Animate Objects In Orifices: The Airway

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Due to the popularity of my Inanimate Objects in Orifices series which takes you through the journey and consequence of foreign bodies in the body from eyes, ears, nose, throat to vagina and penis (see here or here), I will shift gears here to the creepy crawlers like leeches, fish and roundworms that can obstruct an airway and be life-threatening. After all, unintentional injury is in the top 5 leading causes of preventable deaths with choking from foreign body aspiration being fourth among these.  

I have previously touched upon how ophthalmologists routinely remove gnats, parts of flies and other tiny insects that get embedded inside eyelids, in particular in the summer when it is prime time for things that fly in the air to be carried by wind. Alive or dead. And, how organic creatures like bugs or cockroaches can literally crawl deeper into a tortuous canal inside your ear, especially when spooked by the light from ENT physicians’ superhero equipment intended to remove them. This can prompt the little vermin to move inward toward the drum- a less desirable direction for the afflicted patient where they tend to get frightened and cling to it. Imagine the feeling when their position and sound reverberates inside your head.

These scenarios spare no specialties in medicine albeit primary care, radiology or the vast surgical realm. Now, think about the adverse impact and peril a live, actively mobile varmint can cause in your airway. Though more often such aspirations are of inanimate origin, the most common animate ones are fish, leeches and roundworms and the morbidity and mortality can be significant - especially without immediate intervention.

Researchers, in an effort to raise awareness on common presentations and their management in such medical emergencies, published a review of the medical literature in the journal CHEST and I will summarize some of their findings here:

Live Fish Aspiration

Fishermen are particularly at risk. Accidental aspiration is most frequent, but can be due to putting the live fish in the mouth for the dangerous practice of holding it between the teeth while fishing or biting it behind its eyes to kill it - not the greatest ideas. If impaction especially occurs along certain places within the airway (e.g. over the epiglottis or where the trachea splits in two), the patient can rapidly asphyxiate and die. As it squirms so it can breathe, its sharp fins, for example, can exacerbate a patient’s inflammatory reaction causing additional swelling while it further lodges itself. Anabas testudineus is a common culprit in Southeast Asia and due to the inclination of their dorsal and anal fins to enhance forward momentum they resist removal by anchoring and worsening obstruction along with tearing or perforating parts of the person’s anatomy.

Securing the airway is most important as repeated efforts for removal can be damaging if excessive force is used - so methods that are less traumatizing are preferred. Asphyxiation is the cause of death, it happens when the airway remains unstable or there is a delay in stabilizing it. Piecemeal extraction techniques are recommended. Sometimes rapid decomposition of the fish naturally occurs and somewhat helps to free up obstruction, still requiring removal of its residual often bony parts.

Leech Infestation

These parasitic or predatory segmented worms can be found on land or in water. It has suckers at each end that attach to the host by suction or its powerful jaws (some of which have teeth). For the toothed kind, once they puncture skin or mucous membranes to get to the blood, they secrete saliva that ostensibly numbs the area and prevents normal clotting as it promotes bleeding - which can go on for days after detachment.

Symptoms range from coughing up blood, difficulty breathing, bloody noses, painful throats, fatigue or weakness from anemia to cardiopulmonary distress when severe. They can be chronic and confused with signs of asthma or other nonspecific problems.

Freshwater leeches, for example, can cause human airway infestation - often occurring in remote areas that lack clean drinking water and where the hazards are not well known. These can pose a two-part problem. First, because they can store a lot of blood, symptoms may not start or worsen till they enlarge enough to prompt hoarseness and airway obstruction. Second, there is bacteria of multiple types within the blood reservoir that helps the leech to digest but can trigger the human to become septic or develop pneumonia and other infections. This is why if they are stressed or forcibly removed they can release this contaminated blood into the body.

So, careful removal is essential and antibiotics may play a role. Removal has its challenges so the worm doesn’t migrate deeper, often requiring first grasping it and using anesthetics to paralyze it. Cryoadhesion represents a more recent trend.

Take home message

When objects, animate or inanimate, go where they shouldn’t, problems arise that can be life-threatening - so seeking immediate advanced medical care is a safer bet. Often secondary issues come about from the ability of animate items to absorb inflammatory reactions and further swell along with their ability to risk infection and damage tissue due to their sharpness and mobility. It is also of great import to appreciate that there are good and bad ways to remove such trespassers (see the CHEST article here for better understanding).

Once again, the greatest danger is the anatomical location. The airway does not do well when traumatized or obstructed, so early and proper intervention is essential to securing it and thereby saving a life. Knowing the threats in your environment and making sensible choices whenever possible go a long way for prevention.