Friday, November 9, 2007

Foreign bodies in Ear Nose Throat

Am Fam Physician. 2007;76:1185-1189.

Clinical Context

Most patients presenting with foreign bodies in the ear, nose, or throat are children and adults who are intellectually challenged or mentally ill, and successful removal depends on location, type of object, whether the object is graspable, clinician dexterity, and patient cooperation. Foreign bodies in the ear often are lodged at the bony cartilaginous junction and attempts at removal may result in pushing the object farther into the auditory canal or damage to the tympanic membrane. Nasal foreign bodies tend to be lodged below the inferior turbinate or in the upper nasal fossa anterior to the middle turbinate. Pharyngeal foreign bodies may be lodged in the pharynx or hypopharynx.

This is a review of presentations of foreign bodies in the ear, nose, and throat and management strategies that are appropriate for removal.

Study Highlights

  • Foreign bodies in the ear:
    • 75% occur in children younger than 8 years.
    • These objects are usually asymptomatic and are often an incidental finding in children.
    • The most common foreign bodies are beads, plastic toys, pebbles, and popcorn kernels; insects are more common in children older than 10 years.
    • In 30% of children younger than 7 years, the object requires removal with the child under general anesthesia.
    • Graspable foreign bodies (foam rubber, paper) have higher rates of success for removal under direct visualization.
    • Options for removal include water irrigation, forceps, cerumen loops, right-angle ball hooks, and suction catheters.
    • Live insects can be rapidly killed before removal by instilling alcohol, 2% lidocaine, or mineral oil into the ear canal, but this should not be done if the tympanic membrane is perforated.
    • Irrigation should be avoided in patients with button batteries because of the risk for liquefaction tissue necrosis.
    • Acetone may be used to dissolve Styrofoam foreign bodies or to loosen cyanoacrylate (eg, Super Glue adhesive).
    • After the first failed attempt at removal, complications increase and success rate falls.
    • Otolaryngologic referral should be made for patients requiring general anesthesia.
    • After removal of a foreign body, all orifices should be examined for other objects.
    • Otic antibiotic drops are required for concurrent otitis externa or when trauma is present.
  • Foreign bodies in the nose:
    • Nasal foreign bodies tend to be located on the floor of the nasal passage, and most can easily be removed in the office or emergency department.
    • Patients often present with foul-smelling unilateral nasal discharge.
    • Before removal, 0.5% phenylephrine should be used to reduce edema, and topical lidocaine should be used to provide analgesia.
    • Techniques include forceps, curved hooks, cerumen loops, or suction catheters.
    • In addition, a thin, lubricated, balloon-tip catheter (5- or 6-French Foley) can be passed past the foreign body, the balloon inflated, and removal completed by pulling the inflated catheter balloon forward.
    • Button batteries must be removed from the nose immediately because of the danger of liquefaction necrosis of the surrounding tissue.
    • Sedation is discouraged for removal because of the risk for increased complications from reducing the gag and cough reflex.
    • Patients may be able to expel the foreign body by blowing their nose while blocking the other nostril.
    • If this fails in a young child, positive pressure ventilation can be delivered through the child's mouth, with the rare potential complication of barotraumas to the ear.
    • Appropriate infection control should be exercised as the foreign body will be expelled through the cheek.
  • Foreign bodies in the throat:
    • All pharyngeal foreign bodies are medical emergencies that require airway protection.
    • Common obstructing objects in children include balloons, soft plastic, and food particles or boluses.
    • Patients with nonobstructing or partially obstructing foreign bodies present with choking, dysphagia, odynophagia, or dysphonia, whereas those with complete airway obstruction present with immediate respiratory distress, and emergency intervention is essential.
    • Other presentations include undiagnosed coughing, stridor, or hoarseness.
    • Clinicians must have a high index of suspicion in patients with unexplained upper airway symptoms, especially in children with a history of choking.
    • Early consultation with an otolaryngologist is advisable because foreign bodies are difficult to visualize without endoscopy.
    • Sedation is required for endoscopic removal.

Pearls for Practice

  • Foreign bodies in the ear, nose, or throat are most likely to present in children. Foreign bodies in the ear tend to be asymptomatic, nasal foreign bodies present with unilateral foul-smelling discharge, and pharyngeal foreign bodies show symptoms and signs of complete or partial obstruction.
  • Obstructing pharyngeal foreign bodies are a medical emergency, whereas attempts at removal of foreign bodies from the ear and nose depend on location, type of object, whether the object is graspable, clinician dexterity, and patient cooperation.


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