Emergency Medicine Australasia (2004) 16, 17–20

Blackwell Publishing, Ltd. Ask the experts: ENT and maxillofacial problemsManagement of foreign bodies in ENT

Management of foreign bodies in the ear, nose and throatSashi KumarEmergency Department, The Canberra Hospital, Canberra, Australian Capital Territory, Australia

Abstract

This article presents a summary of the common foreign bodies (FB) and a practicalapproach to diagnosis and management. Removal of FB requires good lighting, a cooperativeor fully restrained patient and a gentle approach by the clinician. An accurate diagnosisof the FB should be made prior to attempts to remove it and most, if not all FB could besafely removed the following day under better lighting conditions, sedation or anaesthesiain a fasted patient by a more senior clinician.

Key words: button battery, fish bone, foreign body.

Ear

Most patients who present with a foreign body (FB)in the ear are less than 5 years of age or adults withintellectual handicap. Typical FBs found in the earare beads, buttons, cotton buds and pieces of paper orcloth. Usually the patient knows what the FB is andwhen it was inserted. The presenting complaint maybe pain, sensation of the FB or loss of hearing.

Live foreign body in the ear

Adults who enjoy the outdoor life and spend the nightout camping may present with a live insect in theexternal ear canal.

This is a true ear, nose and throat (ENT) emergency.Every effort should be made to kill the insect safelyand quickly. This provides immediate symptom reliefand avoids further damage to the sensitive epidermis

that lines the inner two thirds of the ear canal and thetympanic membrane.

There are several methods with which to kill theinsect in the ear. It is important to remember that anyliquid used to kill the insect can irritate the sensitiveskin and the tympanic membrane and cause furtherdamage. It is not advisable to use insecticide spray oralcohol. It is also important to remove the insect intactand not leave any residual body parts in the ear canal.

A simple and effective method is to use a 10-mL ‘waterfor injection’ plastic ampoule. A few drops of the waterare gently squeezed into the ear canal until full. A brightlight is shone on the ear. The desperate insect, now drown-ing, if capable of freeing itself, swims to the surface andcan be helped out using the plastic ampoule as a ‘liferaft’. If the insect cannot free itself it drowns and dies.1

The removal of the dead carcass from the ear is notan emergency and can be done safely using forcepsunder direct vision or by syringing.

Correspondence: Dr Sashi Kumar, Emergency Department, The Canberra Hospital, PO Box 11, Woden, ACT 2606, Australia. Email: sashi.kumar@act.gov.au

Sashi Kumar, FACEM, Staff Specialist.Conflicts of interests: None

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Management of inert foreign bodies

Identify the FB without any doubt before trying toremove it.

The child or adult with intellectual handicap mayneed to be restrained before any attempt at removalis made. Good lighting, preferably with a headlightstrapped to the forehead of the clinician and a fullyco-operative or restrained patient are vital.2

If the patient is fasted, consider using sedation withmidazolam or nitrous oxide. Another approach is witha general anaesthetic as a day case procedure.

The two methods of removal of a FB in the ear aredry and wet. The dry method is using a forceps or aJobson Horne probe to gently lever out the FB. Thewet method uses a syringe and warm tap water at bodytemperature. Cold water may produce a caloric effectand cause vertigo and nystagmus. If the FB is closeto the ear drum or is tightly wedged at the isthmus( junction of the outer cartilagenous and inner bonyear canal), avoid repeated attempts. Bring the patientback the following day fasted for an examination andremoval under a general anaesthetic.

It is essential to re-examine the ear canal andtympanic membrane after removal to assess anydamage to the delicate skin of the ear canal andthe tympanic membrane.

If there is any bleeding or pain, further attemptsto remove the foreign body should not be made andthe patient should be referred to the ENT the next day.Remember that a FB in the ear is not a dire emergencyand can always wait another 24 h for removal.

Nose

The type of patient who presents with accidental FBsin the nose is the same as for the ear. Commonly foundFBs in the nose are beads, buttons, pieces of paper orcloth. A common finding is a unilateral foul smellingnasal discharge. Patients with intellectual disability oftenpresent with such symptoms and the carer accompany-ing the patient usually is well aware of the problem.

Management

Accurate identification of the FB is essential beforeany attempts are made to remove it. There are severalreports in the literature of a swollen inferior turbinatebeing mistaken for a pink bead. Attempts at removalhave led to disastrous consequences.

Any FB in the nasal cavity immediately producesan inflammatory response with engorgement of themucous membrane and a discharge. This coats theFB and makes it slippery. If it is a round object witha smooth surface (i.e. a bead) it will be impossible tograsp with forceps.

With adequate restraint and good lighting use thering end of a Jobson Horne probe (Fig. 1) to go aboveand behind the FB, pressing it gently down. Rollthe FB out along the floor of the nasal cavity.3 It isessential to re-examine the nose after the foreignbody is removed. If there is pain or bleeding during theattempt, further efforts should be stopped immediatelyand pressure applied to the nasal cavity (to stop thebleeding) by pinching the nose. The patient can be safelydischarged home to return fasted for an anaestheticlater or the next day.

Several other methods are described to removeFBs from the nose. If the child is co-operative it maybe possible to teach the child to occlude the oppositenostril and blow hard through the involved nostrilto push out the object.

Another newly popular method is to occlude theopposite nasal cavity by digital pressure and blowhard into the mouth of the child similar to performingmouth to mouth resuscitation. This can be done bythe doctor or parent. If the FB is so deep in the nasalcavity that there is a risk of aspiration of it, it isbest practice to place the patient in the tonsillectomyposition (under anaesthetic) and push the FB intothe oropharynx using a catheter. Retrieval is completedwith a Magill’s forceps under direct vision.

Figure 1. Common ear, nose and throat (ENT) instruments. (Fromleft to right) Tilley’s dressing forceps, thudichum nasal speculum,Jobson-Horne probe.

Management of foreign bodies in ENT

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As with the ear, removal of a FB from the nasalcavity is not a dire emergency. Patients can be dis-charged home to return later fasted for removal underanaesthetic.

Throat

Coins are a common cause of FBs in children. In adultsthe usual causes are chicken or meat bones, fish bonesand occasionally objects such as partial dentures anda food bolus. In most cases there is a history of chok-ing and the patient may present with odynophagia(pain on swallowing) but more often with dysphagia(difficulty in swallowing).

The oesophagus narrows at three sites: the cricopharynx (C6), at the level of the aortic arch (T4) andthe gastro-oesophageal junction (T10). Foreign bodiescan lodge at any of these sites (Fig. 2).

In food bolus obstruction it is essential to carryout an endoscopy to rule out a sinister cause for theobstruction such as stricture or malignancy.

Fish bones

A lateral soft tissue radiograph of the neck will showa fish bone in the pre vertebral soft tissue shadow. Thesuperior and inferior cornua of the thyroid cartilage,greater horn of hyoid bone and cricoid lamina mayappear like an FB but are usually overlying the trachealair shadow and not in the prevertebral soft tissue.

Thickening of the prevertebral soft tissue occursif adequate time has lapsed since ingestion. Gas inthe soft tissue suggests perforation. This indicatesthat there is a high risk of developing mediastinitis.

Management

If the patient localizes the FB to one side of the neck(especially below the angle of the mandible) it is likelythat the fish bone has lodged in the oro pharyngealarea, (e.g. the tonsillar tissue), anterior or posteriorpillar of the faucial tonsil or posterior third of thetongue. It may be possible to visualize the FB by directexamination of the oropharynx using a headlightand tongue depressor. Upon identification, the FB canbe safely removed under direct vision using a Tilley’snasal forceps.

If the patient localizes the FB at or below the cricothyroid level and in the midline it is not possible toremove it under direct vision on an awake patient. Itis unwise to use local anaesthetic on the oro/ laryngopharynx in an attempt to remove the FB as the patientmay aspirate during the attempt due to the loss of gagreflex.

The ability to see a fish bone on a lateral neck X-raydepends upon the type of fish and the size and mineralcontent of the bone. Salt water fish bone of adequatesize may have enough mineral content to be seen.Fresh water fish bone or a small sliver of bone may nothave enough mineral content to be seen. If the boneis identified on the X-ray it requires removal underanaesthetic by endoscopy. Patients who present withsymptoms of a fish bone FB but no X-ray evidence canbe safely discharged with the following advice. ‘Overthe next 48–72 h if they have increasing odynophagia,develop dysphagia, haematemesis or fever (infection)they return immediately for an endoscopy under generalanaesthesia’.

If the symptoms improve over the next 48–72 hwith none of the above it is likely that the fishbonehad scratched the mucous membrane and dislodgedleaving the symptoms of a FB due to the laceration.

Other foreign bodies

Foreign bodies such as meat and chicken bone ordentures are usually seen on the X-ray. Patients needadmission for urgent endoscopy and removal underanaesthesia (Table 1).

A chest and abdominal X-ray is useful in identifyingFBs in the thoracic oesophagus or stomach. When aFigure 2. The three areas of narrowing of the oesophagus.

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FB such as a coin or safety pin is identified belowthe level of the diaphragm (in the stomach) the patientis reassured and discharged. Repeat X-rays of theabdomen to follow the course of the FB after it hadpassed the gastro oesophageal junction are not needed.The parent is advised to return if there are anysymptoms of abdominal pain, distension or vomitingsuggestive of obstruction or perforation. In most casesthe FB will be passed safely in the next few days.

Button batteries

Liquefaction necrosis and perforation can occur rapidlywhen a disk battery is lodged in the oesophagus.4Urgent endoscopy and removal of the battery shouldtake place if this occurs.

If the battery is lodged past the oesophagus inthe stomach 85% are passed within 72 h.5 Several casereports have been published of mercury poisoningfollowing break down of button/disk batteries althoughthis is rare.

The current view is that unless the battery is lodgedin the oesophagus, most if not all, will pass in thenext 48–72 h and the patient can be safely dischargedfollowing reassurance.6

Tracheo-bronchial tree

Inhaled FBs are most commonly seen in children under4 years of age. Common objects are nuts, food, plastic,metal, teeth or part of a toy.7

Commonly there is a history of choking followed byparoxysmal coughing which then subsides. Complete

obstruction of upper airway or trachea is rare but lifethreatening and should be managed as per basic andadvanced life support guidelines for airway obstruction.

If the FB is lodged below the level of carina, a triadof choking, paroxysmal coughing and wheeze is presentin 91% of patients.8

Management

The suspicion of an inhaled FB is based upon history.Every attempt is made to make a positive diagnosisif it involves vegetable matter such as nut or food. Aretained organic FB in the tracheo bronchial tree cancause ongoing mucosal irritation, pneumonia or lungabscess.

A chest X-ray may show air trapping or persistenthyperinflation of a segment, lobe or entire lung.Unilateral wheeze or persistent cough and fever arehighly suggestive of a retained FB.9 All patients with asuspicious history with any physical or radiologicalfindings are admitted for immediate endoscopicexamination under general anaesthesia.

References

1. Kumar S. An interesting method of removal of live foreign bodyfrom the ear. Emerg. Med. 1998; 10: 278.

2. Cameron P (ed.). 17 Ears, Nose and Throat. In: Textbook ofAdult Emergency Medicine, 1st edn. Sydney, Australia: Churchof Light, 2000; 461–3.

3. Evans JNG (ed.). Paediatric Otolaryngology — Foreign bodiesin the nose. In: Scott Brown’s Otolaryngology, 5th edn. Oxford,UK: Butterworth-Heinemann, 1987; 276–9.

4. Gordon AC, Gough MH. Oesophageal perforation after buttonbattery ingestion. Ann. R. Coll. Surg. Engl. 1993; 75: 362.

5. Litovitz TL, Schmitz BF. Ingestions of cylindrical and buttonbatteries: An analysis of 2382 cases. Pediatrics 1992; 89: 747–57.

6. ASGE. Guideline for the management of ingested foreign bodies.ASGE Gastroentestinal Endoscopy 2002; 55: 802–6.

7. Evans JNG (ed.). Foreign bodies in the larynx and trachea. In:Scott Brown’s Otolaryngology, 5th edn. Oxford, UK: Butterworth-Heinemann, 1987; 438–48.

8. Black RE. Bronchoscopic removal of aspirated foreign bodiesin children. Am. J. Surg. 1984; 148: 778–81.

9. Tintinalli J, Krome RL, Ruiz E. Otolaryngologic Emergencies.In: Emergency Medicine: A Comprehensive Study Guide, 3rd edn.New York, USA: McGraw–Hill, 1992; 843.

Table 1. Common foreign bodies in the oesophagus

Radiolucent Radio opaque

Fish bone, fresh-water fish — small bone

Fish bone, salt-water fish — large bone

Food bolus Chicken boneMeat chunk Meat bone

DenturesPull top of drink canButton batteryCoinSafety pinPaper clip