2. COMMON EMERGENCIES
FOREIGN BODY EAR, NOSE, THROAT
RESPIRATORY DISTRESS FOLLOWING TRACHEAL PATHOLOGY
EPISTAXIS
3. FOREIGN BODY EAR
Could be living or non living
Non-living:- commonly seen: a piece of paper or
sponge, grain
seeds, slate pencil, piece of chalk o metallic ball
bearings, broken end of match stick, cotton swab,
vegetable foreign bodies.
Living:- lying or crawling insects like
mosquitoes, beetles, cockroach or an ant
4. METHOD OF REMOVAL
(i) Forceps removal
(ii) Syringing
(iii) Suction
(iv) Microscopic removal with special instruments
(v) Postaural approach
5. Forceps removal and Suction removal
Soft and irregular foreign bodies like a piece of paper,
swab or a piece of sponge can be removed with fine crocodile
Forceps or suction.
7. Post aural approach
Postaural approach is used to remove
foreign bodies impacted in deep
meatus, medial to the isthmus or
those which have been pushed into
middle ear.
8. Microscopic removal with special
instruments:
In all impacted foreign bodies or in those where earlier attempts at
extraction have been made, it is preferabl to use general anaesthetic and
an operating microscope.
9. Living foreign body
Maggots:Flies may be attracted to
foul smelling ear discharge and lay
eggs which hatch out into larvae
called maggots.
Treatment- instilling chloroform
water to kill maggots, which can
later be removed by forceps.
10. Removal of living foreign body
Live insects:Flying or crawling insects like
mosquitoes,cockroach or an ant may enter
ear canal and cause intense irritation and
pain .
Fig- dead insect in EAC
11. Foreign body in Nose
Mostly seen in children .
may be organic or inorganic.
Pieces of paper, chalk, button, pebbles
and seeds are common objects.
Pledgets of cotton or swab may be
accidentally left in nose.
12. Method of removal
Pieces of paper or cotton swabs
can be easily remove with a pair
of forceps.
13. Rounded foreign bodies can be removed
by passing a blunt hook past the foreign
body and gently dragging it forward along
the floor.
Patient is placed in Rose’s position, a pack
is inserted into the nasopharynx and the
foreign body retrieved with a forceps or a
hook
14. Nasal myiasis:
Maggots are larval forms of flies. They are seen to infest
nose, nasopharynx and paranasal sinuses causing extensive
destruction
15. Removal of maggots:
Maggots should be picked up with forceps.
Instillation of chloroform water and oil kills
them.
Nasal douche with warm saline is used to
remove slough, crusts and dead maggots.
16. Foreign body of air passage
In children, peanut is most common
vegetable foreign body; others include
almond seed, peas, beans, gram or wheat
seed, watermelon seed, pieces of carrot or
apple.
Non-vegetable matters include plastic
whistle, plastic toys, safety pins, nails, all-
pin, wires or ball bearings.
17. In adults, foreign bodies are aspirated
during coma,
deep sleep or alcoholic intoxication. Loose
teeth or denture
may be aspirated during anaesthesia
(A) PA view neck and chest
with denture at the level of
thoracic inlet.
(B) Lateral view—neck of the
same patient showing metallic hooks
at thoracic inlet
18. Nature of foreign bodies:
1. Nonirritating type. Plastic, glass or metallic foreign
bodies are relatively nonirritating and may remain
symptomless for a long time.
2. Irritating type. Vegetable or foreign bodies like peanuts,
beans, seeds, etc. set up a diffuse violent reaction
leading to congestion and oedema of the tracheobronchial
mucosa— called “vegetal bronchitis.”
19. Method of removal:
Laryngeal foreign body:A large bolus of food obstructed above the cords may
make the patient totally aphonic,unable to cry for help.
The measures consist of pounding on the back, turning the patient upside
down and following Heimlich manoeuvre.
20. Heimlich manoeuvre. Stand behind the
person and place your arms around his
lower chest and give four abdominal
thrusts.
The residual air in the lungs may
dislodge the
foreign body providing some airway
21. Cricothyrotomy or emergency tracheostomy
should be done if Heimlich manoeuvre fails.
22. Tracheal or Bronchial foreign body
can be removed by bronchoscopy
and under general anaesthesia.
Emergency removal of these
foreign bodies is not indicated
unless there is airway obstruction
or they are of the vegetable nature.
23. Methods to remove tracheobronchial
foreign body
1. Conventional rigid bronchoscopy.
2. Rigid bronchoscopy with telescopic aid.
3. Bronchoscopy with C-arm fluoroscopy.
24. 4. Use of Dormia basket or Fogarty’s
balloon for rounded
objects.
5. Tracheostomy first and then
bronchoscopy through
the tracheostome.
6. Thoracotomy and bronchotomy
for peripheral foreign
bodies.
7. Flexible fibreoptic bronchoscopy
25. Foreign body of food pasaage:
An ingested foreign body may lodge in:
1)Tonsil
2)Base of tongue
3)Vallecula
4)Pyriform fossa
5)Oesophagus
26. Tonsil:Sharp fish bone or needle may lodge in
tonsillar crypts
Base oF tongue or Vallecula:it is usually fish
bone or needle.
It can be removed by curved forceps and
endoscope.
27. Posterior pharyngeal wall: a wire,needle
or staple can reach PPW when ingested
accidently with food.It can be removed with
forceps.
Pyriform fossa:fish bone,chicken or a
bone,needle or a denture can lodge in
pyrifrom fossa.It can be removed under local
anesthesia with curved forceps.
28. Oesophagus:Usual foreign bodies
that get lodged in
the oesophagus are a coin, piece of meat,
chicken bone,
denture, safety pin or a marble,
Disc batteries, nails, screws, plastic objects
29. Removal of foreign body in
Oesophagus
Endoscopic removal:Most of the foreign bodies in
oesophagus can be removed by oesophagoscopy under
general anaesthesia.
Both rigid and flexible scopes can be used/
Cervical oesophagotomy:Impacted foreign bodies located above thoracic
inlet may require incision in the neck and opening of cervical esophagus.
31. Disc batteries
They contain sodium hydroxide,
potassium hydroxide and mercury which
leaks through them to cause oesophageal injury.
It is observed that a disc battery causes damage to mucosa in 1 h, muscle
coat in 2–4 h and perforation of the oesophagus in 8–12 h, therefore it
should be removed promptly.
32. If lodged in stomach, a radiographic follow up is conducted every 4–7
days, parents instructed to observe stools daily for spontaneous passage.
If patient is a child under 6 years and battery sizes 1.5 cm or more, follow-
up X-ray examination is done and after 48 h of ingestion and if the battery
is still in stomach it is removed endoscopicaly.
33. Epistaxis
Causes:They may be divided into:
1. Local, in the nose or nasopharynx.
2. General.
3. Idiopathic.
34. Local causes:
Trauma. Finger nail trauma, injuries of nose, intranasal
surgery, fractures of middle third of face and base of
skull, hard-blowing of nose, violent sneeze.
2. Infections
(a) Acute: Viral rhinitis, nasal diphtheria, acute sinusitis.
(b) Chronic: All crust-forming diseases, e.g. atrophic
rhinitis, rhinitis sicca, tuberculosis, syphilis septal
perforation, granulomatous lesion of the nose.
35. 3. Foreign bodies
(a) Nonliving: Any neglected foreign body, rhinolith.
(b) Living: Maggots, leeches.
4. Neoplasms of nose and paranasal sinuses.
(a) Benign: Haemangioma, papilloma.
(b) Malignant: Carcinoma or sarcoma.
5. Atmospheric changes. High altitudes, sudden decompression
(Caisson disease).
36. General causes:
1. Cardiovascular system. Hypertension, arteriosclerosis,
mitral stenosis, pregnancy (hypertension and hormonal).
2. Disorders of blood and blood vessels. Aplastic
anaemia, leukaemia, thrombocytopenic and vascular
purpura, haemophilia, Christmas disease, scurvy, vitamin
K deficiency and hereditary haemorrhagic telangectasia.
3. Liver disease. Hepatic cirrhosis (deficiency of factor II,
VII, IX and X).
4. Kidney disease. Chronic nephritis.
37. 5. Drugs. Excessive use of salicylates , other analgesics, anticoagulant.
6. Mediastinal compression. Tumours of mediastinum
7. Acute general infection. Influenza, measles, whooping cough, rheumatic
fever, infectious mononucleosis, typhoid, pneumonia, malaria
8. Vicarious menstruation (epistaxis occurring at the
38. Classification:
Anterior Epistaxis:When blood flows out from the front of nose with the
patient in sitting position.
Posterior Epistaxis Mainly the blood flows back into the throat. Patient
may swallow it and later have a “coffee-coloured” vomitus.
This may erroneously be diagnosed as haematemesis.
39. Management:
Trotter’s method patient is
made to sit, leaning a little
forward pinching the nose
withthumb and index finger
for about 5 min.,
40. Cauterization:This is useful in anterior epistaxis when bleeding point
has been located.
The area is first topically anaesthetized
and the bleeding point cauterized with a bead of silver
nitrate or coagulated with electrocautery
41. Anterior nasal packing:If bleeding
is profuse and/or the site of bleeding is difficult to localize,anterior packing
should be done.
use a ribbon gauze soaked with liquid paraffin. About 1 m gauze is
required
..
42. First, few centimetres of gauze are
folded upon itself and inserted along the floor and then
the whole nasal cavity is packed tightly by layering the
gauze from floor to the roof and from before backwards.
Packing can be done in Vertical layers or Horizontal layers as shown in fig.
43. Posterior nasal packing:
It is required for patients
bleeding posteriorly
into the throat.
A postnasal pack is first
prepared by tying three
silk ties to a piece of gauze
rolled into the shape of a cone
.
A rubber catheter is passed
through the nose and its end
brought out from the mouth .
44. Ends of the silk threads are tied to it and catheter withdrawn from
nose. Pack, which follows the silk thread,
is now guided into the nasopharynx
with the index finger.
Anterior nasa lcavity is now packed and
silk threads tied over a dental
roll.
The third silk thread is cut short and allowed to hang
in the oropharynx.
45. Endoscopic cauterization: bleeding point is localized
with a rigid endoscope. It is then cauterized with
a malleable unipolar suction cautery or a bipolar cautery.
Elevation of mucoperichondrial flap and submucous resection (smr)
Operation: In case of persistent or recurrent bleeds from the septum,
just elevation of mucoperichondrial flap and then repositioning
it back helps to cause fibrosis and constrict blood
vessels.
46. Transnasal Endoscopic Sphenopalatine Artery Ligation (TESPAL):
done with rigid endoscopes under topical anaesthesia with sedation or under
a general anaesthesia.
A mucosal flap is lifted in posterior part of lateral
nasal wall, sphenopalatine artery (SPA)is localized as
it exits the foramen and closed with a vascular clip.
47. Embolization: Internal maxillary
artery is localized and the
embolization is performed with
absorbable gelfoam and/or polyvinyl
alcohol or coils.
Both ipsilateral or bilateral
embolizations may be required for
unilateral epistaxis because of cross
circulation.
48. Tracheostomy
Tracheostomy is making an opening in
the anterior wall of trachea and
converting it into a stoma on the skin
surface.
