International Journal of Pediatric Otorhinolaryngology 77 (2013) 12911294

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Association between the self-insertion of nasal and aural foreign bodies and
attention-decit/hyperactivity disorder in children
Fatih Celenk a,*, Cem Gokcen b, Nazli Celenk c, Elif Baysal a, Cengiz Durucu a, Muzaffer Kanlikama a
a

Department of Otorhinolaryngology, Gaziantep University Faculty of Medicine, Turkey

Department of Child and Adolescent Psychiatry, Gaziantep University Faculty of Medicine, Turkey
c
Department of Child and Adolescent Psychiatry, Mersin University Faculty of Medicine, Turkey
b

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 13 March 2013
Received in revised form 10 May 2013
Accepted 11 May 2013
Available online 14 June 2013

Objective: To investigate whether the prevalence of attention-decit/hyperactivity disorder (ADHD) is

higher in children presenting with nasal and aural foreign bodies than in the control group.
Methods: The present study was conducted between April 2012 and December 2012 and included 60
pediatric patients presenting with self-inserted nasal and aural foreign bodies and 50 healthy controls
aged between 3 and 9 years. The Conner Parent Rating Scale (CPRS) and Turgays DSM-IV based ADHD
and disruptive behavior disorders screening scale (T-DSM-IV-Scale) were used to investigate ADHD.
Results: The difference between the patient group and the control group was signicant with respect to
the abnormal scores obtained from all the subscales (p < 0.05). In children between 5 and 9 years of age,
the abnormal scores were signicantly higher in the patients than the controls for all the subscales
(p < 0.05). However, in children between 3 and 4 years of age, there were no signicant differences
between the patients and the controls for the scores obtained from all the subscales (p > 0.05). No
statistically signicant difference was found between the patients with a previous history of selfinserted foreign bodies and those without any history of foreign body insertion (p > 0.05).
Conclusions: The ndings of our study demonstrated a possible association between the self-insertion of
nasal and aural foreign bodies and ADHD. Clinicians should be aware of the possible presence of ADHD in
children, especially in those patients between 5 and 9 years of age who present with self-inserted nasal
and aural foreign bodies.
2013 Elsevier Ireland Ltd. All rights reserved.

Keywords:
Attention-decit/hyperactivity disorder
Foreign body
Nasal
Aural

1. Introduction
Attention-decit/hyperactivity disorder (ADHD) is one of the
most common childhood psychiatric disorders [1]. In a recent
meta-analysis, the estimated prevalence of ADHD in childhood and
adolescence was reported to be between 5.9% and 7.1% [2]. The
characteristic features of ADHD are inattentiveness, hyperactivity
and impulsivity [3,4]. Children with ADHD are at higher risk for
unintentional injuries than unaffected children [57]. The causes
of increased risk for injuries among children with ADHD have not
been claried. Impulsiveness, hyperactivity, inattentiveness and
aggressive or risk-taking behaviors in children with ADHD may
make them more prone to unintentional injuries [6,8]. These
behaviors may result in the inability of children with ADHD to
comprehend the consequences of certain activities [9].

* Corresponding author at: Department of Otorhinolaryngology, Gaziantep

University Faculty of Medicine, Gaziantep, Turkey. Tel.: +90 505 3912781.
E-mail address: facelenk@yahoo.com (F. Celenk).
0165-5876/$ see front matter 2013 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijporl.2013.05.012

Nasal and aural foreign bodies are commonly encountered in

the pediatric population. Foreign body insertion comprises
approximately 11% of all otorhinolaryngological emergency cases
[10,11]. Although foreign-body insertion appears to be a simple
problem, it can have several important consequences. Nasal
foreign bodies may cause epistaxis, infection, tissue necrosis,
septal perforation, bronchopulmonary aspiration and even death if
the objects pass through the lower airways [12]. Insertion of the
aural foreign body or manipulating it in the external ear canal may
result in tympanic membrane perforation, canal laceration, otitis
externa, hematoma and hearing loss due to ossicular chain damage
[13]. Complications related to foreign bodies may occur in 22% of
these patients [10].
The self-insertion of a foreign body into the nose or external ear
canal may be considered an unintentional injury [9]. Although
otorhinolaryngeal foreign bodies are quite common and have the
potential to cause signicant morbidity and even mortality, the
association between ADHD and foreign-body insertion has not
been extensively studied. Only one published investigation has
examined the prevalence of ADHD among children with

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self-inserted foreign bodies. To the best of our knowledge, no

controlled study exists that addresses this issue. Therefore, the aim
of the present study was to investigate whether the prevalence of
ADHD is higher in children presenting with nasal or aural foreign
bodies than in the corresponding control group.
2. Materials and methods
This prospective study was conducted between April 2012
and December 2012 and included children between 3 and 9 years
of age who presented to the emergency department or the ear,
nose and throat (ENT) outpatient clinic with self-inserted nasal
and aural foreign bodies. The initial evaluation and management
of the patients were performed by an ENT surgeon. A detailed
medical history was obtained, and a thorough head and neck
examination was performed on all of the patients. Each patients
age and gender, type of object and site of the foreign-body
insertion were noted. In addition to a careful otoscopic
examination for aural foreign bodies, an anterior rhinoscopic
examination was performed, employing a nasal speculum and
headlight to search for nasal foreign bodies. Foreign bodies in the
ear were removed using an angled ear curette and/or a Hartmann
micro-ear forceps under an otoscopic or microscopic view.
Angled curettes, bayonet forceps or a punch forceps were used to
remove anteriorly located nasal foreign bodies, as facilitated by
anterior rhinoscopy. A 2.7-mm rigid endoscope or exible beroptic endoscope was used for posteriorly located nasal foreign
bodies. Removal of the foreign body was performed under
general anesthesia in uncooperative children.
After the appropriate intervention for the removal of the foreign
body, the parents were informed about the study. If the parents
agreed to participate in the study, they lled out a form that
included questions regarding the patients age and gender,
previous accidental injuries, previous foreign-body insertion, type
of object and site of the foreign-body insertion. Children with
motor and mental retardation or pervasive developmental
disorders, foreign-body cases in which the object was inserted
by another person, were excluded from the study. The control
group was composed of healthy children who were matched to the
patient group with respect to age and gender. The patients and
controls were divided into 2 groups according to their age. Group 1
consisted of patients and controls who were between 3 and 4 years
of age, and group 2 consisted of patients and controls who were
between 5 and 9 years of age.
The Conner Parent Rating Scale (CPRS) and Turgays DSM-IVbased ADHD and disruptive behavior disorders screening scale (TADHD) were used to assess the behavioral characteristics of ADHD
and to determine the severity of the symptoms. CPRS is one of the
popular rating scales for ADHD evaluations [14], and the Turkish
adapted and validated form of this scale is available [15]. The
inattention and hyperactivity subscales of the Turkish form of the
CPRS were utilized in this study. The parents responded to each
item on a 4-point Likert scale (0 = never, 1 = rarely, 2 = often, and
3 = always). A score of at least 5 points on the inattention subscale
(CPRS-IA) and 6 points on the hyperactivity-impulsivity subscale
(CPRS-HA) were considered to be abnormal for inattentiveness and
hyperactivity, respectively. The T-ADHD scale consists of DSM-IV
criteria for destructive behavioral disorders, and this scale was
validated and adapted for the Turkish language [16,17]. This scale
was used for screening of ADHD (inattentiveness and hyperactivity), oppositional deant disorder and conduct disorder; each
symptom was rated on a 4-point Likert scale (0 = never,
1 = occasionally, 2 = often, and 3 = very often). Two ADHD subscales were utilized in this study. A score of 2 or 3 on at least six of
the hyperactivity (T-ADHD-HA) and inattention items (T-ADHDIA) was used as the criterion for hyperactivity-impulsivity and

inattentiveness. The scales were completed by the parents and

evaluated by a child psychiatrist.
The study protocol was reviewed and approved by the
institutional ethics committee. Informed consent was obtained
from all the parents. Students t-test, Chi-square test and
Fishers Exact Test were used to analyze variables. Continuous
variables were compared with Students t-test and categorical
variables were compared with Chi-square test and Fishers Exact
Test. The difference between the two groups was considered to be
statistically signicant when p < 0.05.
3. Results
Sixty children who presented with self-insertion of nasal or
aural foreign bodies met the inclusion criteria, including 30 (50%)
male and 30 (50%) female patients. The age of the patients ranged
between 3 and 9 years, with a mean of 4.43  1.5 years. The control
group consisted of 50 healthy children, namely, 23 (46%) male and 27
(54%) female participants. The age of the control subjects ranged
between 3 years and 8 years, with a mean age of 4.76  1.4 years. No
statistically signicant differences in age or gender existed between
the patients and the controls (p = 0.676). Group 1 consisted of 38
patients and 22 controls between 3 and 4 years of age, and group 2
consisted of 22 patients and 28 controls between 5 and 9 years of age.
There were 35 (58.3%) aural and 25 (41.7%) nasal foreign bodies. The
most common foreign bodies were beads (n = 34, 56.7%), followed by
seeds (n = 5, 8.3%), nutshells (n = 3, 5%), metal fragments (n = 3, 5%),
pen-nibs (n = 3, 5%), batteries (n = 2, 3.3%), eraser fragments (n = 2,
3.3%), small stones (n = 2, 3.3%), paper (n = 2, 3.3%), food items (n = 2,
3.3%), pills (n = 1, 1.6%) and buttons (n = 1, 1.6%). General anesthesia
was required to removal the foreign body in 8 (13.3%) patients.
Twenty patients with a self-inserted foreign body (33.3%) and 4
controls (8%) had abnormal scores on the CPRS-IA. Twenty-two
patients (36.7%) and 6 controls (12%) had abnormal scores on the
CPRS-HA. Seven patients (11.7%) and 1 control (2%) had abnormal
scores on the T-ADHD-IA. Twenty patients (33.3%) and 7 controls
(14%) had abnormal scores on the T-ADHD-HA. The difference
between the patient group and the control group was signicant
with respect to abnormal scores on all 4 subscales (p < 0.05).
The abnormal scores of the patients and controls on all 4 subscales
are summarized in Table 1. In group 1, no signicant differences
were determined between the patients and the controls for the
scores obtained from all 4 subscales (p > 0.05). However, within
group 2, the abnormal scores were signicantly higher in the
patients compared with the controls for all the subscales
(p < 0.05). The distribution of abnormal scores for the patients
and controls within each age group for the 4 subscales, as well as
the corresponding p values, are presented in Table 2.
Within the patient group, there was no statistically signicant
gender-related difference in the scores on all the subscales
(p > 0.05). Thirteen (21.7%) patients had histories of a self-inserted
foreign body. Three children had experienced multiple past
episodes of self-insertion of a foreign body, and all of these
subjects had abnormal scores on at least 3 of 4 subscales. Seven
(11.7%) patients had a history of previous injuries, such as burns,
head trauma or extremity fractures. No statistically signicant
difference was found between the patients with a previous history
Table 1
Comparison of the abnormal scores of the patients and controls.
Measure

Patients (n = 60)

Controls (n = 50)

CPRS-IA
CPRS-HA
T-ADHD-IA
T-ADHD-HA

20
22
8
20

4
6
1
7

0.001
0.003
0.031
0.019

(33.3%)
(36.7%)
(13.3%)
(33.3%)

(8%)
(12%)
(2%)
(14%)

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Table 2
Distribution of abnormal scores based on age.
Measure

CPRS-IA
CPRS-HA
T-ADHD-IA
T-ADHD-HA

Group 1 (34 years, n = 60)

Group 2 (59 years, n = 50)

Patients (n = 38)

Controls (n = 22)

Patients (n = 22)

Controls (n = 28)

8
12
2
10

2
3
1
4

0.299
0.122
1.000
0.473

12
10
6
10

2
3
0
3

0.000
0.005
0.005
0.005

(21.1%)
(31.6%)
(5.2%)
(26.3%)

(9.1%)
(13.6%)
(4.5%)
(18.1%)

of self-inserted foreign bodies and those without any history of

foreign-body insertion (p > 0.05).
4. Discussion
In the present study, we found that children with self-inserted
foreign bodies had signicantly higher rates of abnormal scores on
all of the subscales compared with the control participants. The
rate of abnormal inattention scores was 4-times higher with the
CPRS-IA and 6-times higher with the T-ADHD-IA in the patients
compared with the controls. The rate of abnormal hyperactivity
scores was approximately three-times higher in the patients than
in the controls. To the best of our knowledge, only one published
study exists that evaluates the relationship between ADHD and
self-inserted foreign bodies [9]. Those authors used two scales for
the assessment of ADHD in 34 children presenting with selfinserted foreign bodies, compared their ndings with the
prevalence rate that was previously reported (5.1%) and found
that their measured hyperactivity rates were higher. Our ndings
were consistent with that report by Perera et al. [9].
Impulsiveness, hyperactivity, inattentiveness, aggressiveness
and risk-taking behavior exhibited by children with ADHD are
suggested to be associated with increased risk of injuries [6,8].
These behaviors may cause lack of awareness of danger and an
inability to comprehend the consequences of an activity [9]. Based
on this point of view, foreign-body insertion may be categorized as
an injury because the affected children insert foreign objects into
their body cavities without considering the possible magnitude of
the consequences. Nasal and aural foreign-body injuries are
potentially serious and are frequently encountered childhood
emergencies [10]. Particularly, nasal foreign-body insertion may
become a life-threatening condition due to the risk of airway
blockage. Therefore, the possible etiological and predisposing
factors for foreign-body insertion should be elucidated to prevent
injuries and recurrent self-insertion of the foreign bodies.
The mean age of the patients was approximately 4 years, and
patients between 3 and 4 years of age were predominant in our
study. Several publications have addressed the sociodemographic
risk factors related to otorhinolaryngological foreign bodies.
Rybojad et al. [18] investigated the sociodemographic risk factors
involved in 1011 otolaryngological foreign-body cases and
reported that male patients between 1 and 3 years of age
constitute the largest population. In a series of 353 foreign-body
cases, children between 4 and 8 years of age comprised the largest
group [19].
We found a signicant difference between the patients and the
controls with respect to abnormal scores in children between 5 and
9 years of age. The CPRS-IA scores were abnormal in approximately
one-half of the patients, and the abnormal scores were 7-times
higher in the patients compared with the controls in this age group.
The abnormal scores on the other subscales were also higher
within the patient group within this age range. We found no
statistically signicant association with respect to the inattention
and hyperactivity subscale scores in children between 3 and 4
years of age. In accordance with our ndings, Perera et al. [9]
determined abnormal hyperactivity scores in 17.6% of the patients

(54.5%)
(45.4%)
(27.3%)
(45.4%)

(7.1%)
(10.7%)
(0%)
(10.7%)

over 5 years of age and in 2.9% of the patients between 3 and 4

years of age. These age-related ndings in both studies can be
explained by the difculty in diagnosing ADHD in younger
children. The diagnosis of ADHD in younger children is challenging
because individuals in this age group usually exhibit behavioral
characteristics of ADHD, including high activity levels, impulsivity,
and short attention spans [20].
Perera et al. [9] found that 20% of the children reported
previous episodes of self-insertion and that 17.1% of the children
had previously suffered from other unintentional injuries
requiring hospitalization. Although we also found that the rates
of patients with previous self-insertion (21.7%) and accidentalinjury histories (11.7%) were higher than the estimated prevalence of ADHD (5.1%), there was no signicant difference
compared to those subjects without past episodes of selfinsertion or accidental injuries. However, all of the patients with
multiple past episodes of foreign-body insertion had abnormal
scores on at least 3 of 4 subscales, suggesting that children with
multiple past episodes of foreign body insertions are more likely
to be diagnosed with ADHD. Additional large controlled studies
are necessary to address these issues.
5. Conclusions
The ndings of our study demonstrated the possible
association between the self-insertion of nasal or aural foreign
bodies and ADHD. Clinicians should be aware of the possible
presence of ADHD in children, especially in those patients
between 5 and 9 years of age who present with self-inserted
nasal or aural foreign bodies. Screening, diagnosis and treatment
of ADHD in children with self-inserted foreign bodies may
prevent not only subsequent foreign-body insertions but also
unintentional injuries.
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