Foreign Bodies
Children are notoriously curious and enjoy experiments. Foreign bodies in the ear and upper aerodigestive tract are very common, particularly in young (preschool) children who, as their manual dexterity develops, are inclined to insert objects into the ear, nose, and mouth.
4.2.1 Foreign Bodies in the Ear
Foreign bodies in the ear are often fairly innocuous ( ▶ Fig. 4.1). The parent or carer may report their suspicions, or the child may have been seen inserting an object in the ear. Hearing loss and pain are reported in some cases. Many children are completely asymptomatic and the foreign body is an incidental finding by the carer or doctor.
Fig. 4.1 Foreign body in the ear.
The physical characteristics, size, and duration of the foreign body are very important. Inert objects such as beads, fragments of toys, crayons, and sponge are commonly found and may lead to impaction of wax and to otitis externa if not removed. Organic objects such as nuts, food particles, and occasionally insects tend to be more prone to infection.
Batteries are not uncommon, may be very destructive, and should be promptly removed. “Button” batteries may look innocuous but modern technology has produced very powerful small electrochemical cells, and even if they do not leak, they can cause an electrochemical reaction when in contact with tissue. If left, they can give rise to desquamation of the skin and soft tissue, osteitis of the bones of the ear canal, and perforation of the drum.
Removal of foreign bodies from the nose and ear should only be attempted if the clinician has the appropriate equipment and experience. An inert foreign body, such as a bead or piece of plastic, may be removed by gentle syringing. Otherwise, microsuction and instrumentation may be needed. Multiple failed attempts may result in further trauma and distress to the child making any further attempts impossible without general anesthesia.
Tips and Tricks
Check both ears; mischievous children may not always volunteer the whole truth.
4.2.2 Foreign Bodies in the Nose
Objects in the nose may present several days or weeks after they have been inserted with an offensive unilateral discharge and/or epistaxis. There may be crusting at the vestibule, and in prolonged cases, the skin of the vestibule and above the upper lip can become excoriated and inflamed. Sometimes the child may report self-insertion of such a foreign body but more often they present with symptoms.
Planning the timing for removal of nasal foreign bodies depends on the nature of the foreign body and the symptoms. As with ear foreign bodies, batteries can be notoriously destructive, even over a period of a few hours, and need to be removed as soon as possible. If they can be removed in the outpatient setting or the emergency department, this would be ideal, and if the child needs a general anesthetic, it should be arranged as soon as the child is starved and ready. The potential risk of inhalation of nasal foreign bodies is well recognized, but there is little evidence that this is a significant risk. 2 In a neurologically normal child, a nasal foreign body that slips back into the pharynx will almost certainly be swallowed rather than inhaled. If the child is neurologically compromised, for example, with a poor swallow and an absent gag reflex, it may be best to admit the child and arrange very early removal to avoid the risk of aspiration. It is recommended that a nasal foreign body should be removed at the earliest reasonable opportunity, 3 ideally on the next available operating list.
Tips and Tricks
Removal of ear and nose foreign bodies:
Nonorganic foreign bodies in the ear that are not completely occluding the ear canal may sometimes be removed by syringing with warm water.
Spherical bead-like objects can often be removed with suction.
Always use good lighting and appropriate instruments.
Grasping instruments, for example, “crocodile” forceps, are best for irregularly shaped objects, but for smooth or impacted material such as beads, use a hook-like instrument to gently dislodge the object from behind rather than letting it slip in further.
Live insects should be immobilized prior to removal. This is best achieved by filling the ear canal with fluid containing an anesthetic such as lidocaine.
Button batteries in the ear and the nose can cause rapid and severe tissue destruction. Arrange for urgent removal.
Presentation and Early Management
Foreign bodies inhaled or ingested are a true medical emergency. A foreign body in the airway can cause rapid progressive airway obstruction, and a foreign body in the esophagus can compress the trachea and cause severe asphyxia. These children need prompt referral to the ENT department.
A clinical history of sudden coughing, choking, shortness of breath, and wheeze should alert the clinician to the possibility of inhalation, even if nobody has seen the child ingest or inhale an object. Similarly, drooling and a painful swallow would suggest an ingested foreign body. The nature of the foreign body is very important and again the clinician should be especially wary of very sharp objects and of batteries ( ▶ Fig. 4.2, ▶ Fig. 4.3). 4
National Health Service (NHS) England Patient Safety Alert
In December 2014, NHS England issued the following Patient Safety Alert on the risk of death and serious harm from delays in recognizing and treating ingestion of button batteries 5:
“Ingestion of button batteries can cause serious harm and death. Severe tissue damage results from a build up of sodium hydroxide (caustic soda) as a result of the electrical current discharged from the battery, and not, as commonly supposed, from leakage from the battery. The sodium hydroxide causes tissue burns, often in the oesophagus, which can then cause fistulisation into major blood vessels, resulting in catastrophic haemorrhage. Even apparently discharged (‘flat’) batteries can still have this effect, and button batteries pushed into ears or nostrils can also cause serious injuries.
“Button battery ingestion affects all age groups, although most cases involve children under the age of six who mistake the battery for a sweet, or older people with confusion or poor vision who mistake the battery for a pill. Older children and adults may ingest batteries as a means of self harming.
“Review of incident reports from a recent four year period identified five cases where severe tissue damage occurred after apparent delays in suspecting, diagnosing or treating button battery ingestion in small children; one child died.
“Incident reports suggested that when ingestion was reported, healthcare staff did not recognise the need for this to be treated as a medical emergency. Additionally, symptoms of tissue damage such as haematemesis, haemoptysis and respiratory difficulties can manifest up to 28 days after ingestion of the battery. Incident reports suggested that where such symptoms occur, staff did not always consider the possibility of prior button battery ingestion.
“Removal of the battery alone may be insufficient action to prevent further damage, with further symptoms manifesting later; patients need expert input, and careful monitoring and follow-up. One further incident described the death of a child from late complications after they had been treated and sent home.
“A further 241 incidents also described a range of battery types swallowed as self-harm by inpatients; whilst only one incident described severe tissue damage from delay in treatment, the incident reports suggested some nursing and medical staff believed battery ingestion would be harmless unless the battery was damaged or leaking, and therefore urgent advice was not always sought.
“Whilst the focus of this Alert is on prompt recognition and treatment of ingestion, healthcare providers caring for children, vulnerable adults or people who may self-harm should also consider if action to protect patients from button battery ingestion needs to be taken; the review of incidents above identified six occasions when older patients accidentally swallowed button batteries from hearing aids.”
Reproduced with permission. Contains public sector information licensed under the Open Government License v3.0.
Fig. 4.2 Foreign body in the left nostril.
Fig. 4.3 Button batteries. (Courtesy of Gerhard H Wrodnigg.)
The size of the object and the site of the impaction and the timing of inhalation are important. A foreign body in the larynx or trachea may be quickly fatal. Immediately after ingestion/impaction or inhalation of a foreign body, the child is usually in considerable distress and needs prompt intervention. In children with potentially fatal impaction, first-aid measures at the scene can be lifesaving. These includes the Heimlich maneuver, positioning maneuvers and the removal of a foreign body obstructing the laryngeal inlet using a laryngoscope and Magill forceps if the attending physician is suitably trained and skilled. Suctioning may be needed as the child will often vomit.
In the case of a foreign body impacted in a bronchus, the child may have some degree of oxygen desaturation but will usually breathe well using the unaffected lung. Airway endoscopy need not be immediate and it is best to arrange safe transfer under supervision to a center where the child can have a laryngotracheobronchoscopy and removal of the foreign body under controlled conditions, with the support of a skilled pediatric anesthetist and ideally with access to a pediatric intensive care unit (PICU).
In some children, the inhalation may have occurred days or weeks previously and they may present with new features of unexplained cough or wheeze or even an unusual pneumonia. Retained foreign bodies, especially organic matter such as peanuts and food particles, can be an extreme irritant, and if treatment is delayed, the child may get bronchiectasis and chronic lung infection. In the case of a foreign body that is radiolucent (e.g., a peanut or a food particle), the only radiological evidence may be hyperinflation of the lung on the side where the object has lodged in the bronchus causing partial obstruction, that is, air enters the lung but is “trapped” beyond the foreign body (“obstructive emphysema”; ▶ Fig. 4.4. ).
“All that Wheezes is not Asthma”: Chevalier Jackson
Think of an inhaled foreign body in the wheezy child.
Be suspicious of a foreign body in a child with chronic laryngeal symptoms.
Beware sudden onset of new persistent respiratory symptoms.
Consider a chest (inspiration and expiration) and a lateral neck X-ray if it is safe to do so.
Negative findings on X-ray do not exclude an inhaled or ingested foreign body.
If in doubt, refer for diagnostic endoscopy.
Pharyngeal and upper esophageal foreign bodies need to be removed by pharyngoesophagoscopy. Be ready to undertake laryngotracheobronchoscopy as well if there is any suspicion of inhalation ( ▶ Fig. 4.5, ▶ Fig. 4.6).
Fig. 4.4 Chest X-ray showing hyperinflation of the right lung. Foreign body in the right main-stem bronchus.
Fig. 4.5 Chest X-ray showing a “Coco Chanel” earring in the upper esophagus of a young girl.
Fig. 4.6 Chest X-ray showing a nail in the upper esophagus of an infant boy. Urgent removal is necessary.
4.3 Epistaxis
4.3.1 Presentation
The nasal cavity has a very rich blood supply from both the internal and external carotid arteries. Epistaxis is a very common problem in childhood and is mostly mild and self-limiting. In a small number of cases, it may be severe and potentially life threatening.
The commonest cause of epistaxis in children is local trauma as a result of nose picking. Crusting within the nostrils is often identified in these children. Other causes must be considered especially if epistaxis is recurrent, severe, or fails to settle conservatively. Epistaxis may occasionally be the first sign of underlying hematological abnormalities and coagulopathies, as well as rarer pathology such as juvenile angiofibromas in young boys.
The site of the bleeding in children is typically a prominent retrocolumellar vein or the arterial plexus at Little’s area (Kiesselbach’s plexus) on the mucosa of the septum. Bleeds are typically slow and persistent, and stop quite quickly with pressure. The less common but more troublesome posterior epistaxis originates from the sphenopalatine artery and is a more profuse, prolonged, and severe bleed.
