31 Foreign Bodies in ENT
This chapter covers the problems encountered with a foreign body in the ear, nose and throat (ENT). A button battery foreign body in the ear or upper aerodigestive tract can cause life-threatening and life-changing injury and is an absolute surgical emergency. Sharp or bony throat foreign bodies and irritative bronchial foreign bodies should be removed as an emergency. Patients with a suspected pharyngeal foreign body but normal flexible endoscopy, increasing odynophagia and pain on gentle side-to-side manipulation of the larynx are indications for an examination under anaesthetic.
Placing a foreign body in one’s ear or nose is not the usual practice of a sensible, mentally stable adult, and therefore one tends to see such foreign bodies in children, adults with learning difficulties, or those with mental health problems.
Normally, if the correct environment is created for such patients, they will allow a single attempt at removing the foreign body. An unsuccessful attempt that hurts the patient usually leads to a refusal to allow a second attempt and indeed they may not even allow a second doctor to examine the ear or nose. A correct environment is an uncluttered but child-friendly, warm, quiet treatment room, where the doctor and nurse can be calmly and confidently reassuring.
Nasal and ear foreign bodies are most commonly found in curious young children from the age of about 2 years onwards. Younger children may not have sufficient dexterity to insert an object into their nose or ear and the corollary of this is that such children may need to be discussed with the safeguarding team.
Button batteries as a foreign body in the ear, nose, throat or oesophagus should be highlighted because of the destruction of tissue in contact with the battery that might occur with devastating life-changing and sometimes life-threatening complications. The problem has been known for 30 years but was only recently highlighted with an NHS England safety alert of risk of death or serious harm. A button battery in contact with tissue on both sides of the battery, and even a spent battery, creates an electric current between the terminals. This causes sodium hydroxide to build up in the tissues (it does not occur from leakage from the battery) causing a caustic burn to the tissues in contact with the battery. Therefore, septal perforation, external ear canal skin destruction, tympanic membrane destruction, pharyngeal perforation and oesophageal perforation are all possible with such a foreign body. Tissue destruction has been described within minutes of tissue contact. Its possibility as a foreign body in a patient means it should be regarded as an absolute surgical emergency, and immediate removal of the battery without waiting for a patient to be starved should occur.
31.2 Foreign Bodies in the Nose
The foreign body may be inorganic or organic. Inorganic foreign bodies include buttons, beads, metal, plastic from toys, stones, etc. They are often asymptomatic and may be discovered only accidentally during an examination for an unrelated complaint. Organic foreign bodies include sponge, rubber, paper, wood, peas and nuts. These are irritant and nasal mucosa usually becomes inflamed causing discharge and obstruction. A unilateral nasal discharge in a child should be regarded as being due to a foreign body until proved otherwise. The discharge is initially mucoid, then mucopurulent, and this in turn becomes pungent and sometimes sanguineous. Sinusitis may be a complication. Calcium and magnesium carbonates and phosphates may be deposited around a foreign body to form a rhinolith. Rhinoliths become impacted and usually require removal under a general anaesthetic.
Confirmation of the presence of the foreign body is from the history and examination of the child. The child sits on either a parent’s or nurse’s knee. The anterior nares are exposed by gentle elevation of the nasal tip with a thumb (the rest of the fingers fanned and resting on the top of the head) and examined with a headlight. Alternatively, an auroscope with a 4.5-mm speculum may give a better view. Many children are cooperative provided they feel safe and reassured and it is possible, in many children, to remove a foreign body without the need for general anaesthesia (GA). Good illumination is essential, and all the instruments required should be to hand. The first effort will be the best and often the only attempt the child will allow. If it fails or if the foreign body is situated posteriorly in the nasal cavity, then a general anaesthetic will be required. It is important therefore that the attempt is made, or is supervised by as senior an ENT surgeon as possible. In very young children, it is reasonable for a parent or nurse (with parental consent) to sit the child on his or her lap with one hand firmly holding the head and the other arm tightly holding the trunk and the child’s arms. The child’s legs are secured between the adult’s legs.
Removal is best accomplished with a wax hook or an old eustachian tube catheter. It is passed point downwards above the foreign body, which is brought to the floor of the nose and raked anteriorly. Cupped forceps or crocodile forceps are preferable for the removal of thin objects, such as buttons or soft organic objects, such as sponge.
In every case, the nasal cavity must be examined afterwards as there may be a second foreign body more posteriorly. The child should be discharged with a supply of Naseptin cream if there is mucosal inflammation or infection.