Keywords
foreign body - ear - nose - throat - endoscopy
Introduction
A foreign body (FB) is any object in a region it is not meant to be, where it can
cause harm by its mere presence if immediate medical attention is not sought.[1] It can be found in the ear, nose, and throat (ENT) region. FB may be classified
as animate (living) and inanimate (nonliving). The inanimate FBs can further be classified
as organic or inorganic and hygroscopic (hydrophilic) or nonhygroscopic (hydrophobic).[2] The presence of FBs in the ENT region is one of the most common causes of otolaryngologic
emergencies. FBs can be introduced spontaneously or accidently in both adults and
children. Generally, FBs are more common in younger children; this may be due to various
factors such as curiosity to explore orifices, imitation, boredom, playing, mental
retardation, insanity, and attention deficit hyperactivity disorder, along with availability
of the objects and absence of watchful caregivers.[3] The aim of this study is to analyze FBs in terms of type, site, age, and gender
distribution and method of removal.
Materials and Methods
A retrospective study was performed in the Department of ENT, Head and Neck Surgery
in a tertiary care hospital in the central part of Nepal. The study population includes
the number of patients with ENT FB lodgment who presented in the Outpatient Department
(OPD) or in the emergency room (ER) during the 1-year study period (June 2013 to May
2014). The data were obtained from the hospital record books. Anterior rhinoscopy
and otoscopy examination were performed to diagnose FB of the nose and ear, respectively.
Rigid or flexible nasal endoscopic examination was also performed in suspected cases
of FB in the nasal cavity that was not visualized with anterior rhinoscopy. Similarly,
examination under microscope was an additional method for diagnosis as well as useful
for removal of FB of the ear. Instruments such as Jobson Horne probe, FB hook, Tilley
forceps, and crocodile forceps were used in FB removal from the nose and ear. In addition
to the previously mentioned instruments, syringing and suctioning were other methods
for FB ear removal. Plain X-ray of the neck was done in patients with a history of
FB ingestion. Flexible nasopharyngolaryngoscopy and flexible upper gastrointestinal
endoscopy were done in cases where the FB was not visible in X-ray to rule out presence
of an FB or to determine its site of impaction. This was followed by removal of the
FB from the oropharynx/hypopharynx and esophagus with direct laryngoscopy or rigid
esophagoscopy, respectively.
Results
During the study period, 134 patients visited this hospital with FB in the ENT area;
94 were males and 40 were females. Of the 134 patients, 70 (52.23%) had FB in the
ear, 28 (20.89%) in the nose, and 36 (26.86%) in the throat. The FB was removed with
or without local anaesthesia (LA) in 98 (73.13%) patients, and only 36 patients (26.86%)
required general anaesthesia (GA).
Foreign Bodies in the Ear
A total of 70 patients presented to the hospital with FB in the ear. Of these 70 patients,
28 (40%) harbored animate (living) FBs. These were 22 cases of ticks, 4 cases of cockroach,
1 case each of ant and aural myiasis. The rest (42; 60%) had inanimate (nonliving)
FB in their ears. Of these 42 cases of nonliving FB, 15 were hygroscopic FB in the
form of grams, peanuts, bean seed, and rice grain; the remaining 27 cases were of
nonhygroscopic FB in the form of cotton, paper, eraser, broken matchstick/cotton bud,
foam, and beads.
Of the total 70 patients, 32 (45.71%) were children <10 years of age.
Of 70 cases of FB in the ear, 66 were removed in the OPD and ER with or without LA
and only 4 required examination under microscope under GA for removal of the FB; all
of them were younger than 10 years of age.
Foreign Bodies in the Nose
Twenty-eight patients had FB lodged in the nose. Twenty-seven patients (96.42%), all
of whom were children <10 years of age, had nonliving FB and only 1 patient had living
FB (i.e., maggots), an adult patient with fungating growth due to carcinoma of maxilla.
Of 27 cases with nonliving FBs, 10 patients had hygroscopic FB such as bean, peanut,
corn, and grams, and 17 patients had nonhygroscopic FB such as eraser, paper, sponge,
and plastic and metallic objects.
Of the total 28 patients with an FB in the nose, 27 (96.42%) were of the age group < 10
years. Most of the FBs were removed in the OPD and ER with the application of topical
nasal decongestant. Only 2 patients required removal of the FB under GA.
Foreign Bodies in the Throat
A total of 36 patients presented with the complaint of ingestion of FB. The most common
type of FB was meat bone/bolus in the form of chicken, mutton, or buffalo meat and
the most common site of the impaction was cricopharyngeal junction in 21 patients
(58.3%). The other sites of FB impaction were oral cavity, oropharynx, hypopharynx,
and thoracic esophagus.
All the ingested FB were inanimate, with 26 (72.22%) being organic and 10 (27.77%)
being inorganic. Organic FBs were meat bolus and bone (fish, chicken, mutton, and
buffalo meat). The inorganic FBs included denture, coin, and plastic and metallic
objects.
Age of 60 or more years was the most common group involved with FB in the throat,
with 10 patients presenting with FB impaction. Among all the patients who ingested
an FB, 30 patients (83.33%) required GA under GA for FB removal.
Method of FB Removal
Removal of FB is not always easy. It requires proper instruments and skill. In our
study, most of the nasal and aural FBs were removed in the ER or OPD with or without
LA. Out of 134 FBs in the ENT, 36 (26.47%) required GA for FB removal and rest (98;
73.13%) were removed with or without LA.
Discussion
Adults and older children usually give a history of FB lodgment in ENT. But younger
children are brought to the clinic by anxious parents or relatives. FBs may vary widely
in shape, size, and composition, and the symptoms may range from asymptomatic to acute
life threatening condition.
In our study, the most common age group affected was age < 10 years, similar to results
found in many other studies.[4]
[5]
[6]
[7]
[8] This may be due to the tendency of young children to lodge objects into the natural
orifices of body, accidentally or intentionally.
The ear was the most common site for FBs in young children, who not only insert objects
in their ears but also into the ears of their siblings and friends. Common ear FBs
include cotton wool, bean, bead, paper/plastic, eraser, insect, paddy seed, and popcorn
kernel. Patients usually present with earache, aural fullness, or ear discharge. Occasionally
it may be asymptomatic and found incidentally during routine otoscopic examination.
A high incidence of living FBs (i.e., ticks) in our study is explained by the fact
that the people in the villages of Chitwan go to the jungle to collect fodder and
graze cattle. Many people get ticks in the ear when they go for jungle safari, as
Chitwan is a famous tourist destination in our country and attracts both domestic
and international tourists. Examination under a microscope helps to confirm the presence
of FB in the ear and aids in its removal under intravenous sedation/GA to minimize
trauma to the tympanic membrane and external auditory canal. It is useful especially
in children who are not cooperative to allow proper otoscopic examination when there
is associated otitis externa. Ear syringing led to successful removal of most of the
nonhygroscopic FBs. Negative pressure suctioning can be useful especially when there
is aural or nasal discharge along with the FB.
Our study showed that there is predominance of FBs in the nose in younger children,
which was seen in many other studies.[1]
[3]
[7] Unilateral, foul-smelling, purulent nasal discharge in children must be regarded
as due to FB until proved otherwise. With growth and cognitive development, the introduction
of FB in the nostrils diminishes significantly, which is found only in patients with
psychiatric disorders. FB in the nose or ear is usually unilateral, although it can
be bilateral, as in one of our patient with FB grams in both nasal cavities and another
case of FB erasers in both the external auditory canals. Sometimes there can be multiple
ear or nose FBs as well.
FB ingestion is a common problem. The most frequently swallowed FBs in children include
coins and metallic FBs (parts of playing objects), and meat bones (chicken bone/fish
bone/mutton/buffalo meat) are common in adults and elderly patients.[8]
[9] In our study, meat bone/bolus was the most common FB found inside the throat, and
the most common site of lodgment was the cricopharyngeal region. Such patients come
in clusters, especially during religious festivals like Dashain and Tihar. Heavy consumption
of alcohol and eating meat simultaneously, especially during festivals, along with
poor mastication may be the cause for meat bone/bolus impaction in adults. In elderly,
edentulous patients, defective peristalsis due to age-related neuromuscular incoordination
and poor masticating habits are the predisposing factors for the cause of impaction
of meat bone/bolus in the esophagus. Moreover, in elderly people there are commonly
other underlying pathologies that cause narrowing of the digestive tract. Coin was
the most common FB in the throat in children in our study, which is similar to other
studies[7]
[9]; this may be due to fact that the coins are often handed to younger children and
they accidentally swallow because of their tendency to take things into the mouth,
inadequate control of deglutition, and shouting or crying while playing or eating.
Plain X-ray of soft tissue in the neck is a cost-effective radiologic examination
method useful in the evaluation of FB in the throat. We advise X-rays in patients
with history of FB ingestion. Direct laryngoscopy was occasionally useful in the evaluation
and removal of FB in the oropharynx and hypopharynx. FBs from the digestive tract
are usually removed by rigid esophagoscopy. But flexible upper gastrointestinal endoscopy
is useful especially in the case of ingestion of radiolucent FBs. Moreover, it helps
to detect the site of impaction especially in patients with cervical spondylosis where
neck extension is not possible and to remove the FBs, or to push the FB into the stomach
(e.g., in cases of impacted meat bolus at the distal part of esophagus).
Conclusion
FBs in the ear and nose were found more frequently in children, and the throat was
the most common site of FBs in adults and elderly people. Most of the nasal and aural
FBs can be easily removed in the ER or OPD. Parents/caretaker should not allow children
to play with coins or other small objects to prevent the risk of FB ingestion or insertion.
