FOREIGN BODIES

An object is considered a foreign body if the object is in a location in the body where it is not normally found. Commonly foreign bodies found in children include coins, small toys, foods like peas, beans, nuts or even candy and other small objects like beads or pills. Occasionally dislodged teeth, even bugs may be found. But the most concerning object is a button type battery like camera and watch batteries as these leak harmful substances. Foreign bodies in the aerodigestive tract sometimes occur in children. Foreign bodies refer to any object that is placed in the nose or mouth that is not meant to be there and could cause harm without immediate medical attention56. Definition Defined by Jackson as an object or substance foreign to the location where it is found. Classification of Foreign Body by Jackson 1. Exogenous include substances from outside the body e.g., peanut, beans, stone, seed, coins. 2. Endogenous includes substances from within the body e.g., blood clot, viscid secretions and bits of tumours. 31

Facts about foreign bodies in the aerodigestive tract57 Age: Foreign bodies in the aerodigestive tract are most common in children under the age of 5 years. George P Conners reported increased incidence in children aged 6 months to 4 years. In a study done by Steven C et al, the median age is 3 years 2 months. In the study of Sreenath, the most common age group was 9 months and 2 years. Sex: George P Conners reported the male to female ratio in young children is 1:1. In the older children and adolescents, males are commonly affected than females. In a study by Ashok Polur, the male to female ratio is 1.2:1. Steven C reported even gender distribution. Etiology The causative factors were classified as follows:
1.

Most cases occur as children discover and place small objects in their mouths. Repeated cases may suggest a chaotic home environment and neglect. Children with known GI tract abnormalities or previous complications. Failure of patients normal protective mechanism including deep

2. 3. 4.

sleep, loss of consciousness, epileptic seizures, alcoholic intoxication. 5. Psychopathic factors. 32

Symptomatology of foreign body depends upon the character of the foreign body: 1. 2. 3. Its size Shape of foreign body Type, whether organic or inorganic, also depends on the site of impaction.

Figure-9: Types of Foreign Bodies

33

General

SYMPTOMATOLOGY
Once the accident has occurred or it is suspected, a correct diagnosis assumes greater importance. Sometimes saving a human life depends upon the accuracy of diagnosis and efficient treatment. The variable symptomatology depends upon a series of factors of varying importance. Foreign bodies in fact are never same although, there are certain general rules concerning the etiology, the diagnosis and treatment. Each foreign body presents certain pecularities which simplify or complicate the diagnostic and therapeutic problems, which it imposes58. Initial symptoms are choking, gagging, coughing and wheezing often followed by symptomless interval (foreign body bronchus). The foreign body may lodge in ear, nose, nasopharynx, sinuses, pharynx, larynx, trachea, bronchi, oesophagus or may have been passed by a bowel, coughed out or spit out with or without knowledge of the patient. Initial choking or other manifestations may have escaped unnoticed or may have been forgotten. When a child is known to have choked, gagged and coughed while suspected of having something in his mouth, the case should be regarded as one of the foreign body until proved otherwise by every diagnostic means we possess, and cyanosis is not uncommon. Asphyxia may terminate the case in the initial stage. Pain or other subjective 34

sense of presence of foreign body is not felt in the bronchi and rarely in the trachea58. It is inevitably felt in oesophagus at each swallowing act. Initial contact of the foreign body with respiratory mucosa classically produces choking, gagging, coughing and wheezing, sometimes cyanosis, dyspnea. After these subside other symptoms depend on exact location of the foreign object. If initial reactions cause either expulsion of the offending foreign bodies or its passage into the lower aerodigestive tract, the episode may be unrecognized or quickly forgotten by the patient without further sequelae. The occurrence of late symptoms depends upon patients reaction to the foreign object, infection due to long sojourn, interference with physiological functions of air or food passages. The chief symptoms of foreign body, a fish bone, tooth brush bristle, or pin for example lodged in pharynx, fauces or tonsil is a subjective sense of the presence of foreign body sometimes constant or more often only on swallowing. Foreign Bodies in Ear Patient himself or patient relatives gives history about it. There may be preexisting disease of ear. Example chronic otitis externa, CSOM with otitis externa or presence of it in the meatus. Patient usually gives history of itching or irritation in the ear, each ache, ear discharge, ringing in ears. If the foreign body are pushed into the middle ear, the patient will complain of giddiness, nausea and vomiting59. 35

Foreign bodies within external auditory canal can be classified as inainmate or animate (live insects).In-animate can be: 1.
2.

Inert or corrosive/ irritant Organic or inorganic Hydrophobic or hydrophilic. Foreign bodies in the Nose Objects that are put into the childs nose are usually soft things. These would include, but are not limited to tissue, clay and pieces of toys or eraser. Sometimes, a foreign body may enter the nose while the child is trying to smell the object. Children often place objects in their noses because they are bored, curious or copying other children60. What are the symptoms of foreign bodies in the nose The most common symptom of foreign body in the nose is nasal drainage. The drainage appears only on the side of the nose with the object and often has a bad odour. In some instances, the child may also have a bloody nose. Foreign body is commonly found on or near the floor of nasal fossa. It is often obscured by inflammatory exudate and may remain hidden for many years. Radiography will confirm if the foreign body is radio-opaque. 36

3.

Rhinolith (Snonyms: Nasal Calculi; Concretion in the Nose): The concretion formation in nose results if foreign body gets buried in granulation and remains neglected. This forms a nucleus, around which a coating of calcium and magnesium carbonate occurs and thus a rhinolith form. Sometimes inspissated mucopus or blood clot may be a nidus, around which such a change may take place. More frequently seen in women then men. They do occur although rarely in the nasopharynx. Single, unilateral more or less irregularly spherical but may show prolongations according to the direction given to their growth by spaces where they originated. But in neglected cases they have been found weighing 85 grams and causing symptoms which simulated a malignant growth. The largest rihnolith recorded was as big as a hens egg, weighed 100 grams had destroyed the septum and turbinates and required a Rouges operation (central sublabial route) for its removal. Its surface is mulberry, grey or brownish black. It is friable and crumble readily under pressure. Salts originate from nasal mucous, tears and inflammatory exudates. Endogenous rhinolith is one formed around nucleus of blood or mucous, is rare before 4th year. Exogenous rhinolith when foreign body becomes coated with salts may occur at any age. Cherry stones account for large number, cotton swab left inadvertantly in nose can act as nucleus. The foreign body may be pushed into the nasopharynx or it may enter posteriorly during a fit of vomiting. In a patient with cleft palate the food 37

swallowed may enter the nasopharynx thus causing symptoms or can stay silent around, which a rhinolith can form. Rhinolith increases in size slowly and is symptomless at onset when large, it produces nasal obstruction. Examination shows a brown or greyish irregular mass near the floor of the nose. It feels stony hard and gritty on probing. X-ray shows a radio opaque shadow. These are surgically removed under general anaesthsia. It may be necessary to break it in nasal fossa and then remove it in piecemeal. Sometimes a large rhinolith may necessitate a lateral rhinotomy procedure for its removal61. Foreign bodies in the airway62 Foreign bodies in the airway constitute a medical emergency and require immediate attention. The foreign body can get stuck in many different places within the airway. Foreign bodies in the airway account for nearly 9 percent of all home accidental deaths in children under 5 years of age. As with other foreign body problems, children tend to put things to their mouths when they are bored or curious. The child may inhale deeply and the object may become lodged in the airway tube (trachea) instead of the eating tube (oesophagus). Food may be the causes of obstruction in children who do not have a full set of teeth to chew completely, or those children who simply do not chew their food well. Children also do not have complete coordination of the mouth and tongue, which may also lead to problems. Children between the ages of 7 months and 4 years are in the greatest danger of choking small objects, including but not limited to the 38

following:

Seeds Toy parts Grapes Hot dogs Pebbles Nuts B Buttons Children need to be watched very closely to avoid a c choking emergency. What are the symptoms of foreign bodies in t the airways? Foreign body ingestion requires immediate medical a attention. The following are the most common symptoms that may i indicate a child is choking. However, each child may experience s symptoms differently. Symptoms may include:

Choking or gagging when the object is first inhaled C Coughing at first Wheezing (a whistling sound), usually made when the child breathes out although the initial symptoms listed above may subside, the foreign body may still be obstructing the airway. The following symptoms may indicate that the foreign b body is still causing an airway obstruction. Stridor (a high pitched sound usually heard when the child breathes) 39

Cough that gets worse Child is unable to speak Pain in the throat Hoarse voice Blueness around the lips N Not breathing. Signs of foreign body airway Wincing sign: The patient feels stabbing pain when larynx is moved from side to side. A triad of signs like audible slap, palpatory thud, asthamatoid wheeze, suggest foreign body in the trachea63. Foreign Bodies in Oral Cavity Foreign body of the oral cavity are very rare because of the accessibility of the oral cavity to the patient64. Foreign Body in Oropharynx:In the oropharynx, foreign bodies are commonly encountered in the tonsil, posterior pharyngeal wall and vallecula. Among these foreign bodies in the tonsil are the most common64. Foreign bodies which have sharp edges are common in the oropharynx. They are small sticks, fibers of tooth brush and fish bones.

1.

2.

40 When there is a foreign body in the oropharynx, patient comes with foreign body sensation and pain which is localized to the region. Foreign bodies in Oesophagus57,65 Most complications of pediatric foreign body ingestion is due to esophageal impaction, usually at 1 of the 3 typical locations. The most common site of esophageal impaction is at the thoracic inlet. Defined as the area between the clavicles on chest radiograph, this is the site of anatomical change from the skeletal muscle to the smooth muscle of the oesophagus. The cricopharyngeal sling at C6 is also at this level and may catch a foreign body. About 70% of blunt foreign bodies lodged in the oesophagus do so at this location. Another 15% become lodged at the mid oesophagus, in the region where the aortic arch and carina overlap the oesophagus on chest X-rays. The remaining 15% become lodged at the lower esophageal sphincter (LES) at the gastro-esophageal junction. Children with pre-existing esophageal abnormalities e.g., repair of tracheo- esophageal fistula are likely to have foreign body impaction at the site of the abnormality. If a child with no known esophageal pathology has a blunt foreign body lodged at a location other than the 3-typical locations described above, the possibility of a previously unknown esophageal abnormality should be considered. Impacted Foreign Bodies A foreign body lodged in GI tract may cause local inflammation

leading to pain, bleeding, scarring and obstruction or it may erode 41 through the GI tract. Migration from the oesophagus most often leads to mediastinitis but may involve the lower respiratory tract or aorta and create an aortoenteric fistula. Migration through the lower GI tract may cause peritonitis. Age Children of all ages ingest foreign bodies. However, incidence is greatest in children aged 6 months to 4 years. This reflects the tendency of small children to use their mouths in the exploration of their world. In the teen years, concomitant psychiatric problems, mental disturbances, and risk-taking behavior may lead to foreign body ingestion. History Children commonly come to medical attention after a care giver witnesses the ingestion of a foreign body or after a child reports an ingestion to a care giver. Alternatively, the child may present because of signs and symptoms or a complication of ingestion. Occasionally, the care giver observes a foreign body that has passed in the stool and brings the child for evaluation. Children with significant complications of foreign body ingestion may be asymptomatic initially. Children may have vague symptoms that do not immediately

suggest foreign body ingestion.

When caring for children, always keep the possibility of foreign body ingestion in mind. 42

FOREIGN BODY EAR NOSE AND THROAT CLINICAL PRESENTATION AND MANAGEMENT
By

Dr.SHALINI SINGH SISODIA

Dissertation Submitted to theRajiv Gandhi University of Health Sciences, Karnataka, Bangalore In partial fulfillmentof the requirements for the degree of
MASTER OF SURGERY
in

OTORHINOLARYNGOLOGY
Under the Guidance of

Dr.MALLIKARJUN REDDY
Professor & H.O.D.

DEPARTMENT OF

OTORHINOLARYNGOLOGY M.R. MEDICAL COLLEGE, GULBARGA-585 105