Valvular glottic obstruction in a baby.

Sir,—Twelve days before admission, a baby girl (aged 9 months, wt 12 kg) had coughed violently while eating boiled egg and bread and, although it was considered possible that she had aspirated some food, she had remained well for 8 h until severe dyspnoea developed during sleep. An initial diagnosis of asthmatic bronchitis was made and she was treated with isoprenaline and bromhexine. On the day of her emergency admission to the paediatric clinic of our hospital, she had suddenly developed severe dyspnoea with inspiratory stridor, and cyanosis. Shortly after admission, bronchoscopy was performed using a 3-mm bronchoscope under general anaesthesia comprising 50% nitrous oxide in oxygen with halothane 1-4%. Bronchoscopy revealed a foreign body lodged directly below the vocal cords. This was white in colour and it moved upwards and downwards with respiration, completely obstructing the larynx during inspiration. After removal, the object was seen to be a fragment of egg shell with a roughened circumference and surface area of 0.5 cm. A second smaller fragment of eggshell was removed from the orifice of the left main bronchus. Further examination of the bronchial tree revealed no abnormality. Cardiac and respiratory rates were monitored using two stethoscopes during the 45-min procedure; atropine 0.3 mg was administered i.v. when a reduction in heart rate from 130 beat min" to 90 beat min" was detected. After operation, steroid and antibiotic therapy were given, and the baby made a good recovery. Many types of foreign material have been recovered from the respiratory tract during bronchoscopy in children; this presentation is unusual in that the onset of severe airway obstruction was delayed for 12 days, when the larger piece of eggshell caused a valve-like obstruction at the level of the vocal cords.