International Journal of Pediatric Otorhinolaryngology 77 (2013) 1291–1294

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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-deficit/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-deficit/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 Turgay’s 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 significant 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 significantly 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 significant differences
between the patients and the controls for the scores obtained from all the subscales (p > 0.05). No
statistically significant 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 findings 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.
ß 2013 Elsevier Ireland Ltd. All rights reserved.

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

1. Introduction
Attention-deficit/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 [5–7]. The causes
of increased risk for injuries among children with ADHD have not
been clarified. 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 ß 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 significant 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

003 0. small stones (n = 2. Two ADHD subscales were utilized in this study.05). The Conner Parent Rating Scale (CPRS) and Turgay’s 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. foreign-body cases in which the object was inserted by another person. Therefore. The control group was composed of healthy children who were matched to the patient group with respect to age and gender.4 years. 1 = rarely. as well as the corresponding p values. A 2. respectively. The abnormal scores of the patients and controls on all 4 subscales are summarized in Table 1. Continuous variables were compared with Student’s t-test and categorical variables were compared with Chi-square test and Fisher’s Exact Test. they filled out a form that included questions regarding the patient’s age and gender.3%) (36. each symptom was rated on a 4-point Likert scale (0 = never.3%).3%) (8%) (12%) (2%) (14%) .3%) aural and 25 (41.7%) nasal foreign bodies. No statistically significant differences in age or gender existed between the patients and the controls (p = 0. batteries (n = 2. and the Turkish adapted and validated form of this scale is available [15]. Thirteen (21. The age of the patients ranged between 3 and 9 years. This scale was used for screening of ADHD (inattentiveness and hyperactivity). However. 56. 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. 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. and group 2 consisted of 22 patients and 28 controls between 5 and 9 years of age.7%) and 6 controls (12%) had abnormal scores on the CPRS-HA. pills (n = 1. followed by seeds (n = 5.3%). namely. Children with motor and mental retardation or pervasive developmental disorders. Results Sixty children who presented with self-insertion of nasal or aural foreign bodies met the inclusion criteria.3%). were excluded from the study.6%). head trauma or extremity fractures. Within the patient group. The initial evaluation and management of the patients were performed by an ENT surgeon. such as burns. After the appropriate intervention for the removal of the foreign body. pen-nibs (n = 3.05). an anterior rhinoscopic examination was performed.05. General anesthesia was required to removal the foreign body in 8 (13. Angled curettes.7%). and 3 = very often). 3. 8. The T-ADHD scale consists of DSM-IV criteria for destructive behavioral disorders. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 1291–1294 self-inserted foreign bodies. Seven (11. with a mean age of 4. The inattention and hyperactivity subscales of the Turkish form of the CPRS were utilized in this study. Student’s t-test. as facilitated by anterior rhinoscopy. 1. metal fragments (n = 3. 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. Group 1 consisted of patients and controls who were between 3 and 4 years of age. 3. In addition to a careful otoscopic examination for aural foreign bodies.05).001 0. are presented in Table 2. previous foreign-body insertion.676).6%) and buttons (n = 1. within group 2. type of object and site of the foreign-body insertion were noted. The difference between the two groups was considered to be statistically significant when p < 0. 2 = often. 2. Twenty-two patients (36.7-mm rigid endoscope or flexible fiberoptic endoscope was used for posteriorly located nasal foreign bodies.3%) (33.031 0. The parents responded to each item on a 4-point Likert scale (0 = never. the parents were informed about the study. Each patient’s age and gender.05). In group 1. CPRS is one of the popular rating scales for ADHD evaluations [14]. type of object and site of the foreign-body insertion. Informed consent was obtained from all the parents. Removal of the foreign body was performed under general anesthesia in uncooperative children. No statistically significant difference was found between the patients with a previous history Table 1 Comparison of the abnormal scores of the patients and controls. The patients and controls were divided into 2 groups according to their age. 1 = occasionally. Measure Patients (n = 60) Controls (n = 50) p CPRS-IA CPRS-HA T-ADHD-IA T-ADHD-HA 20 22 8 20 4 6 1 7 0. and all of these subjects had abnormal scores on at least 3 of 4 subscales. eraser fragments (n = 2. food items (n = 2. no significant differences were determined between the patients and the controls for the scores obtained from all 4 subscales (p > 0. The age of the control subjects ranged between 3 years and 8 years.5 years.3%). 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. 2 = often. Twenty patients with a self-inserted foreign body (33. The study protocol was reviewed and approved by the institutional ethics committee. previous accidental injuries.7%) patients had histories of a self-inserted foreign body. The distribution of abnormal scores for the patients and controls within each age group for the 4 subscales.7%) and 1 control (2%) had abnormal scores on the T-ADHD-IA. and a thorough head and neck examination was performed on all of the patients. bayonet forceps or a punch forceps were used to remove anteriorly located nasal foreign bodies.76  1.3%) and 4 controls (8%) had abnormal scores on the CPRS-IA. the abnormal scores were significantly higher in the patients compared with the controls for all the subscales (p < 0. 3.7%) (13. There were 35 (58. 3.3%) and 7 controls (14%) had abnormal scores on the T-ADHD-HA. 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. and group 2 consisted of patients and controls who were between 5 and 9 years of age.43  1. To the best of our knowledge. If the parents agreed to participate in the study. Chi-square test and Fisher’s Exact Test were used to analyze variables. including 30 (50%) male and 30 (50%) female patients.3%). Seven patients (11. no controlled study exists that addresses this issue.7%) patients had a history of previous injuries. paper (n = 2.019 (33. 3. oppositional defiant disorder and conduct disorder.3%). 3. The control group consisted of 50 healthy children.1292 F. and this scale was validated and adapted for the Turkish language [16. Three children had experienced multiple past episodes of self-insertion of a foreign body. 5%). employing a nasal speculum and headlight to search for nasal foreign bodies. The most common foreign bodies were beads (n = 34. with a mean of 4. 5%). The difference between the patient group and the control group was significant with respect to abnormal scores on all 4 subscales (p < 0. 1. Celenk et al. 5%). nose and throat (ENT) outpatient clinic with self-inserted nasal and aural foreign bodies. 23 (46%) male and 27 (54%) female participants. Twenty patients (33.17]. A detailed medical history was obtained. there was no statistically significant gender-related difference in the scores on all the subscales (p > 0.3%) patients. Group 1 consisted of 38 patients and 22 controls between 3 and 4 years of age. and 3 = always). nutshells (n = 3. The scales were completed by the parents and evaluated by a child psychiatrist.

S. The abnormal scores on the other subscales were also higher within the patient group within this age range.3%) (9. 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. Additional large controlled studies are necessary to address these issues. Barthel. aggressiveness and risk-taking behavior exhibited by children with ADHD are suggested to be associated with increased risk of injuries [6. Tomita.6%) (4. 38 (2012) 366–370.7%) (0%) (10. A. Psychiatry 20 (2007) 386–392. [9] H.7%) and accidentalinjury histories (11. Clinicians should be aware of the possible presence of ADHD in children. [9]. The rate of abnormal hyperactivity scores was approximately three-times higher in the patients than in the controls. [4] G. 6 (2006) 38–44.D. Int. children between 4 and 8 years of age comprised the largest group [19].000 0. Ambul.5%) (45. . Celenk et al.8]. Perera. Opin.9% of the patients between 3 and 4 years of age. we found that children with self-inserted foreign bodies had significantly higher rates of abnormal scores on all of the subscales compared with the control participants.4%) (27. Fritz. Li. The mean age of the patients was approximately 4 years. Impulsiveness.A.L. Neurotherapeutics 9 (2012) 490–499. Epidemiology of attention-deficit/hyperactivity disorder across the lifespan. Pediatrics 102 (1998) 1415–1421. Rybojad 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. V. Biederman. These age-related findings in both studies can be explained by the difficulty in diagnosing ADHD in younger children.A. Psychiatry 164 (2007) 942–948. C.1%). Polanczyk. 5. J. impulsivity. and the abnormal scores were 7-times higher in the patients compared with the controls in this age group. Butz. Horta. DiScala. 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. [3] M.S. nasal foreign-body insertion may become a life-threatening condition due to the risk of airway blockage. nonfatal injuries: US school-age children. S. Rappley.000 0. References [1] G. all of the patients with multiple past episodes of foreign-body insertion had abnormal scores on at least 3 of 4 subscales. I. We found no statistically significant association with respect to the inattention and hyperactivity subscale scores in children between 3 and 4 years of age.3%) (45. L. Child Care Health Dev.N.005 0. n = 50) Patients (n = 38) Controls (n = 22) p Patients (n = 22) Controls (n = 28) p 8 12 2 10 2 3 1 4 0.M. Those authors used two scales for the assessment of ADHD in 34 children presenting with selfinserted foreign bodies. Otorhinolaryngol. suggesting that children with multiple past episodes of foreign body insertions are more likely to be diagnosed with ADHD. G. Braz. Several publications have addressed the sociodemographic risk factors related to otorhinolaryngological foreign bodies. Clinical practice. Perera et al. Opin. diagnosis and treatment of ADHD in children with self-inserted foreign bodies may prevent not only subsequent foreign-body insertions but also unintentional injuries. de Lima.R.D. Identified attention-deficit/hyperactivity disorder and medically attended. Shilon. In accordance with our findings. M. Our findings were consistent with that report by Perera et al. Pediatr.F. In a series of 353 foreign-body cases. N. Pediatr. Azevedo. However. Lescohier. [2] E.1%) and found that their measured hyperactivity rates were higher. Nasal and aural foreign-body injuries are potentially serious and are frequently encountered childhood emergencies [10]. Rohde. J.6%) (5. The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review. Injuries to children with attention deficit hyperactivity disorder. Conclusions The findings of our study demonstrated the possible association between the self-insertion of nasal or aural foreign bodies and ADHD.6% of the patients (54. 1997–2002. J. Although we also found that the rates of patients with previous self-insertion (21.O. especially in those patients between 5 and 9 years of age who present with self-inserted nasal or aural foreign bodies. Med.4%) (7. I. only one published study exists that evaluates the relationship between ADHD and self-inserted foreign bodies [9]. Y. there was no significant difference compared to those subjects without past episodes of selfinsertion or accidental injuries. 352 (2005) 165–173. Fernando. 19 (2007) 565–569. [9] determined abnormal hyperactivity scores in 17. L. To the best of our knowledge. Attention deficit-hyperactivity disorder. 74 (2008) 7–15.005 0.473 12 10 6 10 2 3 0 3 0. Gross-Tsur. [6] Y. [5] K.M. These behaviors may cause lack of awareness of danger and an inability to comprehend the consequences of an activity [9].5%) (18. C. [7] C. compared their findings with the prevalence rate that was previously reported (5. A. Pediatr. [8] P. Ko´s. Therefore.G. The CPRS-IA scores were abnormal in approximately one-half of the patients. [10] R.7%) were higher than the estimated prevalence of ADHD (5. We found a significant difference between the patients and the controls with respect to abnormal scores in children between 5 and 9 years of age. 4. Screening.A.05).1%) of self-inserted foreign bodies and those without any history of foreign-body insertion (p > 0. A. Aran. Rohde.A. Accidental injuries are more common in children with attention deficit hyperactivity disorder compared with their non-affected siblings. Attention deficit/hyperactivity disorder and pediatric burn injury: important considerations regarding premorbid risk.7%) over 5 years of age and in 2. Curr. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Measure CPRS-IA CPRS-HA T-ADHD-IA T-ADHD-HA Group 1 (3–4 years.1%) (31. Polanczyk. including high activity levels. Curr. and patients between 3 and 4 years of age were predominant in our study. Am. Particularly. Reuben. [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.122 1. A. J. Otorhinolaryngol. Pollak. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 1291–1294 1293 Table 2 Distribution of abnormal scores based on age. J. Yasawardena. Shaked.299 0. Prevalence of attention deficit hyperactivity disorder (ADHD) in children presenting with selfinserted nasal and aural foreign bodies. Pastor. Based on this point of view. Willcutt. Karunaratne.1%) (13. The diagnosis of ADHD in younger children is challenging because individuals in this age group usually exhibit behavioral characteristics of ADHD. 73 (2009) 1362–1364. the possible etiological and predisposing factors for foreign-body insertion should be elucidated to prevent injuries and recurrent self-insertion of the foreign bodies.1%) (10. S.2%) (26.005 (21. B. Engl. inattentiveness. M. Complications of ENT foreign bodies: a retrospective study. Figueiredo. and short attention spans [20]. Perera et al. Discussion In the present study. hyperactivity. n = 60) Group 2 (5–9 years.

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