An unusual cause of severe dyspnea: A laryngeal live leech: Case report

CASE REPORT – OPEN ACCESS

InternationalJournalofSurgeryCaseReports32(2017)9–11

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International Journal of Surgery Case Reports

j o u r n al ho m e p a g e :w w w . c a s e r e p o r t s . c o m

An unusual cause of severe dyspnea: A laryngeal live leech: Case report

Said Anajar

, Rachid Ansari, Jawad Hassnaoui, Reda Abada, Mohammed Roubal, Mohammed Mahtar

ENTDepartment,FaceandNeckSurgery,HospitalAugust,20’1953,UniversityHospitalCentreIBNRochd,Casablanca,Morocco

a r t i c l e i n f o

Articlehistory:

Received3October2016

Receivedinrevisedform8December2016 Accepted9December2016

Availableonline25January2017

Keywords:

Dyspnea Hemoptysis Leech Casereport

a b s t r a c t

INTRODUCTION:Foreignbodiesintheupperairwaysareoneofthemostchallengingotolaryngology emergencies,leechespresentaveryrarecauseofairwayforeignbodiesaroundtheworld.

CASEREPORT:A6-year-oldgirlwasreferredtoourotolaryngologydepartmentatatertiaryuniversity hospitalwithaseveredyspneaandhemoptysis.Nasofibroscopyrevealedadarklivingleechinthesupra- glotticareawhichextendstotheglottis.Thepatientwasurgentlyadmittedtotheoperatingroom,the leechwasgraspedandremovedwithaforeignbodyforcepswithafulllengthofmorethan6cm.All symptomswererelievedpostoperativelyandshewasdischargedonedaylater.

CONCLUSION:Leechesshouldbesuspectedasanairwayforeignbodyinpatientswitharecenthistory ofdrinkingfromstreamwater.Preventionremainsthebesttreatmentforsuchcasesbasedsimplyon hygienemeasureslikenotdrinkingstreamwaterdirectlyandfilteringdrinkingwaterbeforeitisused.

©2017TheAuthors.PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.Thisisanopen accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Foreignbodiesintheupperairwaysareoneofthemostchal- lengingotolaryngologyemergencies,leechesareaveryrarecause ofairwaysforeignbodiesaroundtheworld.Leechesaresegmented wormsthataregenerallyfoundinstreams,poolsandsprings.They canenterthehumanbodywhenpeopleswim incontaminative streamsordrinkinfestedwater.Wereportanunusualcaseofa 6−year-oldgirlwithaseveredyspneacausedbylaryngealleech infestation.

2. Case

A6-year-old girl (Fig. 1)wasreferred toourotolaryngology departmentatatertiaryuniversityhospitalwithaseveredyspnea andhemoptysis.Herparentsreportedthat2monthafterdrinking fromstreamwater,thepatientdevelopedhemoptysisanddyspho- niawithoutodynophagiaordysphagia.Nasofibroscopyrevealed adarklivingleechinthesupraglotticareawhichextendstothe glottis(Fig.2).Thepatientwasurgentlyadmittedtotheoperat- ingroom.Anorotrachealtubeandmaterialfortracheotomywere cautiouslyprepared.Undergeneralanesthesia,arigidlaryngoscope wasplaced,takingcarenottotouchtheleech,pushingtheepiglottis

∗ Corresponding author.Present address:5, Street BordeauxRue ait baha, Casablanca,Morocco.

E-mailaddress:[email protected](S.Anajar).

Fig.1.A6-year-oldgirl.

forwardandexposingtheentirelaryngealcavity.Thelaryngoscope wassuspendedandthevestibulewascarefullyexamined.Aliving leechwaslocatedontheanteriorsupraglotticareawithitssucking headstuckintotheanteriorcommissurejustbelowthevocalcords.

Theleechwasgraspedandremovedwithaforeignbodyforceps withafulllengthestimatedtobemorethan6cm(Fig.3).Allsymp-

http://dx.doi.org/10.1016/j.ijscr.2016.12.007

2210-2612/©2017TheAuthors.PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

CASE REPORT – OPEN ACCESS

10 S.Anajaretal./InternationalJournalofSurgeryCaseReports32(2017)9–11

Fig.2.Nasofibroscopyshowingaleech.

Fig.3. Leechextraction.

tomswererelievedpostoperativelyandshewasdischargedaday later.

3. Discussion

Leechesareparasitesthatliveonoccasionalbloodsuckingby attachingtofish,amphibians,andmammals[1].Theyuseanterior suckersconsistingofthejawand teethtoattachtotheirhost’s mucousmembranetofeed.Leechescansecreteananticoagulant enzymenamedhirudin,which inhibitscoagulationoftheblood [2,3].Therefore,signsofbleedingcanbeseen,suchasepistaxis, hematemesis,hemoptysis,orevenanemia,dependingontheexact siteoftheinfestation[3].

Leechescaningestblooduptoapproximately9timestheirown bodyweight[4].Signsofairwaysobstructionsuchasnasalobstruc- tion,dyspneaorsuffocationcanthereforeprogressovertime[4].

Besides,aforeignbodysensation,dysphagiaorhoarsenessmayalso befound[3,4].

Thereareonlyafewreportsoflivingleechesstuckinthelarynx [5].Leechescanattachtothemucosaoftheentireupperaerodi- gestivetractbutaleechstuckinthelarynxisrarelyseen[6].

Thepresenceofalivingleechintherespiratorytractshould besuspectedinpatientswhocomplainofhemoptysis,hoarseness, andrespiratorydistressofunknownoriginwitharecenthistory ofcontactwithuntreatedwater.Thesymptomsmaybemisdiag- nosedaslaryngitis,asthma,infectionssuchastuberculosisoreven malignancies[7].

Direct laryngoscopy under general anesthesia is the best approachforremovalofaleechfromtheaerodigestivetract.As aleech attachesstronglywithitssuckinghead,removalshould bedonecarefully[7].Howtheleechisgraspedisalsoimportant becauseit is slipperyand couldrupture easily,thus,using for- cepswithbluntjawsisrecommended.Greatcareshouldalsobe takentoentirelyremoveallpartsofthebody.Ruptureoftheleech withpartsoftheheadremainingcouldresultincontinuedbleed- ingbecausethesuckerscontainhirudin,whichisananticoagulant enzyme.Someexpertsadviseusinglidocaineintoughcasesasit causesrelaxationoftheheadsuckers.

4. Conclusion

Leeches should be suspected as an airway foreign body in patientswitharecenthistoryofdrinkingstreamwater,itshould bediagnosedandtreatedpromptlytoavoiddisastrousoutcomes.

Nasofibroscopymakesadefinitediagnosistodetectaleechinthe larynx.Directlaryngoscopyistheprocedureofchoicetoextractit.

Preventionremainsthebesttreatmentforsuchcasesbasedsimply onhygienemeasureslikenotdrinkingstreamwaterdirectlyand filteringdrinkingwaterbeforeitisused.

Conflictofinterest

Theauthorsdeclarehavingnoconflictsofinterestforthisarticle.

Funding None.

Ethicalapproval

Writteninformedconsentforpublicationoftheirclinicaldetails and/orclinicalimageswasobtainedfromtheparentofthepatient.

Consent

Writteninformedconsentforpublicationoftheirclinicaldetails and/orclinicalimageswasobtainedfromtheparentofthepatient.

Authorcontribution None.

Registrationofresearchstudies

RESEARCHREGISTRYUIN:researchregistry1665.

Guarantor Dr.AnajarSaid.

Acknowledgement None.

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S.Anajaretal./InternationalJournalofSurgeryCaseReports32(2017)9–11 11

References

[1]P.Zhang,R.Zhang,J.Zou,etal.,Ararecasereportoftrachealleechinfestation ina40-year-oldwoman,Int.J.Clin.Exp.Med.(UnitedStates)7(10)(2014) 3599–35601.

[2]T.San,E.Gurkan,A.Karaaslan,etal.,Anunusualcauseofhemoptysis:leechin thesupraglotticregionofthelarynx,J.Craniofac.Surg.(UnitedStates)25 (March(2))(2014)531–532.

[3]S.Touzani,T.Joulali,A.Derkaoui,etal.,Theleech:anunusualrespiratory emergency,PresseMed.(France)44(March(3))(2015)347–348.

[4]I.Kaygusuz,S.Yalcin,E.Keles,Leechesinthelarynx,Eur.Arch.

Otorhinolaryngol.258(2001)455–457.

[5]C.K.Pandey,R.Sharma,A.Baronia,A.Agarwal,N.Singh,Anunusualcauseof respiratorydistress:liveleechinthelarynx,Anesth.Analg.90(5)(2000) 1227–1228.

[6]I.Kaygusuz,S.Yalc¸in,E.Keles¸,Leechesinthelarynx,Eur.Arch.

Otorhinolaryngol.258(9)(2001)455–457.

[7]Y.Mohammad,M.Rostum,B.A.Dubabo,Laryngealhirudiniasis:anunusual causeofairwayobstructionandhemoptysis,Pediatr.Pulmonol.33(3)(2002) 224–226.

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