Pill in the Pyriform sinus, What Anaesthesiologists Should know About it
A 51-year-old male, with no known comorbidities, was scheduled for elective lumbar spine surgery. He was fasting from midnight 10 P.M and took a tablet of Pantoprazole at 6 A.M with of a sip water as per department protocol. At 8 A.M. patient was induced with intravenous agents, and bag-mask ventilation was uneventful. During video laryngoscopy to our surprise, a foreign body near the right pyriform sinus was seen (Figure 1).
Figure 1
Screenshot of Videolaryngoscope showing tablet residue in right pyriform sinus during induction of general anesthesia.
The foreign body was removed with Magill forceps and Endotracheal intubation was performed. After extubation, the patient confirmed he had no difficulty swallowing or foreign body sensations in the throat. However, he did feel the need for more water to swallow the tablet given in the morning. It is common to find food particles around the glottis during intubation in patients with altered sensorium. Here we present a rare case where a foreign body was found in a patient with normal swallowing reflex in the peri glottic area. It was noticed during laryngoscopy and was removed safely. This was probably because of the restriction of clear fluid intake prior to surgery. However, to prevent such occurrences in the future we looked into factors affecting swallowing of tablets. The quantity of water is found to be directly proportional to the ease of swallowing a tablet.1 Tablets less than 7 mm in diameter and extension of the head while swallowing had shorter oral transit time.2 Also, tablet residues are most commonly found in the vallecula, pyriform sinus, and base of the tongue.2 It is important to give clear instructions to patients about medications on the morning of surgery. The smallest tablet available of the same drug is to be ordered and preferably swallowed in a sitting upright position with the head extended. The tablets should be swallowed with 100 ml of water, also allowing more water if the patient needs it. A maximum of 400 ml can be given 2 hours before scheduled surgery per the latest guidelines.3 These instructions will keep patients comfortable and prevent residues in the pharynx.
Article DOI
