FOREIGN BODIES IN THE EAR, NOSE AND THROAT

By T. G. \Vil~so.~, 2I.B., F.R.C.S.I., Hon. F.R.C.S., Edin. Royal City of D~blin Hospital

F OREIGN bodies are perhaps more commonly found in the ears and air- and food-passages~,, than elsewhere in the body, and they can be very dangerous in these situations.

Foreign bodies in the food and air-passages can be and often are immediately fatal. There were for instance two recent cases, one in England and one at Indianapolis, in America, where racing motorists died suddenly at the wheel from inhaling chewing-gum. In these cases not only did the drivers die, but the racing f ra terni ty , spectators and other drivers were put in great peril of their lives. These were, of (,ourse, extreme incidents, but even when the victim survives the immediate danger, death may ensue later from complications such as meningitis, brain abscess, pneumonia or lung abscess.

Ge~eral Classification. Foreign bodies may in general be divided into two categories, non-vegetable and vegetable. Of these the vegetable type can be the more serious, par t icular ly perhaps in the lung, because vegetable f~,reign bodies may absorb moisture and swell, and they f requent ly become infected. Foreign bodies may also be subdivided into animate and non-animate, or living and dead. The most commonly found animate foreign bodies are maggots, flies and earwigs. They are most commonly found in the ear and nose, and most often in tropical climates. I t is not unknown for seeds to sprout in these situations, par t icular ly in hot, moist countries.

The subdivision of foreign bodies into non-vegetable and vegetable is most important, and it follows that when a foreign body of unknown etiology is di..~covered, the first thing to do is if possible to ascertain its composition.

Foreig~ Bodies in the Ear. I t has been well said that a foreign body in the ear is never dangerous until somebody tries to remove it. In the adult foreign bodies are usually introduced accidentally, and they subsequently are very often forgotten. By fa r the commonest object found is a pledget of cotton-wool. The pat ient usually has a discharge from the ear : he puts a little cotton-wool into the meatus to soak it up, forgets it is there and adds another piece on top of it. The original pledget gets covered with wax and it is in fact usually mistaken for a plug of wax. I t comes away very easily with syringing and no great harm is done.

Other foreign bodies found in the adult are often introduced when scratching an i tchy meatus. Bits of straw and match-ends are used for the purp~)se, a bit breaks off and is forgotten unti l it begins to produce symptoms. There is also, of course, an occasional fly or earwig to be found.

Children under the age of four or five years seem to take an inordi- nate pleasure in put t ing foreign bodies of all sorts into the various orifices of the body. Cherry-stones, buttons, beads and pebbles are great

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favourites, and, of course, one also occasionally sees flies and other insects whi~.h have found their own way in.

Treat~tent. These eases must be approached with care if damage to the middle-ear is to be avoided. I t is not unknown for the ossicles to be removed under anaesthesia.

F i r s t it is impor tant to determine if possible the nature of the foreign body, that is whether it is mineral, vegetable or perhaps animal in origin. I f it is vegetable, and swelling and infection of the tissues have not yet occurred, it should be removed immediately, and it will usually come away easily with efficient syringing. I f swelling and infection of the meatus are present, syringing may be tr ied very tenta- tively. I f this is not successful it is probably better to wait a few days and t ry again when the swelling has been reduced by fomentations and antiseptic creams. Insects such as flies may cause considerable dis- comfort by crawling about inside the meatus. I f they do not come away easily with syringing they may be drowned by flooding them with chloroform, hydrogen peroxide or ordinary lotion.

In the ear, mineral foreign bodies, which as we have seen are most of ten found in infants, are potentially very dangerous. They can be very difficult to remove, par t icular ly when they have passed the narrow- ing of the meatus which occurs at the junction of the cartilaginous and bony meatus. Articles such as beads and pebbles frequently will not come away with syringing and will require to be removed instru- mentally. A useful ins t rument for the purpose is Har tmann 's forceps, which has an open bite. The ordinary aural dressing-forceps is not near ly so efficient. Occasionally a small right-angled hook is very use- ful. In using all these instruments it is very easy to push the foreign body beyond the isthmus, and if this happens its extraction is rendered much more difficult. Occasionally it proves impossible to remove the foreign body in this way, and it then becomes necessary to remove the foreign body by open operation through a post-aural incision as used in the simple mastoid operation.

Foreign Bodies in the Nose. Foreign bodies in the nose are practically always found in young children, and pebbles, bits of paper, peas and beans seem to be the most favoured objects to insert.

A unilateral, blood!], offensive discharge in a small child is practicall!! pathog~wmonic of a foreign body. There is, however, a fair ly common variant, in which both nostrils are involved. This is the child who picks its blankets and stuffs both nostrils with the wool.

These cases are easily dealt with provided the child is held properly. The nurse or, preferably, the mother, takes the child in her lap. She places his legs between hers, holds both the child's hands with one of hers, and holds his forehead firmly with the other. In this way the ,-hild can, if necessary, be held in a vice-like clamp--i t need not be too firmly held unless it s t ruggles- -and the foreign body is picked out quickly and easily with Ha r tmann ' s forceps. I t is very seldom that these eases require a general anaesthetic. The blanket-pickers should have their blankets sewn inside sheets. The others may be brought along soon again to have another foreign body removed. They grow out of the habit in time.

SURGICAL ASPECTS OF ACCIDENTS IN CHILDHOOD 7 |

Foreign Bodies in the Pharynx. Small fish-bones and other ,,bj~.~.l., f requent ly stick in the tonsil or the lingual tonsil and can be e~sil.v s~, . and removed. Others may find their way lower down in the hyI)o- pharynx. Small broken dentures are f requent ly swallowed, and patients should be warned not to wear broken dentures at any time, awl not to wear small dentures, while asleep. They are easily remov~,d by indirect (mirror) or direct laryngoscopy.

Foreign Bodies in the Lary~x. Foreign bodies which stick in the larynx are another story. They are usually sharp objects, otherwise they would not stick there. They cause considerable discomfort wi~h stridor and loss of voice. A useful diagnostic pMnt is that a foreign body in the larynx usually lies in the sagittal plane, antero~posteriorly, while a foreign body in the food-passages usually lies eoronally. As a rule, those laryngeal foreign bodies which come to treatment are removed without difficulty. The unpleasant cases are those in which immediate death by suffocation is caused.

Foreign Bodies in the Lung. When a foreign body slips past the larynx into the lung, a serious state of affairs arises. The pioneer work of Chevalier Jackson of Philadelphia and of Negus in London has shown that foreign bodies play a very important par t in the etiology of lung diseases. As is only to be expected, there is a wide variation in the symptomatology, varying with the nature of the foreign bodies-- that is, whether they are vegetable or non-vegetable in composition. In America peanuts are very commonly inhaled: in this country teeth seem frequent ly to find their way into the lung dur ing extractions.

The symptoms also vary with the size of the patient and the situation of the foreign body. In the great major i ty of cases the foreign body lodges in the r ight main bronchus because of the direct way it springs from the trachea.

A vegetable foreign body- -a pea, a peanut or a bean--will soon cause marked local inflammation, par t icular ly in a child. Subglottie oedema will result, and the symptoms will resemble those of croup or whooping-cough. In adults only a mild local reaction may result.

Small metallic foreign bodies may cause less immediate symptoms. Many cases have been diagnosed and t reated for years as asthma, bronchiectasis, or tuberculosis. I f the foreign body blocks the bronchus completely the resulting atelectasis may be mistaken for an empyema.

The diagnosis is made by first taking a careful history when a history of choking while eating may be elicited. Inspection may then show diminished air-entry to the lower par t of the r ight lung. On ausculta- tion an " asthmatoid wheeze " may be heard, sometimes accompanied by an " audible slap " or a " palpable thud ". I f there is a valvular air-entry past the obstruction the lower par t of the r ight lung may be hyper-resonant; alternatively, if there is a total blockage and atelectasis has occurred there may be dullness due to accumulation of fluid. A radiogram will show a foreign body if it is radio-opaque, and screening will show lack of air-entry and a shift of the mediastinum to the right side in all obstructed cases.

The diagnosis having been made, it only remains to remove the

72 I R I S H J O U R N A L OF MEDICAL SC1EiN'CE

foreign body, and it i~ comforting to know that 98 per cent. ,-an be removed by the route they entered.

Foreign Bodies :in the Oesophagus. Foreign bodies in the oesophagus mostly stick in the post-cricoid region. A foreign body frequent ly met with is a ha l fpemly impacted in this area. It is in fact so common that one feels tha t this coin, now worth so little, should be abolished.

These cases are not difficult or dangerous, but beef-bones, false teeth and other ha rd i r regular objects impacted in this area or elsewhere in the oesophagus may be by no means so easy to deal with; in fact they present the endoscopist with many of his greatest problems. The oesophagus is a much more fragile organ than the bronchial tree. Relaxants and antibiotics have rendered the task of removing foreign bodies easier and safer, but a rup tured oesophagus still usually means at best a s tormy convalescence.

The major i ty of" foreign bodies which pass the post-cricoid region go through the cardiac sphincter and are eventually evacuated. Just occasion- ally a large foreign body will become impacted lower down and will require endoscopic removal.

OLD PEOPLE IN MENTAL HOSPITALS:

A STUDY IN D I A G N O S T I C COMPOSITION AND OUTCOME

By CECIL B. KIDI), M.D., D.P.M. Purdysburn Hospital, Belfast

T H E problems of old people in hospital, particularly mental hospitals, have a t t rac ted much attention lately. This is largely due to the pressing awareness that the increased expectation of

life is providing new and increasing demands on geriatric mental health services. The urgency of this demand emphasises anew the need to car ry out fact-finding surveys into pat terns of patient flow. As these pat terns are known to be changing, it is important to review the prospects of elderly mental patients regarding both the likely duration of hospital stay and the expectation of life.

Method Pu rdy sbu rn Hospital (a mental hospital) serves the catchment area

of the city of Belfast and undertakes the greatest proportion of hospital care of the elderly mental ly ill f rom the area. One hundred patients of both sexes aged 60 years and over were randomly selected for study f rom a series of consecutive admissions to this hospital of the same age group. Each case was assessed personally within three weeks of admission and was examined along standard lines set down by a pro forma technique. As well as physical and psychiatric examination there was a s t ructured interview with the staff, a questionnaire to the