Ear,nose,throat fb

1. oreign Body in Ear ,Nose & Throat
Done by : Elias Zurigat
eliaszaitoun@gmail.com

2. NASAL FOREIGN BODIES
Foreign bodies can be classified either as :
1) Inorganic materials are typically plastic or metal. Common examples include
beads and small parts from toys. These materials are often asymptomatic and may
be discovered incidentally.
2) Organic foreign bodies, including food, rubber, wood, and sponge, tend to be
more irritating to the nasal mucosa and thus may produce earlier symptoms. Peas,
beans, and nuts are among the more common organic NFBs
Iatrogenic nasal foreign bodies include nasal packs, splints, cotton, needles, and
pieces of instruments. Fragments of bone and cartilage may be left in the nasal
cavity postoperatively
Trauma may cause nasal foreign bodies such as bone, cartilage fragments, or
teeth. An exogenous foreign body may lodge in the nasal cavity
Rhinoliths are an unusual nasal foreign body. They are formed by encrustation of a
nasal foreign body with calcium and magnesium salts. The foreign body usually
exogenous, although a nuclei of endogenous origin has been hypothesized.

3. Patient History ….
In most cases, the insertion of the nasal foreign body (NFB) is witnessed, and
the dilemma of diagnosis is eliminated .
Among the delayed presentations, the most common clinical scenario is
unilateral nasal discharge , so “unilateral rhinorrhea is a foreign body until
proven otherwise.”
And vice that clinicians must entertain the diagnosis of NFB in all patients with
nasal irritation, epistaxis, sneezing, snoring, sinusitis, stridor, wheezing, or fever.
Some authors have even reported discovering NFBs as the etiology of more
unusual patient presentations, such as irritability, halitosis (unpleasant breath
odor), or generalized bromhidrosis (body malodor). To avoid complications and
delayed treatment, clinicians must maintain a high index of suspicion for this
diagnosis.
Both types of foreign bodies may present with signs and symptoms of unilateral
nasal obstruction and unilateral rhinorrhea or sinusitis.
Unilateral foreign bodies affect the right side about twice as often as the left

4. The most common locations
for NFBs to lodge are just
anterior to the middle
turbinate or below the inferior
turbinate . Unilateral foreign
bodies affect the right side
about twice as often as the
left. This may be due to a
preference of right-handed
individuals to insert objects
into their right naris.
FBlocation
of

5. Physical
Examination
The patient may present asymptomatically after having been witnessed
inserting the item. Alternatively, the patient may have unilateral nasal
drainage, foul odor, sneezing, epistaxis , or pain. Patients often deny
having placed the foreign body; if the diagnosis is considered, this history
should not lower the practitioner’s suspicion.
The physical examination is the main diagnostic tool, and a cooperative
patient is essential for success. Parents and staff may be needed to
comfort and immobilize a child to allow for a thorough otorhinolaryngologic
examination. Sedation is often helpful in the pediatric population.
Maximal visualization of the nasal cavity is obtained by wearing a
headlamp. Some authors recommend positioning children younger than
age 5 years in a supine lying position and older children in a sitting "sniffing"
position to allow optimal visualization. A nasal speculum may also help to
view the nasal cavity, although some authors report less patient anxiety and
equally good visualization by using one's thumb to pull the nose upward.

6. The object can be found in any area of the nasal cavity, though objects are most
predictably below the inferior turbinate or immediately anterior to the middle
turbinate.[10] Occasionally, evidence of local trauma may exist, with erythema,
edema, bleeding, or a combination thereof. After prolonged exposure, an
increase in these findings is likely to be observed, as well as the presence of
nasal discharge and a foul odor.
In addition to adequate inspection of the nasal cavity, assessing for
complications of the nasal foreign body is important. Visualize the tympanic
membranes for signs of acute otitis media, assess for sinusitis, check for nuchal
rigidity in the toxic child, and auscultate the chest and neck for wheezing or
stridor, which may be a clue of foreign body aspiration.
Lastly, looking for additional foreign bodies, whether they are in the nose or
other body cavities, is important. Differentials to consider in the diagnosis of
NFB include the following: Sinusitis , Polyps , Tumor , (URI) , Unilateral choanal
atresia

7. Complications
Bleeding is the most common complication reported in patients with nasal foreign
bodies (NFBs), although it is characteristically minimal and resolves with simple
pressure.
The foreign body itself may cause irritation to the patient; however, morbidity is
primarily caused by the resulting inflammation, mucosal damage, and
extension
into adjacent structures. Reported complications include the following:
Sinusitis , Acute otitis media , Nasal septal perforation , Periorbital cellulitis ,
Meningitis , Acute epiglottitis , Diphtheria and Tetanus .
Local inflammation from NFBs can result in pressure necrosis. This, in turn,
can cause mucosal ulceration and erosion into blood vessels, producing
epistaxis. The swelling can cause obstruction to sinus drainage and lead to a
secondary sinusitis. Organic foreign bodies tend to swell and are usually
more symptomatic than are inorganic foreign bodies.
A delay in the diagnosis of complications of NFBs, such as sinusitis and
acute otitis media, can result in prolonged morbidity. This can be avoided by
performing a thorough examination and by reexamining the nasal cavity after
removal of the NFB

8. Firmly impacted and unrecognized foreign bodies can in time become coated
with calcium, magnesium, phosphate, or carbonate and become a rhinolith.
Rhinoliths are radio-opaque and typically are found on the floor of the nasal
cavity. Rhinoliths can remain undetected for years and only upon growth
produce symptoms that lead to their discovery. NFBs tend to go unrecognized
for longer periods of time than doforeign bodies in the ear because they
usually produce fewer symptoms and are more difficult to visualize.
Button batteries, magnets, and living foreign bodies can be particularly
destructive. For example, small button batteries may, within hours to days,
cause chemical burns, ulceration, and liquefaction necrosis, leading to septal
perforation.Posterior dislodgement is very rare, but can occur. A recent case
described a near-fatal tracheal aspiration of an NFB during physical
examination

9. Metallic button batteries
Metallic button batteries are small and
shiny and are found in many toys, making
them strong candidates for NFB insertion.
Once inserted into the nose, they cause
destruction via low-voltage electrical
currents, electrolysis-induced release of
sodium hydroxide and chlorine gas, and
even liquefactive necrosis if their alkaline
contents leak out.
Button batteries require prompt removal
and a thorough inspection of the nasal
cavity for complications.

10. Magnetic NFBs
Small magnets have been used recreationally as imitation earrings, as well as
therapeutically for splinting after septoplasty. In the literature, magnetic NFBs have
been shown to cause pressure necrosis and even perforation of the nasal septal
mucoperichondrium. Therefore, they require prompt removal. One report described
using metallic forceps enhanced by the magnetic force of a pacemaker magnet as
a rescue technique after failed removal using the forceps alone
Living NFBs
Larvae and worms have been known to occasionally inhabit the nasal cavities
of persons living in tropical and unhygienic environments. They can lead to the
destruction of the nasal mucosa and subsequent necrosis of septal cartilage
and turbinates. Some authors have even reported extension to the orbit and
paranasal sinuses. Because of the invasive nature of these NFBs, treatment
typically consists of instillation of an agent to kill the larvae or worm, followed by
surgical debridement and antibiotic therapy. These cases should be managed in
conjunction with a specialist.

11. The extent of the workup depends on the clinical scenario. For most isolated
nasal foreign bodies, no diagnostic testing is indicated. With the exception of
metallic or calcified objects, most nasal foreign bodies (NFBs) are radiolucent.
When an alternate diagnosis (eg, tumor, sinusitis) is being considered,
advanced imaging (eg. computed tomography [CT] scanning) may be helpful.
On the other hand, if concern for an ingested or aspirated foreign body exists,
radiography of the chest/abdomen should be performed. An aspirated,
radiolucent foreign body may be inferred by postobstructive air trapping, and
an ingested foreign body will show up if it is radiopaque, as most ingested
foreign bodies are.
Imaging Studies

12. Nasal foreign body removal may be attempted by an experienced clinician if the
object can likely be extracted. If doubt exists about the reasonable probability of
extraction, an otolaryngologist should be consulted. Repeated attempts at
removal may result in increased trauma and potential movement of the item into a
less favorable location. Mechanical removal of a foreign body should not be
attempted if the item appears to be out of range for instrumentation.
Removal should not be performed without adequate sedation in an uncooperative
patient whose head cannot be securely and safely stabilized. Ideally,
nonmechanical techniques such as positive air pressure should instead be
attempted in these patients.
Indications and Contraindications for Removal

13. Preparation
careful planning is important to maximize the likelihood of removal on the first
attempt , caution the object may become more deeply lodged !
emergency airway supplies should be readily available in the event that
manipulation of the foreign body results in aspiration.
Equipment ….
Topical vasoconstriction and anesthesia are helpful for examination and
before removal attempts and may be applied in the form of a small cotton-wool
swab wrung out in lidocaine/phenylephrine solution and If the head of an
uncooperative patient cannot be stabilized, procedural sedation should be
achieved prior to mechanical removal
Positioning
Proper positioning is vital in achieving optimal visualization and stability of the
head. Patients may be placed in the “sniffing position,” either supine or with slight
elevation of the head. Uncooperative patients in whom procedural sedation
cannot be used must be securely immobilized. Even in a cooperative patient,
assistance should be obtained to stabilize the head.

14. Removal Techniques
For easily visualized, nonspherical, non-friable objects, most clinicians
prefer direct instrumentation.
If the object is poorly visualized or spherical or cannot be successfully
removed by direct instrumentation, balloon-catheter removal is a
preferred method. For large, occlusive NFBs, positive pressure
techniques are commonly used.
All attempts at removal can be complicated by mucosal damage and
bleeding. In addition, all failed attempts can result in posterior displacement
of the NFB

15. Removal Techniques :
1) Direct instrumentation : is ideal for easily visualized, nonspherical, nonfriable FBs
2) Balloon catheters : is ideal for small, round objects that are not easily grasped by
direct instrumentation (Foley catheters , Fogarty catheters and Katz Extractor )
3) Positive pressure (Blow nose or Parent’s Kiss or bag-valve mask - Sellick
maneuver .. ?: is ideal for Large, occlusive FBs are especially amenable to the
positive-pressure technique .. Comp : (Self-limited, subcutaneous, periorbital
emphysema ,, barotrauma to the airway, lungs, or the tympanic membranes avoid
using large volumes of forced air
4) Suction : is ideal for easily visualized, smooth or spherical FBs
5) Glue : is ideal for easily visualized smooth or spherical foreign bodies that are dry
and nonfriable . # injury by misplaced glue.
6) Posterior displacement : Rarely, a FB may be so posterior that the above
techniques will not work
7) Magnet : especially useful to remove button batteries
8) Irrigation : carrying a significant risk of aspiration or choking. NOT recommend

16. Foreign body in ear

17.  Children, depending on age, may be able to indicate that they have
a foreign body, or they may present with complaints of ear pain or
discharge.
 Adults may get a foreign body stuck in an attempt to clean the ear,
e.g. with match sticks, or cotton buds . Most adults are able to tell
the examiner that there is something in their ear, but this is not
always true. For example, an older adult with a hearing aid may lose
a button battery or hearing aid in their canal and not realize it.
 Patients may be in significant discomfort and complain of nausea or
vomiting.
 Patients may present with hearing loss or sense of fullness..
 Various objects may be found ,
-Non-biological  toys, beads, stones, folded paper
-Biological  insects or seeds.
HISTORY

18. physical examination
 The physical examination is the main diagnostic tool. Physical
findings vary according to object and length of time it has been in
the ear.
 An inanimate object that has been in the ear a very short time
typically presents with no abnormal finding other than the object
itself seen on direct visualization or otoscopic examination.
 Pain or bleeding may occur with objects that abrade the ear canal or
rupture the tympanic membrane or from the patient's attempts to
remove the object.
 Hearing must be assessed before and after removal if possible .
 With delayed presentation, erythema and swelling of the canal and a
foul-smelling discharge may be present.
 Insects may injure the canal or tympanic membrane by scratching or
stinging.

19. DDX
 Abrasions to ear canal
 Cerumen impaction
 Hematoma
 Otitis externa
 Tumor
 Tympanic membrane perforation

20. WORK UP
 No specific laboratory or radiologic studies are
recommended. The physical examination using otoscope
, head mirror with a strong light source, operating
otoscope or operating microscope is the main diagnostic
tool.

21. Techniques appropriate for the removal of ear foreign bodies include mechanical
extraction, irrigation, and suction. Practitioners should allow the nature of the
foreign body to guide the choice of technique. Irrigation is contraindicated for
organic matter that may swell through osmosis and enlarge within the auditory
canal. 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.[7] Mineral oil, microscope oil, and viscous lidocaine have all been used
successfully for this purpose.
The main danger of a foreign body in the ear lies in its careless
removal.
Management
Methods of removal :-
1) Mechanical extraction
2) Irrigation :note Warming the irrigation fluid (water or normal saline) greatly
enhances patient comfort ,, Advancing the tip too far risks damage to the
tympanic membrane

22. Consider that an underlying illness may have prompted the patient to insert a
foreign body into the ear to relieve discomfort such as pain or pruritus.
Perform a thorough head, ears, eyes, nose, and throat (HEENT) examination in
all patients, since throat pain can refer to the ears.
Always examine the opposite ear and both nares for additional foreign bodies.
Always examine the external auditory canal after the removal of a foreign body to
identify preexisting or iatrogenic tympanic membrane perforations or abrasions.
Acetone has been used successfully to remove chewing gum, Styrofoam, and
superglue from the ear canal.
Ethyl chloride has been used to remove Styrofoam beads from the ear canal
Pearls

23.  Syringing (Irrigation )is the simplest method of foreign body removal .
 Syringing is not painful, therefore pain means either an error in
technique or that there is an otitis externa or a perforation. If there is a
perforation, the ear should not be syringed . Coughing (from the
vagal reflex—the auricular branch of the vagus supplies the drum) or
syncope may complicate syringing. Vertigo with nystagmus will occur if
the water is too hot or too cold.
 Irrigation is contraindicated in otitis media , otitis externa and
perforation
 Vegetable foreign bodies, such as peas, swell with water and are better
not syringed
 Maggots cause a painful ear, and their removal is difficult. Insufflation of
calomel powder is effective treatment.
 For insects, it should be killed prior to removal, using mineral oil or 2%
lidocaine

24.  Avoid any interventions that push the object in deeper.
 It is often dangerous to use forceps to remove an aural foreign body,
since the object easily slips from the jaws of the forceps to go deeper
into the meatus.
 If the child (or adult) is uncooperative do general anaesthesia.
 Consider ENT consult if object : Touching the tympanic membrane , In
the canal for >24hrs , sharp edged , Disk batteries , Vegetable matter

25. MEDICATIONS
After the foreign body is removed, inspect the external
canal. For most foreign bodies, no medications are needed.
However, if infection or abrasion is evident, fill the ear canal
5 times/day for 5-7 days with a combination antibiotic and
steroid otic suspension (eg,cortisporin or cipro HC ).

26. - Plastic, metal pin, seeds, nuts, bones, coins .
- All pharyngeal foreign bodies are medical emergencies that
require airway protection. Because complete airway
obstruction usually occurs at the time of aspiration and results
in immediate respiratory distress .
Foreign body in Throat

27. Symptoms:
 “ The sudden onset of stridor in a formerly normal child must
always be regarded as being due to a foreign body until proved
otherwise. “
 Presentation :-
ƒstridor if lodged in trachea
ƒunilateral “asthma” if bronchial, therefore often misdiagnosed as
asthma
ƒ if totally occludes airway: cough, lobar pneumonia, atelectasis,
mediastinal shift, pneumothorax, death
 Patients with non obstructing or partially obstructing foreign bodies
in the throat often present with a history of choking drooling
,dysphagia, odynophagia, or dysphonia.

28. Tests:
Examine the pharynx and the larynx. A foreign body in the
cervical esophagus will cause pain on pressing the larynx against
the spine.
 Radiography can be helpful in localizing coins, button batteries,
and other radiopaque objects, but most laryngeal foreign bodies,
including many fish bones, are radiolucent.
 esophagoscopy
 laryngoscopy

29. Diagnosis and Treatment
• any patient with suspected foreign body should be
kept NPO immediately
• inspiration-expiration chest x-ray (if patient is
stable)
• bronchoscopy or esophagoscopy with removal
• rapid onset, not necessarily febrile or elevated
WBC

30. Treatment:
In complete obstruction :-
Heimlich's manoeuvre  Stand behind the person, and
place your arms around his lower chest and give four
abdominal thrusts compression of the upper abdomen
to raise intrathoracic pressure. The residual air in the
lungs may dislodge the foreign body providing some
airway.
 Cricothyrotomy or emergency tracheostomy should be
done if Heimlich's manoeuvre fails.
 Once acute respiratory emergency is over, foreign body
can be removed by direct laryngoscopy.

32. COMPLICATIONS
 Airway obstruction.
 laryngeal edema.
 Injury of esophagus by FB
 Pushing the foreign body into the subglottic
space, esophagus, or trachea.