Keywords
foreign bodies - otorhinolaryngology - emergency
Introduction
Foreign bodies (FBs) in the ear, nose, and throat (ENT) are commonly seen in the medical
practice by otorhinolaryngologists, pediatricians, Emergency Department surgeons,
physicians, and even in the primary care setting.[1] Foreign bodies have been estimated to account for ∼ 11% of the cases seen in ENT
emergency services.[2]
[3]
[4] If not properly managed, they have a high potential for morbidity/mortality, and
are costly to manage.[5]
[6]
[7]
Foreign bodies can be introduced spontaneously or accidently in both adults and children.
Generally, ENT FBs are more common in younger children; this may be due to various
factors, such as curiosity to explore orifices, imitation, boredom, playing, intellectual
disabilities, insanity, and attention deficit hyperactivity disorder, along with the
availability of the objects and absence of watchful caregivers.[8]
Consequences of FB injuries vary from low impact disturbances with or without hospitalization
to death. The variability is related to many factors, such as the chemical composition,
shape and dimensions of the FBs, and the anatomical site involved.[9]
This study was performed to analyze FBs in terms of type, site, age, and gender distribution,
method of removal, outcomes and complications.
Methods
A retrospective study was performed in the Department of ENT, Head and Neck Surgery
in a tertiary referral hospital. The study population included all patients presenting
with ENT FB lodgment in the Outpatient Department (OPD) or in the ENT emergency unit
during the 2-year study period (from July 2014 to June 2016). The patients were evaluated
carefully, with thorough history-taking and a complete ENT examination. Radiological
investigations, like X-ray, were performed when the FB was not visible. This was followed
by removal of the FB.
An anterior rhinoscopy was performed to diagnose nasal FBs. Rigid or flexible nasal
endoscopic examinations were also performed in suspected cases of FBs in the nasal
cavity that were not visualized with the anterior rhinoscopy. Direct vision with or
without otoscopic assistance was employed to diagnose aural FBs. Examination under
a microscope was an additional method for diagnosis, and it was useful for removal
of the FB of the ear. For swallowed FBs, direct vision was obtained with a tongue
depressor, indirect laryngoscopy was performed for co-operative patients, or transnasal
flexible endoscopy. Plain X-rays of the neck were taken from patients with a history
of FB ingestion. A rigid endoscopic examination (hypopharyngoscopy/ esophagoscopy)
was performed in cases in which the FB was not visible in the X-ray to rule out presence
of the FB or to determine its site of impaction, as well as to remove it. Rigid bronchoscopic
removal of the FBs was performed for the patients who had radiographic evidence of
an inhaled FB, and for those with strong clinical suspicion of an inhaled FB with
no radiographic evidence.
Data were obtained from the ENT clinic registration books and ward admission record
books. The following data were obtained from the patients: age, sex, type of FB and
the site/side of impaction, complementary tests, duration of insertion, previous attempts
at removal, methods of removal, outcomes, and complications. The patients were grouped
according to the location of the FB into throat FBs (swallowed & inhaled FBs), aural
FBs, and nasal FBs. The data collected from the patients were analyzed using the Microsoft
Excel 2010 (Microsoft, Redmond, WA, US) software. This study was conducted after receiving
approval from the Research Ethics Committee of our institution.
Results
A total of 1,013 patients with ENT FBs were examined and managed at the ENT Department
of a tertiary referral hospital during the period of July 2014 to June 2016. Foreign
bodies represented a large category among ENT emergencies (30% of all ENT emergencies).
A total of 572 cases involved males (56.47%) and 441 involved females (43.53%).The
age of the patients ranged from 1 to78 years, with a mean age of 12.5 years (mean ± standard
deviation [SD] = 12.5 ± 14.2). The major proportion of FB impactions (48.07%) were
found in children younger than 6 years of age, followed by children aged 7–12 years
(28.33%). None of the patients had psychiatric disorders or intellectual disabilities.
Among all of the FBs, swallowed FBs were the most commonly encountered (544 cases-
53.7%), followed by aural FBs (250 cases- 24.68%), nasal FBs (192 cases- 18.95%),
and inhaled FBs (27 cases- 2.67%). [Fig. 1] and [Table 1] describe the distribution of ENT FBs by site, gender and age groups. The type of
FB most commonly encountered differed according to the implicated anatomical site.
The FBs were removed with or without local anesthesia (LA) in 411 (40.57%) patients;
554 (54.69%) patients required removal under general anesthesia (GA); and no FBs were
found in 48 (4.74%) patients, in spite of their positive history, as shown in [Table 2].
Table 1
Distribution of ENT foreign bodies by site, gender and age groups
|
Sex
|
Age
|
Total
|
|
Male
|
Female
|
0–6
|
7–12
|
13–19
|
20–39
|
40–60
|
> 60
|
|
Swallowed FBs
|
314
57.7%
|
230
42.3%
|
342
62.9%
|
90
16.5%
|
17
3.13%
|
38
6.99%
|
36
6.62%
|
21
3.86%
|
544
100%
|
|
Aural FBs
|
160
64%
|
90
36%
|
81
32.4%
|
100
40%
|
15
6%
|
34
13.6%
|
19
7.6%
|
1
0.4%
|
250
100%
|
|
Nasal FBs
|
87
45.31%
|
105
54.69%
|
44
22.92%
|
94
48.96%
|
22
11.46%
|
31
16.14%
|
1
0.52%
|
0
|
192
100%
|
|
Inhaled FBs
|
11
40.74%
|
16
59.26%
|
20
74.1%
|
3
11.11%
|
2
7.41%
|
0
|
1
3.69%
|
1
3.69%
|
27
100%
|
Abbreviations: ENT, ear, nose and throat; FB, foreign body.
Table 2
Methods of removal ENT foreign bodies
|
Removal under LA
|
Removal under GA
|
No FB found
|
Total
|
|
Swallowed FBs
|
30
5.52%
|
466
85.66%
|
48
8.82%
|
544
100%
|
|
Aural FBs
|
216
86.4%
|
34
13.6%
|
0
|
250
100%
|
|
Nasal FBs
|
165
85.94%
|
27
14.06%
|
0
|
192
100%
|
|
Inhaled FBs
|
0
|
27
100%
|
0
|
27
100%
|
Abbreviations: ENT, ear, nose and throat; FB, foreign body; GA, general anesthesia;
LA, local anesthesia.
Fig. 1 Site of foreign bodies (FBs) impaction.
Swallowed Foreign Bodies
This group of patients was by far the most common, with 544 (53.7%) patients presenting
in the study period, of which 314 (57.7%) were males and 230 (42.3%) were females.
A total of 62.9% of the patients who had come with swallowed FBs were children under
the age of 6 years, and 16.5% were children aged 7– 12 years. The most common swallowed
FBs were coins, which represented 410 (75.37%) cases, followed by meat lumps in 32
(5.88%) cases, fish bones in 30 (5.51%) cases, pins in 22 (4.04%) cases, chicken bones
in 20 (3.68%) cases, disc batteries in 14 (2.57%) cases, and other FBs in 16 (2.95%)
cases. [Fig. 2] shows the types of swallowed FBs. The FB most commonly found in children was coins,
while adults presented more with fish bones and chicken bones, while elderly patients
presented more with meat lumps and artificial dentures. The clinical features of these
patients were mainly dysphagia for solids followed by throat pain, FB sensation inside
the throat, odynophagia and pooling of saliva. The most common site of impaction was
the hypopharynx, particularly at the cricopharyngeal sphincter, and it occurred in
370 (68.01%) patients. The other sites of FB impaction were the esophagus in 96 (17.65%)
patients, and the oropharynx and oral cavity, both in 30 (5.51%) patients.
Fig. 2 Types of swallowed FBs.
Radiographs were performed when the FB could not be found to aid in the determination
of the exact site of the FB. These were mainly plain X-ray neck lateral views, and,
when necessary, chest and abdominal radiographs. About 450 (82.72%) FBs were radio
opaque, and 64 (11.76%) FBs showed normal radiograph. In 30 (5.52%) cases, no X-ray
was performed, because the FB was visible to the naked eye, as it was located in the
oropharynx/oral cavity.
Out of 544 swallowed FBs, 466 patients (with FBs in the hypopharynx and esophagus)
had their FBs removed under GA via rigid endoscopy (hypopharyngoscopy/ esophagoscopy);
30 (5.52%) cases (with FBs in the tonsil/oropharynx, valeculla, base of the tongue)
were removed with or without LA by grasping forceps after the tongue had been depressed
with a tongue depressor under proper illumination with a head lamp or with head mirrors
that directed light to the oropharynx. A total of 48 (8.82%) cases had no FBs removed
in spite of positive history because of the descent of the FB or false sensation by
the patient.
No complications were observed, but hospitalization for a few days for observation
was needed in 6 (1.1%) cases that had long-standing neglected coins or disc batteries.
Inhaled Foreign Bodies
A total of 27 cases presented with laryngo-tracheobronchial FBs, of which 11 (40.74%)
were male patients and 16 (59.26%) were females. The highest incidence occurred among
children 0–6 years of age, who comprised 20 (74.1%) cases. The most common inhaled
FBs were beads (12 cases- 44.44%), followed by pins (9 cases- 33.33%), food particles
(2 cases- 7.41%), and other FBs (4 cases- 14.82%). [Fig. 3] shows the types of inhaled FBs.
Fig. 3 Types of inhaled FBs.
The patients presented with strong clinical suspicion of FB inhalation, with a history
of coughing, choking, difficulty in breathing, along with the presence of clinical
signs, like decreased air entry, wheezing, cyanosis, or crepitation. Chest X-ray posteroanterior
(PA) view showed either radio opaque FBs, obstructive emphysema, or collapse of the
affected lung with mediastinal shift.
Rigid bronchoscopy was used to remove the inhaled FB in all cases (100%). Pre-operatively,
the most common complication of FB aspiration was stridor in 3 cases (11.11%), followed
by atelectasis in 2 cases (7.41%), and recurrent pneumonia in 2 cases (7.41%). No
intraoperative or post-operative complications were encountered.
Foreign Bodies in the Ear
Out of the 250 patients who presented with FBs in their ears, 160 were males (64%)
and 90 were females (36%). The highest incidence of ear FBs occurred in children 7–12
years of age, comprising 100 (40%) cases. This was followed by children younger than
6 years of age, who comprised 81 (32.4%) cases. Out of the FBs lodged in the ear,
165 (66%) were in the right ear, and 85 (34%) in the left ear. A total of 50 (20%)
patients had beads in their ears, followed by cotton tips and insects, which were
found in 40 (16%) cases, beans in 38 (15.2%) cases, paper in 20 (8%) cases, metallic
FBs in 20 (8%) cases, and other FBs in 42 (16.8%) cases. [Fig. 4] shows the types of aural FBs.
Fig. 4 Types of aural FBs.
Most of the patients with aural FBs (75%) were asymptomatic at presentation, with
history of verbal admission by the patient or incident witnessed by the caregiver.
Other patients presented with otalgia, bleeding from the ear, otorrhea, tinnitus,
hearing loss, a sense of ear fullness or symptoms of otitis media. All the FBs were
seen on direct vision with or without otoscopic assistance. Regarding their locations,
the most frequent anatomical site of FB in the ear is the bony part of the external
auditory canal. Previous attempts of removing the aural FBs had been made in 50 (20%)
patients before they presented to our hospital.
Of the 250 cases of FB in the ear, 216 (86.4%) were removed in the OD or ENT emergency
unit with or without LA by ear syringing, suctioning, forceps, probe, or fine hook.
Only 34 (13.6%) cases required removal under GA because these patients were uncooperative
or due to impaction of the FB. Live insects were killed first by drowning in olive
oil before eventual ear syringing.
Complications were reported in 30 (12%) patients with FBs in their ears, especially
in those with previous failed attempts at removal. Complications included the following:
otitis externa (14 cases - 5.6%), laceration/bruising of the external canal (8 cases
- 3.2%), tympanic membrane perforation (4 cases - 1.6%), and acute otitis media (4
cases - 1.6%).
Foreign Bodies in the Nose
Foreign bodies lodged in the nose were encountered in 192 patients, 87 (45.31%) of
which were males, and 105 (54.69%) of which were females. A total of 44 (22.92%) patients
were younger than 6 years old, and 94 (48.96%)had ages between 7 and 12. A total of
155 (80.7%) nasal FBs were in the right nasal cavity, and 37 (19.3%) were in the left.
Beads were the most common type of FB found in the nose, constituting 91 (47.39%)
cases. This was followed by stones in 55 (28.65%) cases, beans or seeds in 21 (10.94%)
cases, and other FBs in 25 (13.02%) cases. [Fig. 5] describes the types of nasal FBs.
Fig. 5 Types of nasal FBs.
The patients presented with a history of introduction of the FB by themselves or with
a history of guardians who saw the FB in the nose, local pain, unilateral offensive
nasal discharge in cases of neglected FBs, epistaxis, and other symptoms (rhinitis,
nasal obstruction, sensation of swelling). Most of the FBs were seen on direct vision.
The nasal endoscope was employed to locate deep-seated nasal FBs. Previous attempts
of removing nasal FBs had been made in 20 (10.42%) patients before they presented
to our hospital.
Of 192 cases of FB in the nose, 165 (85.94%) were removed in the OD or ENT emergency
unit with or without LA under direct vision by hook, forceps and by suctioning. Only
27 (14.06%) cases required removal under GA, because these patients were uncooperative
or due to a deep-seated FB.
Only 14 patients (7.29% of all cases) with nasal FBs had complications: acute rhinosinusitis
(6 cases - 3.13%), epistaxis (3 cases - 1.56%), laceration (2 cases - 1.04%), rhinolith
formation (2 cases - 1.04%) and ulceration of the nasal septum (1 case - 0.52%).
Discussion
The present study considered patients examined for ENT FBs in the OD and in the ENT
emergency unit in a tertiary referral hospital for 2 consecutive years (from July
2014 to June 2016). The 1,013 cases of ENT FBs accounted for 30% of all patients examined
in the ENT emergency services during this period. According to the literature, FBs
account for ∼ 11% of the cases observed in ENT emergency services.[2]
[3]
[4] Ear, nose and throat FB injuries represent an emerging problem in the population,
especially in the pediatric age group, because of their human and social costs.[10]
[11] In the present study, FBs represented the most common ENT emergencies; this is similar
to other studies, which also recorded FBs to be the most common ENT emergencies.[12]
In the present study, FBs were more prevalent in children: 48.07% of the patients
aged 6 years or younger, and 28.33% of the patients aged 7–12 years presented with
FBs. Male individuals were the majority by a slight difference (56.47%).These findings
are in agreement with the literature and with reports of FBs being more common in
children around 6 years of age.[2]
[13]
[14] Several factors can be responsible for the age distribution; an analysis of the
literature reveals that the mouthing activity of children appears to be the most important
factor. Insertion of FBs by the little children may also be precipitated by boredom
and frustration, or they also may be mimicking the unhealthy habits of ear and nose
picking by adults.[13]
[15]
[16]
[17] Patients with psychological problems are prone to FB insertion; suitable measures
should be taken to prevent them from putting FBs in their nose or ears.[18]
Many studies in the literature reported aural FBs as the most prevalent.[4]
[19] In the present study, swallowed FBs were the most common (53.7%), followed by aural
FBs (24.68%), nasal FBs (18.95%), and finally FB inhalation (2.67%). In our study,
the most common site of FB lodgment was the throat, which is in corroboration with
other studies that reported similar rates of occurrence of ENT FBs.[20]
[21]
The key to successful removal is immobilization.[4] Quick atraumatic removal of FBs is a real challenge for ENT physicians. Therapeutic
success depends on several factors, but there is no strong evidence to indicate that
one specific removal method should be performed over others.[22] It is known, however, that the permanence of FBs in ENT cavities for over 72 hours
and repeated attempts to remove the FB increase the risk of complications. [2]
[3]
[23] In our study, the FB was removed with or without LA in 40.57% of the patients; 54.69%
of the patients required removal under GA; and no FB was found in 4.74% of the patients,
in spite of positive history. In our study, the need for GA to remove the FBs was
higher than the rates reported in the literature (around 30%).[3]
[6]
[24]
A study by Barreto and Holinger in 2005 mentioned that, among the upper digestive
tract FB cases, fish bone was the most common (70.5%), followed by coin in the esophagus
(6.63%), artificial denture impaction in the esophagus (1.89%), and meat bone impaction
in the esophagus (1.49%).[25] In our study, the most commonly ingested FBs were coins (75.37%), followed by meat
lumps (5.88%) and fish bones (5.51%). Since coins are used as currency, toddlers and
children have easy access to them, and accidentally swallow them. The most common
site of lodgment was the cricopharynx, and that correlates with other studies.[19]
[26] Foreign body ingestion is common among children, but it is frequently observed among
intellectually disabled or mentally ill adults as well.[27]
A total of 85.66% (466 cases) of the patients with swallowed FBs required GA for removal.
A total 5.52% (30 cases) of the patients had the FB removed with or without LA, and
8.82% (48 cases) of the cases had no FB removed in spite of positive history, because
of the descent of the FB or false sensation by the patient. No complications were
observed, but hospitalization for a few days for observation was needed in 6 (1.1%)
cases that had long-standing neglected coins or disc batteries. Disc batteries may
release small amounts of chemicals and voltage that may lead to alkaline chemical
burns, necrosis, or even perforation.[28] Batteries should be removed as soon as possible to prevent these complications.
Inhaled FBs were recorded in 2.67% of the cases in our study. In most series, inhaled
FBs are generally food particles, and the child is eating and playing at the same
time the accident happens.[25]
[29] In the present study FB most commonly reported were beads (12 cases - 44.44%), followed
by pins (9 cases - 33.33%) and food particles (2 cases - 7.41%).
Barretto and Holinger reported a 56.6% prevalence in 1-3 year-old children, and explained
it by the fact that they are learning to walk and have a tendency to put objects in
their mouths.[25] Lescanne et al, in 1997, found that a 1.8:1 sex ratio in favor of males is in agreement
with the literature. They found that children under 3 years old are most often involved,
and the FB location is usually bronchial. They asked the following questions: Is their
higher level of activity what puts boys at a greater risk? Or is it a difference in
pharyngo-laryngeal junction maturity?[29] In our series, children aged 6 years or younger constituted 74% of the cases (8
cases [29.62%] were of children 3 years old or younger); in contrast to the previous
study, the sex ratio was 1.45:1 in favor of females. The differences from other series
in the literature regarding the type of FBs, age and sex of the patients may be caused
by the fact that only selected cases were managed in our department, and most of inhaled
FBs presented to our hospital have been managed in the Cardiothoracic Department.
All cases in our study were managed using rigid bronchoscopy. As stated in literature,
rigid bronchoscopy remains the attitude of choice. It should be performed under GA
and spontaneous ventilation by an experienced operator and an appropriately trained
anaesthetist.[30] In our study, the most common preoperative complication of FB aspiration was stridor,
which was observed in 3 cases (11.11%). No intraoperative or post-operative complications
were encountered. Naragund et al (2014) reported that the most common complication
of FB aspiration encountered pre-operatively was persistent pneumonia, intraoperative
bleeding from the site of the FB, and post-operative bronchospasm.[31]
Cases with predisposing ear problems, like itching, pain, heaviness, discomfort, and
hearing impairment may push children and adults to probe the ear with some object,
leading to FB impaction, as well as injuries.[13]
[32] In our study, children were the most affected age group. The FBs were generally
found in males (64%) more than in females (36%). The most common FBs in children were
beads, insects and disc batteries, while cotton, paper and beans were the most common
in adults.
In 1998, Ainsley and Cunningham reported that the most common FBs in the ear are beads,
plastic toys, pebbles, popcorn kernels and insects. Thirty percent of the patients
in their study required GA to facilitate the removal of an ear FB.[6] The most common ear FBs in our study were beads, followed by cotton tips, insects
and beans.
Most aural FBs can be removed in the office; insects in ears should be killed by instillation
of oil into the external auditory canal. Uncooperative children and some adults require
GA to remove their FBs and to assess the condition of the tympanic membrane using
the microscope.[33]
[34] In our study, most ear FBs (86.4%) were removed in the office, and live insects
were killed first by drowning them in oil before eventual ear syringing. Only 13.6%
of patients required GA to facilitate the removal of ear FBs. The decisive factors
were patient age, cooperation, and the degree of impaction.
Complications due to the presence of an FB or due to the extraction were uncommon;
the complications were recorded in 12% of the cases, and that is in agreement with
a study by Al-Juboori,[35] who recorded a 12.5% complication rate, and in contrast with a study by Singh et
al, who recorded a 77% complication rate.[36] Complications were reported more in patients with previous failed attempts at removal.
The common nasal FBs mentioned in the literature include beads, buttons, toy parts,
pebbles, candle wax, food, paper, cloth, and disc batteries. Most nasal FBs can be
removed with direct visualization using a forceps, curved hooks, or suction catheters.[37]
[38] In the present study, common nasal FBs included beads, stones, and beans.
The FBs observed in the nose in our study were mostly found in children younger than
12 years old (71.88%).These findings are in agreement with the literature.[ 2]
[8]
[21]
[26] Contrary to FBs in the ear, females (105 cases - 54.69%) had a higher incidence
than males (87 cases - 45.31%).
As such, the physician should have several techniques for removing the different types
of FB. Numerous techniques have been well-described.[39] The methods used most successfully for removal of 85.94% (165 cases) of nasal FBs
in our OPD and ENT Emergency unit with or without LA by direct visualization include
the use of forceps, hooks and suctioning. Only 14.06% (27 cases) of nasal foreign
bodies were removed under GA using a nasal endoscope; this was performed in uncooperative
children and for FBs located far posteriorly in the nasal cavity.
The complications that occurred were usually related to repeated attempts at removal.[40] Only 7.29% of the patients (14 cases) with nasal foreign bodies were recorded in
our study to had complications.
Conclusion
Foreign bodies in the ears, nose or throat are a common occurrence in otorhinolaryngology
emergency services. Children are the most affected age group. The most common site
of FB lodgment is in the throat. Ear, nose and throat FBs need to be properly managed
to avoid complications.
