Abstract
We present a case report of a 14-month-old girl who ingested a moth cocoon, which resulted in dramatic symptoms of irritability, drooling, and anorexia. Direct laryngoscopy, bronchoscopy, and esophagoscopy under general anesthesia revealed copious, tenaciously adherent, barbed hairs embedded in her tongue and buccal mucosa. Removal of the hairs with irrigation, suction, and brushing was unsuccessful and was eventually abandoned. In the following 48 hours, the girl recovered uneventfully with supportive care. The hairs were subsequently identified as coming from the hickory tussock moth (Lepidoptera: Arctiidae: Lophocampa caryae ), which is ubiquitously distributed throughout much of North America. This is the first detailed case report of ingestion of an L caryae cocoon.
1
Introduction
Ingestion of foreign substances is not uncommon in young children and may result in esophageal, laryngeal, tracheal, or bronchial foreign bodies. The most common objects are coins, nonmetallic sharp objects, bones, nuts, food debris, and small toys . Depending upon their location, foreign bodies may elicit a variety of symptoms, including anorexia, drooling, coughing, vomiting, and respiratory distress. Otolaryngologists are frequently consulted to extract foreign bodies, which can present a myriad of challenges depending upon their composition and location. Unusual or rare foreign bodies may present unique challenges because caregivers have little or no prior experience with their management and scant reference material to assist them. We present an unusual case of ingestion of a moth cocoon in a young child.
2
Case report
A previously healthy 14-month-old girl was found by her mother to have a foreign body in her mouth while at play outside her home. The mother removed the object, which she believed was an owl pellet because it appeared to contain mammalian hair and bony fragments. She sought medical care because her daughter was irritable, drooling, and refusing oral intake despite removal of the object. The girl was evaluated at our tertiary referral center for further evaluation and care. Her general appearance was notable for drooling and irritability without respiratory distress or cyanosis. Physical examination revealed normal vital signs, copious 2- to 4-mm dark hairs on her tongue and buccal mucosa, and bilateral equal breath sounds. Bedside flexible laryngoscopy revealed no foreign bodies in the nasopharynx, oropharynx, and hypopharynx. Radiographs of the neck and chest were unremarkable.
The patient was taken to the operating room for direct laryngoscopy, bronchoscopy, and esophagoscopy under general anesthesia. After an uneventful inhalational induction of anesthesia, 2% topical lidocaine was applied to the oropharynx and larynx. During spontaneous ventilation, laryngoscopy followed by bronchoscopy down to the mainstem bronchi showed unremarkable findings. She was then intubated with a 4.0-mm inner diameter endotracheal tube. The oral cavity and oropharynx were noted to have hundreds of adherent, dark, hairlike structures ( Fig. 1 ). Attempts at removal of the hairs with irrigation, suction, and brushing were unsuccessful. Esophagoscopy using a Jesberg esophagoscope showed no abnormalities from the cervical inlet to the gastroesophageal junction. The patient emerged smoothly from anesthesia, was extubated without difficulty, and underwent an uneventful postoperative recovery.
She received intravenous hydration overnight and increased her oral intake on the following morning, with a preference for solids over liquids. She required no analgesics other than acetaminophen and showed no evidence of dehydration. She was discharged to home on postoperative day 1. During a follow-up phone call, her mother reported that approximately 25% of the hairs had disappeared within 24 hours of ingestion and 95% of the hairs had disappeared within 48 hours of the ingestion.
The mother retrieved the foreign body from her yard, which was subsequently analyzed. Upon receipt, the specimen was badly damaged, but identification as an owl pellet was dismissed. After comparison with moth cocoon specimens from the Invertebrate Zoology Collection of the Cleveland Museum of Natural History, Cleveland, OH, it was identified as the pupal cocoon from the hickory tussock moth, a member of the family of tiger moths (Lepidoptera: Arctiidae: Lophocampa caryae ). Photographs of the surface of the unknown specimen and museum specimens were taken with a dissection microscope at original magnification ×40. Hairs from the unknown and known specimens were removed with forceps and placed on a microscope slide to compare the barbed hairs. The barbed hairs, as well as the smooth hairs that exhibited apical darkening, confirmed identification as the hickory tussock moth ( Fig. 2 ). The cocoon weighed less than 0.1 g (dry weight) and measured 24 × 13 mm.
2
Case report
A previously healthy 14-month-old girl was found by her mother to have a foreign body in her mouth while at play outside her home. The mother removed the object, which she believed was an owl pellet because it appeared to contain mammalian hair and bony fragments. She sought medical care because her daughter was irritable, drooling, and refusing oral intake despite removal of the object. The girl was evaluated at our tertiary referral center for further evaluation and care. Her general appearance was notable for drooling and irritability without respiratory distress or cyanosis. Physical examination revealed normal vital signs, copious 2- to 4-mm dark hairs on her tongue and buccal mucosa, and bilateral equal breath sounds. Bedside flexible laryngoscopy revealed no foreign bodies in the nasopharynx, oropharynx, and hypopharynx. Radiographs of the neck and chest were unremarkable.
The patient was taken to the operating room for direct laryngoscopy, bronchoscopy, and esophagoscopy under general anesthesia. After an uneventful inhalational induction of anesthesia, 2% topical lidocaine was applied to the oropharynx and larynx. During spontaneous ventilation, laryngoscopy followed by bronchoscopy down to the mainstem bronchi showed unremarkable findings. She was then intubated with a 4.0-mm inner diameter endotracheal tube. The oral cavity and oropharynx were noted to have hundreds of adherent, dark, hairlike structures ( Fig. 1 ). Attempts at removal of the hairs with irrigation, suction, and brushing were unsuccessful. Esophagoscopy using a Jesberg esophagoscope showed no abnormalities from the cervical inlet to the gastroesophageal junction. The patient emerged smoothly from anesthesia, was extubated without difficulty, and underwent an uneventful postoperative recovery.
