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  2. CLINICAL SCENERIALS • Case 1: Following a meal a female patient aged 31 complained of severe pain in the right ear together with localized pain in the right side of the neck during swallowing. This pain was relieved by analgesics and local mouth gurgles containing a local anesthetic, but the pain reappeared after the effect of the drugs was over. Diagnosis & reasons, Explain Severe pain in the right ear, pain relieved by local anesthetics, investigations and treatment.
  3. CLININICAL SCENARIALS CONTINUA….. • Case 2: A 4 year old child was referred to an ENT specialist by a pediatrician because of repeated attacks of severe chest infection (three in number) during the last month that usually resolved by antibiotics, expectorants and mucolytics, but the last attack did not resolve. On examination the lower right lobe of the lung showed no air entry and a lot of wheezes all over the chest by auscultation. A chest x-ray revealed an opacified lower right lobe. Temperature 38 C, pulse 120/min and respiration rate 35/min. Diagnosis and reasons, explain the following manifestations; Last attack of chest infection did not resolve, Wheezes all over the chest, Pulse 120/min, further investigations and txt.
  4. OVERVIEW Common problems: • Introduction of foreign body in esophagus, ear, nose and throat is specially seen in children. • There are many types of foreign body seen in the esophagus, ear, nose and throat. They can aspirate into larynx, trachea and bronchus. • General practitioners should be skilled enough to remove foreign body with their limited resources and they should know when to send the cases to an ENT specialist or to a hospital.
  5. FOREIGN BODY IN THE UPPER FOOD PASSAGES • Applied anatomy • Pharynx It’s the upper aerodigestive section between the choanae and the criccopharyngeal muscles. Divided into three parts: Nasopharynx; from the choanae to the lower edge of the soft palate Oropharynx; from the edge of the soft palate to the level of the tip of the epiglottis Hypopharynx; from the tip of the epiglottis to the entrance of the esophagus
  6. Continua……. • All the three areas above have a continuous carpet of mucous membrane of common epithelial cells---- important in spread of inflammation from one area to another. Each subdivision of the pharynx has a different sensory innervation: the nasopharynx is innervated by a pharyngeal branch of the maxillary nerve [V2] the oropharynx is innervated by the glossopharyngeal nerve [IX] via the pharyngeal plexus; the laryngopharynx is innervated by the vagus nerve [X] via the pharyngeal plexus.
  7. Continua……. • Veins of the pharynx form a plexus, which drains superiorly into the pterygoid plexus in the infratemporal fossa, and inferiorly into the facial and internal jugular veins.
  8. Continua…… • Foreign bodies in the upper food passages is a common emergency in ENT practice. Any object which is retained in the pharynx or oesophagus is a foreign body. Foreign Bodies in Pharynx Small fish or meat bones are the commonly encountered foreign bodies in the pharynx. These may get lodged in the tonsils, valecullae, base of tongue and the pyriform fossae.
  9. Continua….. • Diagnosis: Suggestive Hx. The patient complains of pain and discomfort in the throat. Symptoms usually come on straight away, not a few hours or days later; bones, usually fish, chicken or lamb; pricking sensation or pain on every swallow; dysphagia; drooling; stridor (rare); point tenderness in the neck or pain on gently rocking the larynx from side to side.
  10. Continua.....  Look carefully at the tongue base and tonsil. (esp if the patient localizes it to above the thyroid cartilage, esp to one side).  Perform lateral soft tissue X-rays of the neck and look for foreign bodies at the common sites (tongue base and posterior pharyngeal wall)  soft-tissue swelling alone is suggestive. Air in the upper oesophagus (on xray) is suggestive of an oesophageal foreign body.
  11. Continua….  Proper examination of the throat  Adetailed mirror examination usually reveals the site of lodgement of the foreign body.  Ulceration gives a further clue.  X-ray of the soft tissues of the neck may sometimes be required to detect an otherwise invisible foreign body. Once the foreign body has been located it is removed with an appropriate forceps.
  12. Continua…… • Management  Use a good light source (torch or head-mirror).  Use lidocaine spray to anaesthetize the throat.  Use your finger to see if you can feel a foreign body, even if you cannot see one.  Use Tilley’s forceps for foreign bodies in the mouth or tonsil.  Use McGill intubating forceps for foreign bodies in the tongue base or pharynx. Lie the patient flat, extend the neck and use an intubating laryngoscope to lift the tongue forward.
  13. Continua…. • Referral policy: Any airway compromise should be referred at once. Otherwise, patients should be seen within 6 hours if: failed attempt at removal; good hx, but no foreign body seen; X-ray evidence of a foreign body. In these circumstances, rigid endoscopy under general anaesthesia may be indicated. Should be performed by an experienced ENT surgeon. Remember to keep the patient nil by mouth in case a general anaesthetic is required.
  14. Continua….. Complications: • There is potential for inflammation/infection around an impacted foreign body, leading to abscess formation or perforation of the oesophagus. • Acute airway problem.
  15. FOREIGN BODY IN THE ESOPHAGUS • Applied anatomy It is a fibromuscular tube, about 25 cm long in an adult. It extends from the lower end of pharynx (C6) to the cardiac end of stomach (T11). It runs vertically but inclines to the left from its origin to thoracic inlet and again from T7 to oesophageal opening in the diaphragm.
  16. Continua….. • It shows three normal constrictions and it is important to know their location at oesophagoscopy. They are: 1. At pharyngo-oesophageal j unc tion (C6 )-15 cm from the upper incisors. 2. At crossing of arch of aorta and left main bronchus (T 4)-25 cm from the upper incisors. 3. Where it pierces the diaphragm (T 10)-40 cm from upper incisors. Foreign bodies in the oesophagus can be held up at these constric tions. KEEP 15, 25, 40 CM IN MIND AS ANATOMICAL LANDMARKS IN ESOPHAGOSCOPY
  17. Applied physiology • Manometric studies have shown two high pressure zones in oesophagus and they form the physiological sphincters. The upper oesophageal sphincter starts at the upper border of oesophagus and is about 3-5cm in length and functions during the act of swallowing. The lower oesophageal sphincter is situated at the lower portion of oesophagus. It is also 3-5 cm in length and functions to prevent oesophageal reflux.
  18. Continual……. • Middle portion of oesophagus shows active peristalsis. The waves are weaker in the upper part, becoming gradually stronger towards the lower portion.
  19. Physiology of swallowing • The act of swallowing is divided into three phases: (a) Oral or buccal (b) Pharyngeal (c) Oesophageal (a) Oral or buccal phase: The food which is placed in the mouth is chewed, lubricated with saliva, converted into a bolus and then propelled into the pharynx by elevation of the tongue against the palate.
  20. Continua…… b) Pharyngeal phase: It is initiated when the bolus of food comes into contact with pharyngeal mucosa. A series of reflex actions take place carrying the food past oro- and laryngopharynx into the oesophagus. The communications into nasopharynx, oral cavity and larynx are cut off. (i) Closure of nasopharynx: Soft palate contracts against the Passavant's ridge on the posterior pharyngeal wall and completely cuts off the nasopharynx from oropharynx.
  21. Continua……. (ii) Closure of oropharyngeal isthmus: The entry of food back into oral cavity is prevented by contraction of tongue against the palate and sphincteric action of palatoglossal muscles. (iii) Closure of larynx: Aspiration into the larynx is prevented by temporary cessation of respiration, closure of laryngeal inlet by contraction of aryepiglottic folds, closure of false and true cords, and rising of larynx under the base of tongue. The role of epiglottis in providing protection to larynx is not clear but it is seen to deflect backwards when food passes into the pyriform fossae.
  22. Continua…... (iv) Contraction of pharyngeal muscles and relaxation of cricopharyngeus: Relaxation of cricopharyngeus muscles is so timed and synchronous that food passes from pharynx into the oesophagus during contraction of pharyngea l muscles.
  23. Continua…. (c) Oesophageal phase: After food enters the oesophagus, the cricopharyngeal sphincter closes and the peristaltic movements of oesophagus takes the bolus down the stomach. Gastro-oesophageal sphincter at the lower end of oesophagus relaxes well before peristaltic wave reaches and permits fluids to pass. Bolus of food is passed by contraction of peristaltic waves and then the sphincter closes.
  24. Continua….. • Regurgitation of food back into oesophagus is prevented by (i) tone of gastro-oesophageal sphincter, (iil negative intrathoracic pressure, (iii) pinch-cock effect of diaphragm, (iv) mucosal folds, (v) oesophagogastric angle, and (vi) slight positive intra-abdominal pressure.
  25. Continua….. • The impaction of foreign bodies in the oesophagus is a common occurrence, the complications of which can be extremely serious and even life-threatening. • The most common objects to be swallowed are coins in children, and fish and meat bones in adults followed by metal hooks, artificial dentures and meat lumps.
  26. Continua….. Aetiology : • Children are usually in the habit of swallowing anything they can get hold of. • Also, foreign body lodgement is common in the elderly because of improper mastication and week propulsive movements of the gullet. • Loose fitting artificial dentures may be swallowed during mastication or sleep. • Certain oesophageal conditions like benign strictures or malignancy and sites of anatomical narrowing of the oesophagus may arrest a foreign body.
  27. Continua….. Diagnosis:  If an adult, usually gives a history of having swallowed a foreign body. If the foreign body is arrested in the upper part of the oesophagus, the patient maybe able to localise the pain and site of the lodgement of the foreign body. If the foreign body is lower down, localisation is vague. (possibility of referred pain to the ear)  Dysphagia is another important symptom of foreign body in the oesophagus and should raise the suspicion, particularly in children.
  28. Continua…… • Good history is very helpful. In particular, one needs to establish whether or not there is, or could be, a bone or other sharp foreign body, since this will necessitate early intervention rather than a conservative course.
  29. Continua….. Clinical features:  Immediate onset of symptoms; early presentation – within hours; retrosternal or back pain;  Sense of a blockage in the throat;  Drooling or regurgitation of food;  Dyspnoea with or without hoarseness if the object is lodged close to the larynx;  Point tenderness in the neck;  Discomfort on rocking the larynx from side to side.
  30. Continua…. • PE: detailed examination of the pharyngeal wall, tonsils, valecullae and pyriform fossae should be carried out. X-ray • Plain films of the neck and chest, Ideally both the anterioposterior and lateral views are taken. • Foreign bodies in the oesophagus, particularly flat objects like coins lie in the coronal plane in contrast to laryngeal or tracheal foreign bodies which lie in the sagittal plane.
  31. Continua….. • Remember that some fish bones are radiolucent and therefore do not show up on plain X-ray. • Another suggestive feature is the presence of air in the upper oesophagus or soft-tissue swelling of the posterior pharyngeal wall. Do not confuse the hyoid or thyroid cartilage with a foreign body (calcified tissues). • Remember that on X-ray flecks of calcification are often seen around the larynx. • Oesophageal perforation: air leak into the tissues of the neck. This, too, can be seen on an X-ray of the neck, usually in front of the spine.
  32. Continua… • If the foreign body is not visualised, screening of the chest and abdomen is done to note whether it has passed down. In case of nonopaque foreign bodies, a little barium sulphate is given and its passage down the oesophagus is observed. Barium may be held up or the flow of barium may be split at the site of the foreign body.
  33. Continua…. Treatment: • Endoscopic removal under GA is often required; it is mandatory if there is any suggestion that the object is sharp, as then there is a high risk of oesophageal perforation. • In the case of a soft bolus obstruction, a short period of observation and treatment with intravenous antispasmodic agents may be indicated. • Foreign bodies lodged in the lower 1/3 of the oesophagus are best referred for urgent flexible oesophagogastroscopy.
  34. Continua…. Note: i. Though foreign body removal is an emergency, you must have a knowledge of the location and disposition of the foreign body so that you select the proper endoscopic instruments and orients yourself to the situation. ii. Oesophagoscopy for removal of the foreign body can be done under local and general anaesthesia. iii. If the size of the foreign body is bigger than the diameter of the oesophagoscope, then after having caught the foreign body, all 3 articles, the foreign body, forceps and oesophagoscope are removed as a single unit.
  35. Continua…. iv. With all long foreign bodies, the aim is to search the proximal end. v. In case of pins and needles, their point must be searched for. vi. Avoid doing harm, the mortality which may follow the failure to remove a foreign body does not justify the violent method of its removal. vii. Dentures in the oesophagus present many problems. They often have sharp edges and associated metallic hooks which cause their impaction. Hence, such cases should be properly studied before attempting haphazard removal. They may require division by a sheer before they can be removed.
  36. Continua…. Indications of removal by external route: • An impacted foreign body and perioesophageal abscess associated with a foreign body. • In the cervical oesophagus, foreign bodies can be removed by left lateral oesophagotomy while lower down, thoracotomy is needed to expose the oesophagus and remove the foreign body.
  37. Continua….. Potential complications are life-threatening and include: • Para-oesophageal Abscess • Mediastinitis • Empyema • Airway Obstruction • Tracheo-oesophageal Fistula • Late Stricture Formation • Perforation (chyle thorax)
  38. Continua…. • Perioesophagitis • Impaction of foreign body • Oesophagitis • Perioesophagitis
  39. Foreign body in the ear • Children older than 9 months -pincer grasp. • In adults, insects (eg, cockroaches, moths, flies, household ants) are most commonly found. • In children, the range of foreign bodies is extensive. • Food particles (eg, candy, vegetable matter, beans, chewing gum) • Organic material (eg, leaves, flowers, cotton pieces). • Inorganic objects such as small toys, beads, pencil erasers, and rocks. • They put it out of curiousity.
  40. • The vast majority of items are lodged in the ear canal, which is the small channel that ends at the eardrum. • Although earwax (cerumen) is not technically a foreign body, it does frequently accumulate in the ear canal and can cause discomfort or decreased hearing just like other foreign bodies.
  41. Causes • The vast majority of objects found in ears are placed there voluntarily, usually by children, for an endless variety of reasons. • Insects are well known to crawl into the ear, usually when you are asleep. Sleeping on the floor or outdoors would increase the chance of this unpleasant experience
  42. Symptoms • Pain (most common) and feeling of fullness eardrum are very sensitive • Young children – redness, swelling or discharge (blood, serous, pus) – otitis externa • Decrease hearing • Nausea and vomit because of irritation • Bleeding, traumatizes when trying to remove it • Buzzing in ear – live insect Depend on size, shape, location n substance involved
  43. !Beware! • Button batteries commonly found in many small devices and toys can decompose enough in the body to allow the chemicals to leak out and cause a burn. Urgent removal is advised. • Urgent removal is also recommended for food or plant material (such as beans) because these will swell when moistened. • Urgent removal is indicated if the object is causing significant pain or discomfort.
  44. Continua….. • Most cases of foreign bodies in the ear are not serious and can usually wait until the morning or the following day for removal.
  45. Approach • History: it is important to ascertain the time and circumstances in which the foreign body enter the ear and learn of any attempts to remove it • P/E: main diagnostic tool. Using the headlight or otoscope. Removal requires knowledge of certain skills and techniques depending on its location whether in the external auditory canal, the middle ear or the inner ear.
  46. Treatment • Small object try to gently shake it out by pulling the pinna. • Foreign body can be removed using several techniques. • Mechanical extraction: Modified tweezers or forceps with the help of an otoscope • Suction: Gentle suction can be used to suck out the object. • Irrigation: Irrigation of the canal with warm water and a small catheter can flush certain materials out of the canal and clean out debris.
  47. Continua……… • Insects in the ear canal are often killed with either lidocaine (an anesthetic) or mineral oil. Then with gentle warm water irrigation. • After the foreign body is removed, put the patient on antibiotic drops for five days to a week to prevent infection from trauma to the ear canal.
  48. Contraindication of techniques :- • Irrigation is contraindicated for organic matter that may swell through osmosis and enlarge within the auditory canal and in known case of tympanic membrane perforation. • Insects, organic matter, and objects with the potential to become friable and break into smaller evasive pieces are often better extracted with suction than with forceps. • Live insects in the ear canal should be immobilized before removal is attempted. Mineral oil, microscope oil, and viscous lidocaine have all been used successfully for this purpose
  49. Complications • Otitis externa is a common complication for the presence of the foreign body in the ear. • Perforated tympanic membrane • Complications of ear foreign body removal include canal abrasions, bleeding, infection
  50. Prevention • Curiosity and exploration of one's body is a natural stage of development. Teaching that it is not good to put anything into the ear may prevent some of these. • If you suspect a child has put something in his or her ear, it is important to approach these situations in a nonjudgmental manner, so that the objects can be discovered and safely removed before complications develop.
  51. CAUTION • Don’t use Q-tip cotton bud to get wax out cause wax packed more deeply and hardens • Don’t risk ur ears of getting any foreign body
  52. Foreign body in the nose • It could be : • 1. inorganic , inert (plastic). • 2. organic (bean). • 3. battery. • 4. insect. • 5. toxic material (naphthalene).
  53. Presentation • 1. A fearful child ;irritable, crying. • 2. Unilateral foul smelling nasal discharge, sometimes blood-stained. • 3. Excoriation around the nostril. • 4. Ocassionally, X-ray evidence.
  54. A child with a foreign body in the right nostril
  55. DAnGERS. • 1) Injury from clumsy attempts at removal by unskilled persons • 2) Local spread of infection – sinusitis or meningitis • 3) Inhalation of foreign body – leading to lung collapse and infection.
  56. Continua….. If the child came with an inert inorganic foreign body stuck in his nose and we couldn’t remove it from the 1st trial: • Send him home and ask the parents to bring him back the next day to remove it under GA. • Give him decongestant. • Give him antibiotics.
  57. Continua….. Following should be removed immediately from child nose & can’t wait till the next day: • Bean • Battery: the alkaline material, inside it can burn the nose and cause severe adhesions. • Toxic materials (nephthaline)
  58. Continua…… • Rarely an adult complaining of nasal obstruction is found to have large concretion blocking one side of the nose. • Named Rhinolith- consist many layers of calcium and magnesium salt. • A latter often contains a foreign body.
  59. Endoscopic picture of rhinolith in the right nasal cavity
  60. Rhinolith after it was removed
  61. Coronal CT Image showing above rhinolith between the right inferior turbinate and the septum. In addition, the patient has bilateral sinusitis and a septal deviation.
  62. Foreign body in the Throat The most common foreign bodies are bones, meat bone or fish bone. Young children with their natural tendency to put everything possible into their mouths may swallow a large variety of objects The most common sites for the foreign body to be stucked in are :- 1- tonsils 2-anterior pillar 3-valiculae 4-pyriform fossa
  63. Causes • Swallowing without proper chewing, i.e. eating in a hurry . • talking while eating. • Those with dentures, especially full dentures are more likely to swallow bone, due to reduced sensitivity and inability to chew properly.
  64. Continua…… • Foreign bodies of the larynx fortunately are relatively uncommon. Those impacted in the larynx will require extraction under general anaesthesia. • Those that are impacted with airway obstruction requires emergency re-establishment of the airway by emergency extraction of the foreign body, intubation ortracheostomy .
  65. Symptoms • 1.Anterior jaw pain . • 2.Neck pain . • 3.Chest Pain . • 4.dysphagia . • 5.stridor :- - laryngeal (inspiratory stridor) - tracheal (biphasic stridor ) - bronchial (expiratory stridor)
  66. Continua….. • Important points to ask about in the history :- 1- onset, to know if sudden or not . 2- if the patient was able to continue eating or not , to know if it caused total obstruction or not. 3- chest pain or interscapular pain , to exclude mediastinitis (middle third of the esophagus), it is a common cause of death .
  67. causes Impaired swallow reflex • Impaired cough reflex • Mental retardation • Alcohol or sedative use • General anesthesia • Poor dentition • Dental, pharyngeal, or airway procedures • Loss of consciousness • Convulsions • Maxillofacial trauma
  68. Continua….. • Children between the ages of 7 months and 4 years are in the greatest danger of choking on small objects, including, but not limited to, the following: • seeds • toy parts • grapes • peanuts • pebbles • nuts • buttons
  69. Presentation • In general, aspiration of foreign bodies produces the following 3 phases: • Initial phase - Choking and gasping, coughing, or airway obstruction at the time of aspiration • Asymptomatic phase - Subsequent lodging of the object with relaxation of reflexes that often results in a reduction or cessation of symptoms, lasting hours to weeks • Complications phase - Foreign body producing erosion or obstruction leading to pneumonia, atelectasis, or abscess
  70. Clinical presentation depends on the location of the foreign body • Laryngeal foreign bodies present with airway obstruction and hoarseness or aphonia. • Tracheal foreign bodies present similarly to laryngeal foreign bodies but without hoarseness or aphonia. Tracheal foreign bodies can demonstrate wheezing similar to asthma • Bronchial foreign bodies typically present with cough, unilateral wheezing, and decreased breath sounds, but only 65% of patients present with this classic triad.
  71. DIAGNOSIS - History - PE - Imaging Studies - laryngoscopy and bronchoscopy .
  72. Imaging Studies • anteroposterior and lateral neck radiographs of the airway are the tests of choice in patients in whom laryngeal foreign bodies are suspected • Chest radiographs (inspiratory and expiratory films) demonstrate atelectasis on inspiration and hyperinflation on expiration with a foreign body obstructing the bronchus.
  73. inspiratory
  74. expiratory
  75. complications • Upper airway involvement may cause complete obstruction at the trachea or larynx, or it may only cause an abnormality of the voice . • Complete obstruction of a bronchus will cause atelectasis . • while partial obstruction may cause emphysema, pneumothorax, or pneumomediastinum. Vegetable matter may produce a chronic suppurative pneumonitis.
  76. atelactasis
  77. After removal
  78. Thank you (ARIGATO) And good luck

Editor's Notes

  1. Bronchial are mainly on the right bronchus
  2. Hx-sudden symptoms in a previously healthy child
  3. Signs of obstructive emphysema: 1-tracheal and mediastinal shift from distended hyperresonant lobe 2- if complete collapse then the shift will be towards the affected side