J Oral Maxillofac 50:62-63.
Surg
1992
Calcification of the Cricoid Cartilage Mistaken for a Foreign Body: Report of a Case MICHAEL MCDONALD, DMD,* AND M.A. POGREL, MB, CHB, BDS, FDS, RCS, FRCSt
was then awakened, was breathing without difficulty, and was taken to the recovery room without complication. It was then realized that the radioapacity seen on the radiograph represented calcification of the cricoid cartilage. However, the initial diagnosis of a foreign body in the larynx was supported by the radiologists, anesthesiologists, and otorhinolaryngologists.
SubgIottic calcification can be mistaken for a foreign body, causing unnecessary patient morbidity, particularly in cases of major oral and maxillofacial surgery. A case in which this occurred is presented.
Report of a Case A 27-year-old woman underwent elective orthognathic surgery in February of 199 1 for correction of a dysfunctional malocclusion secondary to bilateral condylar resorption with resultant apertognathia, mandibular retrognathism, and microgenia. The patient’s past medical history included systemic lupus erythematosus, rheumatoid arthritis, and chronic steroid use. Orthognathic surgery consisted of a Le Fort I maxillary osteotomy with a genioplasty, both using rigid fixation. The surgery was carried out without complication. The throat pack was removed before placing the patient in maxillomandibular fixation, and the sponge count was correct. Postoperatively it was elected to leave the patient intubated overnight. The next morning, when the cuff around the endotracheal tube was deflated, the patient was unable to breathe around the tube, and a lateral cervical radiograph was obtained. Her neck film was read as being positive for the presence of a foreign body at the level of C-S to C-6, consistent in appearance with cotton material (Fig 1). Consultation was obtained from the otorhinolaryngology department and it was decided that the patient should return to the operating room for direct laryngoscopy and examination under anesthesia, with foreign-body removal. In the operating room, the patient was given a general anesthetic and released from maxillomandibular fixation. No foreign body was visualized in the posterior oropharynx or around the endotracheal tube using a fiberoptic laryngoscope. With the patient breathing spontaneously, extubation followed by direct laryngoscopy by the otolaryngologist was performed without evidence of a foreign body. The patient
Discussion The possibility of cricoid calcification being mistaken for a foreign body on a radiograph has previously been reported.’ In 1935, Chamberlain and Young2 first noted the problem of mistaking ossified laryngeal cartilages for a foreign body, and others have mentioned unnecessary invasive procedures that have occurred secondary to this embarrassing misdiagnosis.3 In the present case, additional factors were present, such as orthognathic surgery that used the placement of throat
packs, hemostatic packings, anesthetic nasal swabs, and the hardware used for rigid fixation. The inability of the patient to breath around the deflated endotracheal tube was a concern to the anesthesiologist. This, along with the lateral neck film that was reported as positive for a foreign body and the agreement of the otolaryngologists, led to the patient’s return to the operating room for foreign-body removal under anesthesia. Calcification of the larynx can occur in both adults and children, and involve the thyroid, cricoid, and arytenoid cartilages. 4,5When it involves the posterior superior laminar portion of the cricoid cartilage, it may be mistaken for a foreign body. Our patient had a past medical history of systemic lupus erythematosus. Such patients can exhibit cricoid and arytenoid arthritis, which presents radiographically as mucosal edema, that can be mistaken for an opaque foreign body.
Received from the Department of Oral and Maxillofacial Surgery, University of California, San Francisco. * Chief Resident. t Associate Professor. Address correspondence and reprint requests to Dr Pogrel: Department of Oral and Maxillofacial Surgery, University of California, San Francisco, 5 13 Parnassus Ave. 5-738, San Francisco, CA 94 1430440. 0 1992 American
Association
of Oral and Maxillofacial
In planning for the extubation of this patient, the ability to breathe around the deflated endotracheal tube was used as a major criterion. The concern is that extubation followed by rebound laryngeal airway swelling will make reintubation, if necessary, extremely difficult. In this case the patient was unable to breathe around
Surgeons
0278-2391/92/5001-0013$3.00/O
62
63
MCDONALD AND POGREL
FIGURE I. Lateral neck radiograph showing calcification of the cricoid cartilage (arrow).
the deflated endotracheal tube, but breathed without difficulty once extubated in the operating room. The ability to breathe around a deflated cuff is a poor criterion for extubation. When positive, it is a reassuring sign. However, an inability to breath around a deflated cuff can occur in the absence of laryngeal edema if the tube is of a large diameter or if the deflated cuff still blocks the space around the tube. These possibilities, as well as the level of consciousness, oxygen saturation, and quality of breathing should be considered when planning extubation. This case brings to attention the awareness of calcification of the larynx, most notably the cricoid portion, being misdiagnosed as a foreign body. With this
awareness, unnecessary intervention or anxiety can be prevented. References 1. Zizmor J, Noyek AM: Some miscellaneous disorders of the larynx and pharynx. Semin Roentgen01 9:3 I 1, I974 2. Chamberlain WE, Young BR: Ossification (so called “calcification”) of normal laryngeal cartilages mistaken for foreign body. Am J Roentgen01 33:441. 1935 3. Muroff LR. Seaman WB: Normal anatomy of the larynx and differential diagnosis of foreign bodies. Semin Roentgen01 9: 267, 1974 4. Jurik AC: Ossification and calcification of the laryngeal skeleton. ‘5:17. 1984 5. Salmam RA. Kinney LA: Calcified thyroid cartilage. Oral Surg 70806. 1990
Surg
1992
Calcification of the Cricoid Cartilage Mistaken for a Foreign Body: Report of a Case MICHAEL MCDONALD, DMD,* AND M.A. POGREL, MB, CHB, BDS, FDS, RCS, FRCSt
was then awakened, was breathing without difficulty, and was taken to the recovery room without complication. It was then realized that the radioapacity seen on the radiograph represented calcification of the cricoid cartilage. However, the initial diagnosis of a foreign body in the larynx was supported by the radiologists, anesthesiologists, and otorhinolaryngologists.
SubgIottic calcification can be mistaken for a foreign body, causing unnecessary patient morbidity, particularly in cases of major oral and maxillofacial surgery. A case in which this occurred is presented.
Report of a Case A 27-year-old woman underwent elective orthognathic surgery in February of 199 1 for correction of a dysfunctional malocclusion secondary to bilateral condylar resorption with resultant apertognathia, mandibular retrognathism, and microgenia. The patient’s past medical history included systemic lupus erythematosus, rheumatoid arthritis, and chronic steroid use. Orthognathic surgery consisted of a Le Fort I maxillary osteotomy with a genioplasty, both using rigid fixation. The surgery was carried out without complication. The throat pack was removed before placing the patient in maxillomandibular fixation, and the sponge count was correct. Postoperatively it was elected to leave the patient intubated overnight. The next morning, when the cuff around the endotracheal tube was deflated, the patient was unable to breathe around the tube, and a lateral cervical radiograph was obtained. Her neck film was read as being positive for the presence of a foreign body at the level of C-S to C-6, consistent in appearance with cotton material (Fig 1). Consultation was obtained from the otorhinolaryngology department and it was decided that the patient should return to the operating room for direct laryngoscopy and examination under anesthesia, with foreign-body removal. In the operating room, the patient was given a general anesthetic and released from maxillomandibular fixation. No foreign body was visualized in the posterior oropharynx or around the endotracheal tube using a fiberoptic laryngoscope. With the patient breathing spontaneously, extubation followed by direct laryngoscopy by the otolaryngologist was performed without evidence of a foreign body. The patient
Discussion The possibility of cricoid calcification being mistaken for a foreign body on a radiograph has previously been reported.’ In 1935, Chamberlain and Young2 first noted the problem of mistaking ossified laryngeal cartilages for a foreign body, and others have mentioned unnecessary invasive procedures that have occurred secondary to this embarrassing misdiagnosis.3 In the present case, additional factors were present, such as orthognathic surgery that used the placement of throat
packs, hemostatic packings, anesthetic nasal swabs, and the hardware used for rigid fixation. The inability of the patient to breath around the deflated endotracheal tube was a concern to the anesthesiologist. This, along with the lateral neck film that was reported as positive for a foreign body and the agreement of the otolaryngologists, led to the patient’s return to the operating room for foreign-body removal under anesthesia. Calcification of the larynx can occur in both adults and children, and involve the thyroid, cricoid, and arytenoid cartilages. 4,5When it involves the posterior superior laminar portion of the cricoid cartilage, it may be mistaken for a foreign body. Our patient had a past medical history of systemic lupus erythematosus. Such patients can exhibit cricoid and arytenoid arthritis, which presents radiographically as mucosal edema, that can be mistaken for an opaque foreign body.
Received from the Department of Oral and Maxillofacial Surgery, University of California, San Francisco. * Chief Resident. t Associate Professor. Address correspondence and reprint requests to Dr Pogrel: Department of Oral and Maxillofacial Surgery, University of California, San Francisco, 5 13 Parnassus Ave. 5-738, San Francisco, CA 94 1430440. 0 1992 American
Association
of Oral and Maxillofacial
In planning for the extubation of this patient, the ability to breathe around the deflated endotracheal tube was used as a major criterion. The concern is that extubation followed by rebound laryngeal airway swelling will make reintubation, if necessary, extremely difficult. In this case the patient was unable to breathe around
Surgeons
0278-2391/92/5001-0013$3.00/O
62
63
MCDONALD AND POGREL
FIGURE I. Lateral neck radiograph showing calcification of the cricoid cartilage (arrow).
the deflated endotracheal tube, but breathed without difficulty once extubated in the operating room. The ability to breathe around a deflated cuff is a poor criterion for extubation. When positive, it is a reassuring sign. However, an inability to breath around a deflated cuff can occur in the absence of laryngeal edema if the tube is of a large diameter or if the deflated cuff still blocks the space around the tube. These possibilities, as well as the level of consciousness, oxygen saturation, and quality of breathing should be considered when planning extubation. This case brings to attention the awareness of calcification of the larynx, most notably the cricoid portion, being misdiagnosed as a foreign body. With this
awareness, unnecessary intervention or anxiety can be prevented. References 1. Zizmor J, Noyek AM: Some miscellaneous disorders of the larynx and pharynx. Semin Roentgen01 9:3 I 1, I974 2. Chamberlain WE, Young BR: Ossification (so called “calcification”) of normal laryngeal cartilages mistaken for foreign body. Am J Roentgen01 33:441. 1935 3. Muroff LR. Seaman WB: Normal anatomy of the larynx and differential diagnosis of foreign bodies. Semin Roentgen01 9: 267, 1974 4. Jurik AC: Ossification and calcification of the laryngeal skeleton. ‘5:17. 1984 5. Salmam RA. Kinney LA: Calcified thyroid cartilage. Oral Surg 70806. 1990
