Introduction

Upper aerodigestive emergencies (UADEs) can cause significant morbidity and mortality (1). They encompass foreign body aspiration/ingestion, obstructive infections (including acute tonsillitis with airway obstruction or aphagia, peritonsillar abscess, retropharyngeal abscess, parapharyngeal abscess, Ludwig’s angina), acute neoplastic obstructions, trauma (including blunt, penetrating, and gunshot injuries to the neck), and caustic ingestion injury (1). Anaphylaxis with airway compromise and smoke inhalation injury also comprise airway emergencies. In some instances, these conditions can be effectively and efficiently managed by the duty physician, with an excellent prognosis, while in other cases, prompt diagnosis and intervention by the otolaryngologist is indispensable (1). UADEs can occur in all age groups; foreign bodies of the upper airway and digestive tract are more frequent in children (2) and the elderly (3), while blunt and penetrating neck injuries are more common in adults (4). In addition to the complexity of management, early and accurate identification is sometimes challenging. For instance, the accurate diagnosis of upper aerodigestive tract foreign bodies may be missed even by an experienced general practice physician (1), leading to complications. 
In low-middle-income countries (LMICs), UADEs pose diagnostic and therapeutic challenges to otolaryngologists. Late presentation of patients, late diagnosis, and late referral for specialized care, coupled with a paucity of specialists, and modern diagnostic and therapeutic facilities, represent major setbacks (1). In semi-urban settings in Cameroon specifically, specialists are generally available in tertiary-level hospitals. There is currently only one otolaryngologist, two general surgeons, and no gastroenterologist in each of the two tertiary facilities of the southwest (SW) region, with equipment at the bare minimum. They receive mostly referred patients from lower-level facilities and can treat most patients with UADEs. Despite the relevance of these conditions, current updated information is scarce in our setting in general and in the SW region of our country in particular. Some authors have studied aerodigestive foreign bodies, particularly while little data are available on UADEs in general. Providing current data on this health problem could improve patient management and outcomes. We therefore carried out this study, whose objectives were to define the socio-demographic and clinical characteristics of patients presenting with UADEs, describe the various causes of emergencies, and report treatment and outcome.

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Materials and Methods

Study design and procedure
This study was a hospital-based retrospective study, conducted at Buea and Limbe regional hospitals from January to March 2024. Cameroon is an LMIC, partitioned into 10 administrative regions. Each region comprises at least one tertiary-level hospital with specialists, serving populations varying from about 1 million to over 4 million. Buea and Limbe are semi-urban cities, within which the two main referral hospitals of the SW region are situated. We included records of all patients admitted and treated for UADEs at Buea and Limbe regional hospitals during a 10-year period, from January 2014 to December 2023. Records lacking at least one item from each of the main data groups, that is, socio-demographic data, clinical data, cause of UADE, treatment, and progress, were excluded. A consecutive sampling method was used. Potentially eligible files were identified from the registers of the outpatient/emergency departments. This unit receives all patients admitted into the hospital. Following identification of the patients, we retrieved the records from the following units: surgical department, theater, pediatrics, intensive care, and private wards, given that each of these departments keeps records of their clients. After consultation of these records, ineligible files were excluded at this point. The procedure was similar in both hospitals, given their similarity in structure and organization. 

Statistics
Data collected included socio-demographic characteristics: age, gender, level of education, and occupation. Clinical data comprised presenting symptoms (dyspnea, dysphagia, odynophagia, fever, bleeding, dysphonia, cough, and choking), signs identified (respiratory distress, stridor, active bleeding, and neck swelling/tenderness), type of emergency (foreign body aspiration/ingestion, infection, trauma, neoplasm, and caustic injury), organ involved (oral cavity, nasal cavity, pharynx, larynx, trachea, and esophagus), treatment modality (conservative, endoscopic, and surgical), and progress (length of hospital stay, complications, discharge, and death). Poor outcome was defined as ensue of complications or death. Complications were defined as any new medical problem that occurred during the period of hospitalization or after treatment. A data entry form was used to gather data. Results were presented as means for quantitative variables and percentages for qualitative variables. Data were analyzed using International Business Machines Statistical Product and Service Solutions (IBM SPSS) version 25 (IBM, Chicago, IL, USA). The chi-square test was used for comparison, and statistical significance was set at p < 0.05.

Ethical considerations
Ethical approval was obtained from the Institutional Review Board of the Faculty of Health Sciences of the University (approval number 2023/2219-11/UB/SG/IRB/FHS). Administrative authorizations were sought from the Public Health Authorities of the SW region and the administration of the concerned hospitals. Confidentiality and privacy were ensured during data collection by using assigned codes. 

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Results

Socio-demographic and clinical characteristics of participants
A total of 101 potentially eligible records were sorted out from both hospitals. Among them, 18 were duplicates, while relevant data were missing from 9 files. Seventy-four files were included in the study. Males were predominant (46; 62.2%), and the most represented age group was 1–10 years (19; 25.7%). Table 1 represents the socio-demographic characteristics of participants. Figure 1 shows symptoms presented by patients. Signs identified included respiratory distress (34; 45.9%), inflamed tonsils (19; 25.7%), active bleeding (14; 18.9%), stridor (12; 16.2%), and neck swelling/tenderness (12; 16.2%). Figure 2 depicts organs affected by UADEs and their respective proportions.

 

Table 1.

Socio-demographic characteristics of participants

aNot applicable for minors.

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Figure 1.

Symptoms presented by patients affected by upper aerodigestive emergencies.

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Figure 2.

Organs involved in upper aerodigestive emergencies.

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Causes
Infections represented the dominant cause (31; 41.9%). Table 2 depicts the various forms of UADEs found. Peak age groups were 1–10 years for foreign bodies and acute tonsillitis, 21–30 years for trauma and infections, and >50 years for tumors.

 

Table 2.

Causes of emergencies identified according to age group

FB, foreign body; UADE, upper aerodigestive emergency.

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Treatment and in-hospital outcome
The majority of patients (56; 75.7%) were treated by surgical means, among whom nine (16.1%) had tracheotomies. Endoscopic management was used in 10 patients (13.5%), while 8 patients (10.8%) were managed conservatively. Fifty-two patients (72.2%) were admitted for <6 days, 13 patients (18.1%) for the duration between 6 and 10 days, and 7 patients (9.7%) for more than 10 days. Table 3 represents the length of hospital stay according to the cause. The outcome was good for the majority of patients (67; 90.5%). Two patients requested discharge against medical advice. Two patients with caustic injury developed esophageal stricture (2.7%). Five patients died: four had laryngeal tumors and one had a peritonsillar abscess. Table 4 shows the outcomes according to the cause of emergency. Causes of UADEs that were significantly associated with poor outcomes were neoplastic causes (OR 4.2, 95% CI 1.2–6.8, p = 0.03) and caustic injury (OR 5.8, 95% CI 2.2–8.3, p = 0.02).​

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Table 3.

Length of hospital stays according to cause of emergency

NB: Two patients were discharged against medical advice.

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Table 4.

Outcomes according to cause of emergency

NB: Two patients were discharged against medical advice.
CI, confidence interval.
aOdds ratio from chi-square test with Yates correction.

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Discussion

UADEs are common in children, with infectious causes being the leading etiology. Though the outcome was generally good, neoplasms and caustic injuries seemed to be associated with poor outcomes.
UADEs are rare in most settings, though authors from another sub-Saharan African country (4) reported many cases, without being able to explain the high prevalence they found. Young children represented the most exposed group, a finding consistent with numerous prior studies (1,5). Children’s susceptibility to upper respiratory infections and their complications (6,7), as well as the predominance of foreign body ingestion/aspiration and caustic injuries among children (8,9), could explain this. Concerning gender predominance, there is no evidence that upper aerodigestive infections are more common in males. Nevertheless, head and neck cancers, which represented a significant portion of causes, show a strong male predominance (10,11). UADEs due to penetrating neck injuries or gunshot to the neck are typically male injuries as well, sustained following interpersonal violence or road traffic accidents (12). Unsurprisingly, the most common presenting symptoms were obstructive in nature. Presumably, the discomfort and alarm caused by these symptoms could explain why they motivated patients to seek medical attention. Difficulty in breathing, odynophagia, and dysphagia were reported to be the most common clinical symptoms in other settings (1). Infectious conditions, encompassing peritonsillar abscesses, Ludwig’s angina, acute tonsillitis with airway obstruction, and parapharyngeal abscesses, were the leading cause of UADEs. Andrade et al. in Brazil reported similar results (13). However, authors from other settings found different results: Vassiliu et al. in the United States (14) and Krishnamoorthy et al. in Malaysia (15), respectively, described traumatic injuries and airway/esophagus foreign bodies as the most frequent etiologies of UADEs. The observed disparities could be related to the specificities of the settings concerned. Upper respiratory infections constitute the initial conditions that potentially cause UADEs via complicated forms. They are not only very common in LMICs but also seem to present the highest mortality rates in low Socio-economic Development Initiative countries (16). Traumatic injuries, despite being a common cause in other settings, were not found to be dominant in our sample. Severe penetrating neck injuries require immediate intervention. Due to the distance of most parts of the SW region from the referral hospitals, many patients might have died before getting medical assistance. Regarding foreign bodies, the relatively small proportion could be due to the unavailability of otolaryngologists and specialized endoscopic equipment in these hospitals in the earlier years of the study period. Affected patients were therefore referred to other facilities located in urban cities. The next most common group of etiologies after infections was neoplasms. More often than not, the diagnosis of head and neck cancers is made at advanced stages, explaining why many patients present with obstructive complications. The scarcity and overt unevenness in the distribution of specialists (17) and equipment for the diagnosis, assessment, and treatment of cancer could justify this. Remarkably, only one public institution in our country provides the full cancer treatment package. 
Interestingly, the outcome of UADEs was generally good, as a significant majority of patients were discharged home. Neoplasms and caustic injuries seemed to be associated with poor outcomes, that is, complications and/or death. Head and neck cancers with obstructive symptoms are generally locally advanced; they require long-term multidisciplinary management (18). Likewise, caustic injuries are managed in a progressive, stepwise fashion (19). The absence of adequate equipment and complete management teams in these facilities constitutes a setback in optimal patient assessment and treatment and could partly account for the observed outcome. It is relevant to assert that we studied in-hospital outcomes only due to the challenges in patient follow-up after discharge in our setting. Our findings are relevant to primary care physicians who have contact with the bulk of patients in our facilities. Infections still represent a heavy burden in our setting, and our findings suggest that they are the cause of most UADEs, which are potentially life-threatening. Proper identification, assessment, and treatment of upper respiratory infections would contribute to reducing the prevalence of this problem. Policymakers should improve the provision of equipment and specialist care in health facilities across the country. Specifically, screening, diagnosis, and full treatment of head and neck cancers should be made possible in tertiary-level hospitals in order to reduce late identification and optimize care. 
The retrospective nature of this study constitutes a limitation, as written information could not be verified. Moreover, the hospital-based nature and the fact that the outcome was limited to the admission period make the results not generalizable. Finally, the absence of otolaryngologists practicing in the hospitals involved, in the earlier years of the study period, underestimates the real frequency of this problem.

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Conclusion

This study provides insight into UADEs and management in a semi-urban setting. Despite the limited availability of specialist care and equipment, the outcome was generally good. The implications of our findings are of public health relevance, given the predominance of infectious causes that are mostly preventable by immunization and effective antibiotic therapy. 

Acknowledgments
The authors are grateful to the administrative authorities of the hospitals involved in this study.

 

Author contributions

EC-N and NN conceived and designed the study. EC-N and NZ conducted data collection. NZ performed data analysis. E-CN, NN, and NDMM interpreted the results and provided critical insights. EC-N drafted the manuscript. All authors reviewed and agreed to the final manuscript.

 

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