed minimal subglottic oedema. complete by a foreign body) Postoperatively the child was given ampicillin is a much safer first aid procedure in young and dexamethasone and kept under observa- non-breathing, unconscious victims of tion. She was sent home in good health after choking.'6 This manoeuvre appears to be two days. responsible for many successful rescues result- ing in a marked decline in paediatric deaths Discussion from foreign body aspiration in the US.' Most cases of foreign body aspiration occur in Several series have discussed non-lethal children less than 3 years of age.2A Children laryngeal obstruction8 "'. but none have tend to put objects impulsively into their specially addressed subglottic foreign bodies. mouths and run the risk of aspiration. Most Recently Halvorson et al reported that subglot- aspirated foreign bodies cross the larynx and tic foreign bodies pose a diagnostic challenge get lodged in the trachea or bronchus with an and in the majority of cases there is a delay in occasional one remaining in the larynx. The diagnosis.'3 Therefore, a high index of suspi- reported incidence of laryngeal lodgement of cion and specific questioning by the emergency aspirated foreign body varies from 2% to department physician should aid in differenti- 1 1%.58 Two kinds of foreign bodies may lodge ating patients with a laryngeal foreign body in the larynx. One is a large object like a piece from acute epiglottitis, laryngotracheobronchi- of meat that may cause life threatening tis, and asthma. Radiography of the soft tissue supraglottic or glottic obstruction. This type of neck and chest may not show any abnormali- accident is more common in adults than in ties as only 10%-15% of aspirated foreign children and is not a diagnostic dilemma as it bodies are visualised radiologically.'8 In late causes complete laryngeal obstruction and presentations the local response to the foreign sudden death. The National Safety Council in object is seen as a narrowing of the subglottic

the US has documented more than 240 deaths region on radiography, which is definitive or http://emj.bmj.com/ in children due to foreign body aspiration.' suggestive of foreign bodies. Nearly half (44%) of the cases of fatal choking The removal of a laryngeal foreign body in childhood are due to aspiration of various under general anaesthesia is a potentially diffi- types of food (hot dogs 17%, candy 10%, nuts cult and hazardous operation especially in the 9%, and grapes 8%).9 The other kinds of case of infants and young children.'3 '7 A laryngeal foreign bodies are sharp and thin detailed preoperative assessment is essential objects. Such objects can get embedded easily since the anaesthesia, like the operative tech- either at the laryngeal inlet, usually getting nique, is determined by the site of the foreign on September 29, 2021 by guest. Protected copyright. lodged between the vocal cords in the sagittal body and any secondary complications. It plane and causing non-fatal partial obstruction requires a team effort, which involves a skilled of the airways,'" or they can get embedded in and experienced endoscopist and an equally the subglottic region." skilled and experienced anaesthetist and a The initial response to aspiration is choking scrub nurse. Close cooperation between the and coughing followed by stridor, sternal otolaryngologist and anaesthetist is essential to recession, coughing, and hoarseness.'2 The maintain the airway at all times. The common- majority of aspirated foreign bodies caught in est method of removal of a foreign body in a the airways of children are spontaneously spontaneously breathing patient is through a eliminated by coughing and at times laryngo- rigid bronchoscope.2 '9 Muscle relaxation is spasm may cause a briefperiod of cyanosis and usually advisable because the consequences of transient choking. Laryngeal foreign bodies a patient bucking violently during airway with sharp edges cause not only dyspnoea but instrumentation, especially with a rigid bron- also odynophagia.1° choscope, are severe, for example unnecessary After passing the laryngeal inlet an aspirated bleeding and airway rupture.20 In smaller chil- foreign body tends to be pushed upwards by dren a useful technique is to use the tip of a the protective cough reflex; sharp and flat rigid bronchoscope to retract the vocal cords. objects can get impacted in the subglottic Thereby, a deeply embedded, subglottic, for- region, which is narrow and conical in shape." eign body is easily spotted. Complications after In neonates the larynx lies higher up at the level bronchoscopy are uncommon, but laryngo- of lower border of vertebral body of C4 and spasm and laryngeal oedema have been ob- does not reach the adult position of C5-6 until served. may be prevented by Painful elbow and von Willebrand's disease 153

adequate topical analgesia of the larynx and 7 Krejovic B, Cvetkovic S, Popovic S. Les corps etrangers du intravenous dexamethasone may help to re- larynx. journal Francais d'Oto-Rhino-Laryngologie 198 1;30:

465-8. J Accid Emerg Med: first published as 10.1136/emj.16.2.150 on 1 March 1999. Downloaded from duce laryngeal oedema. 8 Rothmann BF, Boeckman CR. Foreign bodies in the larynx The physician and tracheobronchial tree in children. Ann Otol Rhinol Laryngol 1980;89:434-6. should, therefore, consider subglottic impac- 9 Harris CS, Baker SP, Smith GA, et al. Childhood - tion of the aspirated foreign body in cases with tion by food-a national analysis and overview. JAMA 1984;251:2231-5. sudden onset of dyspnoea with odynophagia. 10 Darrow DH, Holinger LD. Foreign bodies of the larynx, Soft tissue neck radiographs are the most use- trachea and bronchi. In: Bluestone CD, Stool S, Kenna MA, eds. Paediatric otolaryngology. 3rd Ed. Philadelphia: ful investigation but should be done under WB Saunders, 1996:1394. proper supervision of the patient and in the 11 Brama I, Fearon B. Laryngeal foreign bodies in children. Int presence of a doctor capable of performing an Jf Pediatr Otorhinolaryngol 1982;4:259-65. 12 Esclamado RM, Richardson MA. Laryngotracheal foreign emergency tracheostomy in a child. There is bodies in children. AmJDis Child 1987;141:259-62. need for a programme to educate the public in 13 Halvorson D, Merritt RM, Mann C, et al. Management of subglottic foreign bodies. Ann Otol Rhinol Laryngol the proper first aid measures when dealing with 1996;105:541-4. victims of aspirated foreign bodies. This will 14 Battersby EF. Paediatric anaesthesia. Scott-Brown's otolaryn- prevent the kind of complications that were gology. Volume 6. 5th Ed. London: Butterworth, 1987: 503-26. seen in our cases. 15 Standards and Guidelines for Cardiopulmonary Resuscita- tion (CPR) and Emergency Cardiac Care (ECC). National 1 National Safety Council. Accidentfacts. Itasca, IL: National Academy of Sciences-National Research Council. JAMA Safety Council, 1995. 1986;255:2905-89. 2 Banerjee A, Rao S, Khanna SK, et aL Laryngo-tracheo- 16 Heimlich HJ. A life-saving maneuver to prevent food- bronchial foreign body in children. J Laryngol Otol choking. JAMA 1975;234:398-401. 1988;102: 1029-32. 17 Kent SE, Watson MG. Laryngeal foreign bodies. J Laryngol 3 Mu L, He P, Sun D. Inhalation of foreign bodies in Chinese Otol children: a review of 400 cases. Laryngoscope 1991;lO1: 1990;104:131-3. 657-60. 18 Moskowitz D, Gardiner U, Sasaki CT. Foreign body aspira- 4 Svensson G. Foreign bodies in tracheobronchial tree. tion. Potential misdiagnosis. Arch Otolaryngol Head Neck Special references to experience in 97 children. Int J Pedi- Surg 1982;108:806-7. atr Otorhinolaryngol 1985;8:243-51. 19 McGuirt WF, Holmes KD, Feehs R, et al. Tracheobronchial 5 Cohen SR, Lewis GB, Herbert WI, et al. Foreign bodies in foreign bodies. Laryngoscope 1988;98:615-8. airway. Ann Otol Rhinol Laryngol 1980;89:437-42. 20 Woods A. Paediatric bronchoscopy, bronchography, and 6 Kim IG, Brummitt WH, Humphry A, et al. Foreign body in larygoscopy. In: Berry FA, ed. Anaesthetic management of the airway-a review of 202 cases. Laryngoscope 1973;83: difficult and routine paediatic patients. New York: Churchill 347-54. Livingstone, 1986: 189-247.

An acutely painful elbow as a first presentation of von Willebrand's disease

H D M Poncia, J Ryan http://emj.bmj.com/

Abstract night and she attributed them to sleeping in an A 26 year old woman presented to the awkward position. Her elbow was held in a accident and emergency department with flexed position. Flexion and extension were a painful right elbow. There had been no both restricted. Radiographs were taken which history of trauma. Clinical examination showed prominent anterior and posterior fat on September 29, 2021 by guest. Protected copyright. suggested an effusion, which was con- pads (fig 1 ). A synovial effusion was suspected firmed on radiological examination. Her and her elbow was aspirated to provide elbow was aspirated and revealed a hae- symptomatic relief. Surprisingly, aspiration of marthrosis. Subsequent investigations re- the produced 7 ml of blood. She was vealed a diagnosis of von Willebrand's given a broad arm sling to rest her elbow. One disease (vWD). A spontaneously occur- week later her elbow was much improved and ring effusion of the elbow may be due to a full extension was only limited by 10 degrees. haemarthrosis. Aspiration of blood in the At six weeks her elbow was back to normal. absence oftrauma may lead to a diagnosis On further questioning the patient gave a of an occult coagulopathy in addition to Department of history of occasional bruising and heavy Accident and relieving pain. The diagnosis and treat- periods during the previous 2-3 years. She was , ment ofvWD is discussed. on no medication. Her mother also had a Royal Sussex County (JAccid Emerg Med 1999;16:153-154) history of bruising. In view of this history and Hospital, Eastern the findings of a spontaneous haemarthrosis, Road, Brighton Keywords: von Willebrand's disease; haemarthrosis; she was referred for a assess- BN2 5BE elbow haematological H D M Poncia ment. J Ryan Investigations revealed a normal full blood Case report count, liver function, biochemistry, inter- Correspondence to: A 26 year old woman, normally fit and well, national normalised ratio, and activated partial Mr Ryan (e-mail: [email protected]). presented to the accident and emergency thromboplastin time ratio. However von Will- (A&E) department with a painful right elbow. ebrand factor (vWF) antigen and vWF activity Accepted 7 August 1998 Symptoms had developed spontaneously over- were low, 31 IU/100 ml (50-200) and 29