Choking on a grape: an unusual type of upper airway obstruction

Abstract

ForewordBradwell, a London doctor, stated in 1663 ‘‘Of things thatendanger stopping of the breath in swallowing, some aresharp, and some blunt… I have heard of a child inWoodstreet strangled with a grape.’’ [1, 2]Case reportAfter a mother had fed a 4-year-old boy a grape he sud-denly became ‘‘blue in the face’’ and started to ‘‘wheeze.’’The boy died about 1 h from the original onset of symp-toms, on his way to hospital. During the autopsy the nextday the non-chewed grape was found wedged between theanterior side of the epiglottis and the upper side of the rootof the tongue, caught between the median glosso-epiglotticfold and the tonsils (Figs. 1, 2). In this position the grapepressed on the epiglottis, pushing it backwards toward thelaryngeal inlet, obstructing it completely. There were noinjuries to the oral, pharyngeal, or laryngeal mucosae.Pleural petechial hemorrhages, congestion, and tissueswelling, as well the fluidity of the blood were noted duringthe autopsy. The cause of death was choking by obstructionof the upper airway by a non-chewed grape.DiscussionChoking refers to blockage of the internal airways, usuallybetween the pharynx and the bifurcation of the trachea.Causes of choking include metallic, plastic, or other for-eign bodies, food material, as well as acute obstructivelesions—edema of the glottis or larynx [3]. Long-standingbenign tumors or other conditions could also compromisethe upper respiratory tract, causing choking [4–6].In adult cases, the most common cause of laryngealobstruction is by a bolus of food, that is, a ‘‘cafe coronary.’’The term was first used by Haugen in 1963 for sudden andunexpected death occurring during a meal because of theaccidental occlusion of the airway by a bolus of food [7].Choking and obstruction of the trachea or main bronchi byaspiration of a foreign body is a common cause of acci-dental death in children aged from 1 to 5 years, that is, a‘‘creche coronary’’ [1, 2, 8]: more than 90 % of cases occurin infants and children younger than 5 years, with 65 % ininfants younger than 2 years [1]. Round foods are the mostfrequently aspirated foreign objects causing death [2]. Thephases of acute fatal airway obstruction are entrance of theobject into the airway, obstruction of the airway, andfailure to expel once obstruction has occurred [8].The case presented in this paper could indicate anotherpossible mechanism of upper airway obstruction in cases ofchoking, beside penetration of the object into the airway.During the first oropharyngeal phase of swallowing, thefood-bolus is forced by the tongue posteriorly toward thepharynx, as the tongue pushes upward against the hardpalate. The superior constrictor muscle of the pharynx thencontracts, preventing the movement of bolus into thenasopharynx. At the same time, the epiglottis slidesdownward to prevent the bolus from entering the larynxand the trachea [9]. Hence, it is easy to presume that a