Foreign Bodies

In Ear Nose and

Throat
Adapted from source
 FB Aspiration
• FBA is a common cause of mortality and
morbidity in children, especially in those younger
than two years of age
• Tracheobronchial foreign body aspiration is a
potentially life-threatening event
• During 2000, ingestion or aspiration of a foreign
body (FB) was responsible for 160 unintentional
deaths and more than 17,000 emergency
department visits in children younger than 14
years in the United States.
• Before the 20th century, aspiration of a FB had a
very high mortality rate. With the development of
modern bronchoscopy techniques, mortality has
fallen dramatically
• Death caused by suffocation following FBA is the fifth most
common cause of unintentional-injury mortality in the
United States
• Approximately 80 percent of these episodes occur in
children younger than three years, with the peak incidence
between one and two years of age
• At this age, most children are able to stand, are apt to
explore their world via the oral route, and have the fine
motor skills to put a small object into their mouths
• Another presentation is the elder sibling putting various
objects in the younger brother’s or sister’s mouth
• Commonly aspirated
foreign bodies in
children include
peanuts (36 to 55
percent of all FBs in
Western society), other
nuts, seeds (particularly
watermelon seeds in
Middle Eastern
countries), food
particles, hardware,
and pieces of toys
• The majority of aspirated foreign bodies in
children are located in the bronchi
• Larynx: 3 percent
• Trachea/carina: 13 percent
• Right lung: 60 percent (52 percent in the main
bronchus, 6 percent in the lower lobe bronchus,
and <1 percent in the middle lobe bronchus)
• Left lung: 23 percent (18 percent in the main
bronchus and 5 percent in the lower bronchus)
• Bilateral: 2 percent
 Presentation
• Children who present with severe respiratory distress,
cyanosis, and altered mental status have a true
medical emergency that demands prompt recognition
• History of choking and coughing
• However, in the more common, less emergent
situation, the physical examination may reveal
generalized wheezing or localized findings such as
focal monophonic wheezing or decreased air entry.
• The classic triad is wheeze, cough, and diminished
breath sounds
• They also can present delayed with fever and other
signs and symptoms of pneumonia
• Unresolving pneumonia and recurrence of pneumonia
also can be due to a FB in a distal bronchus
• Plain radiographic
evaluation of the chest
may or may not be
helpful in establishing
the diagnosis of FBA,
depending upon
whether the object is
radioopaque, and
whether and to what
degree airway
obstruction is present
• The most common
radiographic findings
in lower airway FBA
are hyperinflated lung,
atelectasis,
mediastinal shift, and
pneumonia
• -Obstructive
emphysema
 Management
• ABC
• Life threatening FBA-rare to reach hospital, but if
the child present with complete airway
obstruction-not speaking not coughing not
breathing and cyanosed dislodgement can be
attempted
• Back blows/chest compressions in infants
• Heimlich Maneuver-older children
• These intervention should be avoided in children
who have a partially compromised air way
because this my convert a partial to a complete
obstruction
 Management
• If imminent loss of air way is present rigid bronchosopic
extraction of the FB is the choice of treatment(but
frequently not available at hand)
• Intubation is the next best option and during intubation
if he FB seen in the larynx or above then it can be
removed and airway cleared
• Intubation may permit some ventilation until rigid
bronchoscopy is possible
• Vocal cords and cricoid ring are the narrowest points in
the air way depending on the age
• Therefore cricothyroid puncture also can be attempted
in desperate situations (This procedure will establish an
airway whether it’s a FB or other causes of airway
obstruction in majority of cases)
 Management
• Prevention of paediatric FBA is possible through
legislation, caregiver education, and continued
product safety vigilance.
• Do not let children play with beads and small
hard objects and also age appropriate toys and
food should be given to them
• Hard and/or round foods should not be offered to
children younger than four years of age; these
include (but are not limited to), hot dogs,
sausages, chunks of meat, grapes, raisins, apple
chunks, nuts, peanuts, popcorn, watermelon
seeds, raw carrots, hard candy
• Rigid Brochoscopy should
be performed ASP
• Ventilating rigid
brochoscope, suction
tubes, various types of
forceps and hopkins rod
telescopes has
revolutionized endoscopic
extraction of inhaled FBs
• Flexible Bronchoscope may
be used specially in adults
• Rarely removal via a
thoracotomy may be
needed
 Foreign Body in Nose
• Common in children of 2-3yrs
• Parents may notice child putting a FB or an
accidental finding
• FB can be irritative to the mucosa and inturn give
rise to a an inflammatory reaction
• This will give rise to a unilateral offensive nasal
discharge (This a FB in the nose until proven
otherwise)
• There can be associated vestibulitis
 Management
• History and examination to confirm the presence of a
FB
• Examination of the anterior nares with light reflected
on the elevated tip of the nose
• If nothing visible auroscope will give a better view
• It is possible to remove without GA in many children
(Anteriorly placed visible FBs)
• First effort will be the best and often the only
attempt the child will allow. There is no emergency
therefore do not rush have suction, instruments and
assistant ready before doing this
• Batteries and chemical containing FBs need to be
removed urgently
• Sweets will dissolve and can clear spontaneously
• Removal will be best accomplished with a hook or
curved instrument
• It is passed point downwards above the FB, which
is brought to the floor of the nose and raked
anteriorly
• Forceps can also be used but caution in round
hard objects
• In every case nasal cavity must be examined
afterwards as there can be second FB more
posteriorly
 Counsel parents
• Child might cry
• Bleeding-stop spontaneously
• Failure of the procedure and residual Fbs
• Second attempt under GA
 Foreign Body in the Ear
• Common in school children
• Not uncommon in adults-usually its cotton buds
• Non urgent situation unless live object
• Animate object (live) make it inanimate (kill) by
drowning (use oil)
• Most foreign bodies can be removed by syringing
(with water)-do not use if ear drum is perforated
• FB of vegetative origin may start to germinate
with contact with water and therefore the
swelling of the FB may worsen the scenario
• FB in the external ear canal is usually seen on
otoscopy and removal may appear to be easy
• But usually require the skills and facilities for this
because attempts of removal by untrained person
may lead to complications
• Suction and fine hooks can be used
• Super glue is in fashion these days but caution
• Operating microscope is required at times
• Once FB removed the ear should be examined to
check for any damage
 FB in the Oesophagus
• Impaction is commonest at the cricopharyngeus
level
• Also where the oesophagus crossed by the left
main bronchus
• Strictures ? Malignant
• Positive history, localise fairly accurately to the
level of impaction, dysphagia and excessive
salivation are symptoms
• Conservative methods(Specially if it is a food
bolus)
• Buscopan
• Benzodiazepines
• Glucagon injections
• Coca Cola
• Examination and Radiography may be normal
• Early esophagoscopy is required
• Rigid Endoscopy is recommended for sharp
objects
• Oesophageal perforation is a fatal complication
 FB in the Pharynx
• Sharp and irregular FBs may become impacted in
the tonsils, base of tongue, Vallecula and
pyriform fossa
• Small fish bones are the commonest and usually
lodged in the tonsil
• Patient usually an adult will be able to localise the
side and the site with reasonable accuracy
• Removal under direct vision is the treatment