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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 1  |  Page : 22-27

Foreign bodies in the ear, nose, and throat of children - A 10 years' experiences at a tertiary care teaching hospital


1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India
2 Department of Community Medicine, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India

Date of Submission08-Jun-2020
Date of Decision03-Aug-2020
Date of Acceptance02-Sep-2020
Date of Web Publication31-Mar-2021

Correspondence Address:
Prof. Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar-751003, Odisha
India
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DOI: 10.4103/smj.smj_65_20

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  Abstract 


Background: Foreign bodies (FBs) in the ear, nose, and throat are frequently encountered clinical entities among the children. These ear, nose, and throat FBs are often seen by pediatricians, primary care physicians, and otolaryngologists. Aim of the Study: The objective of this study is to analyze various types of FBs in the ear, nose, and throat among children and its clinical profile with its treatment in the pediatric age group. Materials and Methods: This descriptive retrospective study was carried out at a tertiary care teaching hospital. During 10-year period from April 2010 to May 2020, 452 pediatric patients with FB in the ear, nose, and throat were managed. The clinical profile and management of these children were analyzed. The clinical data were collected from the admission charts and clinic tickets. Results: In this study, the majority of the FBs were found in the nasal cavity, which constitutes 30.53%, whereas 28.31% found in the external auditory canal, 11.72% in the pharynx, 13.49% in the esophagus and 15.72% in laryngotracheobronchial (LTB) tract. The age ranges from 0 to 16 years, with a mean age was 7.21 years. The majority of the ear, nose, and throat FBs were found in the age group of 0–5 years. Out of the 452 cases, 243 (53.76%) were removed under general anesthesia. Vegetable seed was the most common FB in the nose. Coin was the most common FB in the esophagus, whereas vegetable seeds were the most common FB found in the bronchus. The open safety pin is a hazardous LTB FB. Conclusion: FBs in the ear, nose, and throat of children are common. The accurate diagnosis and treatment of the FBs in the pediatric age is often challenging. These FBs can be associated with significant morbidity and complications if not removed immediately.

Keywords: Children, ear, foreign body, nose, throat


How to cite this article:
Swain SK, Behera IC, Nahak B. Foreign bodies in the ear, nose, and throat of children - A 10 years' experiences at a tertiary care teaching hospital. Sahel Med J 2021;24:22-7

How to cite this URL:
Swain SK, Behera IC, Nahak B. Foreign bodies in the ear, nose, and throat of children - A 10 years' experiences at a tertiary care teaching hospital. Sahel Med J [serial online] 2021 [cited 2021 Aug 3];24:22-7. Available from: https://www.smjonline.org/text.asp?2021/24/1/22/312742




  Introduction Top


Foreign body (FB) in the ear, nose, and throat of children is often encountered by pediatricians, otolaryngologists, and primary care physicians.[1] FBs in the ear, nose, and throat are the cause for frequent visit to otorhinolaryngological emergency units. Children are usually exploratory and curious, and so FB in the ear, nose, and throat are common in them.[1] These children may insert or swallow the FB by themselves or by their friends during playing. A FB is any object in a location which is not meant to be and cause harm by its mere presence, so it need immediate attention for removal.[2] The FB can be divided into inanimate (nonliving) and animate (living). The inanimate FBs is again classified into organic or inorganic and hygroscopic (hydrophilic) or nonhygroscopic (hydrophobic).[3] Certain factors among the children give temptations for FB insertion in the ear, nose, and throat, such as curiosity, fun making, imitation, boredom, mental retardation, and insanity. [4],[5] The simple FB insertion into the ear, nose, and throat may cause significant morbidity with costly interventions for removal. FB in the ear, nose, and throat are thought as the avoidable cause for morbidity and mortality.[6] The FB from the ear and nose can be removed easily, but the aspiration of the FB into the airway can cause stridor and even death.[6] The paucity of the data on FB in the ear, nose, and throat among children in this region of the world necessitated this study for analyzing the details of the children with FB in the ear, nose, and throat.


  Materials and Methods Top


This descriptive retrospective study was conducted at the Otorhinolaryngology and pediatric department of a tertiary care teaching hospital. This study was approved by our institutional ethical committee (IEC) with reference number IEC/IMS/SOAU/12/22.02.2010. This study population included the children with FBs in ear, nose, and throat during the period between April 2010 and May 2020. It comprises 452 children with FBs in ear, nose, and upper aerodigestive tract those attended the outpatient department of Otorhinolaryngology, pediatric, and emergency department. Details of the data regarding FBs were collected from the hospital record book, such as the registration book of the otorhinolaryngology outpatient department and ward admission record stations. In this study, parameters taken into considerations are age, gender, clinical presentations, investigations, types of the FB and site of the FB, and removal of the FB. The children included in this study were in the age range of <16 years. The inclusion criteria of this study included children with a history of ear, nose, and throat FB those required intervention for its removal. Those children with no history of FB insertion but found FB during the surgery were also included in this study. The exclusion criteria included children with suspected FBs in the ear, nose, and throat, but no such FB found after proper examination under general anesthesia. All the adult patients (age >16 years) with FB in the ear, nose, and throat were excluded from this study. All the participant children were evaluated thoroughly with proper history taking and complete otorhinolaryngological examination. In the case of suspected FBs child was seated on his or her parent's or nursing staff's lap with legs, arms, and head immobilized. Anterior rhinoscopy was performed with headlight for suspected FB in the nose. If FB not visible by anterior rhinoscopy, flexible or rigid nasal endoscopic examination was done in suspected cases of nasal or nasopharyngeal FB. Flexible nasopharyngolaryngoscopic examination was done to examine the pharynx and larynx in suspected cases of FB at the larynx and pharynx. Similarly, examination under microscope or otoendoscope was done in case of suspected FB in the ear. Instruments such as FB hook, Jobson Horne probe, Tilley forceps, and crocodile forceps were used for FB removal from the nose and ear. Radiological tests such as X-rays and computed tomography (CT) scan were done as per requirement or when the FB was not visible. Plain radiographs of the soft-tissue neck and chest with the lateral and anterior view were done in all cases of the esophageal and laryngotracheobronchial (LTB) FB and some cases of the nasal and pharyngeal FB. After confirmation of the FB with the exact location, these were removed under general anesthesia. Data were recorded and analyzed using the Statistical Package for the Social Science (SPSS) software, v20 ( IBM company, Armonk, New York, USA).


  Results Top


During this study period, 452 children visited the hospital with FB in the ear, nose, and throat. Out of the 452 children, 264 (58.40%) were boys and 188 (41.59%) girls. The male-to-female ratio was 1.4:1. The age ranges from 0 to 16 years, with a mean age was 7.21 years. The highest incidence of the ear, nose, and throat FBs (45.57%) were found in the age group of 0–5 years. This is followed by children with 6–10 years (33.62%) and 11–16 years (20.79%) [Table 1]. Vegetable seed (27.65%) was the most common FB found in this study. Out of 452, 138 (30.53%) had FB in the nose, 128 (28.31%) in the ear, 72 (15.92%) in LTB airway, 61 (13.49%) in esophagus, and 53 (11.72%) in pharynx [Table 2].
Table 1: Ear, nose, and throat foreign bodies in different age groups

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Table 2: Age and site of the foreign bodies

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In the ear, the most common location of the FB was at the bony part of the external auditory canal. Insect in the ear canal is a common FB [Table 3]. Vegetable FBs were commonly found in nasal cavities, whereas the fishbone FBs were more in pharynx and coin in the esophagus [Table 4]. Fishbone was the major (21/53; 39.62%) FB in the pharynx, whereas the vegetable seeds such as peanut and groundnuts were the most common type of FBs (39/72; 54.16%) in the LTB airway [Table 4]. Out of 72 LTB FB, 43 were seen in the right bronchus, 25 in the left bronchus, 2 in the larynx, and 2 in the trachea [Table 3]. One open safety pin [Figure 1] was found in the laryngeal airway. The most common clinical presentation in nasal FB was rhinorrhea, whereas breathing difficulty was common in LTB FB. Blockage sensation in the ear canal was the common clinical presentation in FB of the ear [Table 5].
Table 3: Different locations and interventions done for foreign bodies of the ear, nose, and throat

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Table 4: Types of foreign body found in ear, nose, and throat

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Figure 1: X-ray of the soft tissue of neck showing open safety pin in larynx

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Table 5: Clinical presentations of ear, nose, and throat foreign bodies

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In all (128) ear FBs, no imaging was done as these FBs visible to the naked eye. Out of 138 FBs of the nose, 92 cases did not require imaging as these are visible to outside. Metallic FB in the nose is easily confirmed by X-ray. X-ray of the neck and chest was done in all cases of the LTB FBs, whereas CT scan was done in 42 cases of the LTB FBs. After confirmation of FB with the exact site, it was removed under general anesthesia or in awake depending on the location of the FB. The FB removed with or without local anesthesia/awake in 209 cases (46.24%), and 243 cases (53.76%) required general anesthesia for removal of the FB [Table 5]. All the FBs from the ear, nose, and pharynx removed successfully with different interventions [Table 3] without any complications, whereas two children out of the 72 LTB FBs died after removal of it after the third postoperative day because of the prolonged hypoxemia. All 61 cases of FB in the esophagus were removed successfully with rigid esophagoscopy under general anesthesia. In this study, children with FB of the LTB airway and food passage presented early within 24 h. Out of 266 FBs of ear and nose, 176 cases presented in late, i.e., after 24 h.


  Discussion Top


FBs in the ear, nose, and throat constitute for approximately 11% of the emergency cases in Otorhinolaryngology.[7] Sigmond Freud described anal and phallic Oedipal stages which follow the oral stage of development, and hence, it predisposes a child for anal manipulations, also provides them pleasures for manipulating the different orifices such as the ear, nose, and throat.[8] FB entry into the ear, nose, and throat of the children depends on the watchfulness of the parents or caregivers and availability of the FB.[9] The insertion of the FB among children may be aggravated by boredom, frustration, and mimicking to unhealthy habits of picking of the ear and nose of the children by the adults.[7] Education or literacy rate is an important factor for avoiding FB insertion.[7] One study documented that FB insertion is often associated with low socioeconomic conditions. [7],[10] Attention deficit hyperactive disorder (ADHD) is an important risk factor of the child for self-insertion of the FB in the ear, nose, and throat among pediatric age group. Approximately 25% of the ADHD children have previous history of FB insertion, whereas 20% of these children have previous history of accidental injuries and hospitalization.[11] Children are most commonly affected with ear, nose and throat FBs because they are unable to masticate the foods and also have inadequate control over deglutition. The children have tendency to shout, cry, and play at the time of eating.[12] Younger children are prone for FB insertion in the ear, nose, and throat.[12] In this study, majority of the FBs were found in the age group of 1–5 years. In this study, out of 452 FBs in the ear, nose, and throat, majority (30.53%) of FBs were found in the nose. Insertions of FBs were more commonly found in the nasal cavity in this study, which might be due to easy accessibility of it. The FB insertions in children are usually accidental in nature. The FBs may vary widely in size, shape, and composition. The laterality of the FB in ear and nose were more on the right side, and the common right side may be due to right-handedness of the children.[13] In this study, out of 72 LTB FB, 43 were seen in the right bronchus, 25 in the left bronchus. FBs in the ear are often asymptomatic and incidental findings in children.[14] Certain factors predispose for insertion of FB in the ear such as itching in ear, pain, heaviness, discomfort and decreased hearing which compels both in children and adult persons for probing the ear and insertion of FB.[7] Some children with FB in the ear may present with otalgia, ear discharge, hearing loss, and sense of fullness in the ear. In this study, majority of the children with FB in the ear presented with blockage of the ear. Approximately 75% of the patients with FBs in the ear are young with age <8 years.[15] The common FBs of the ear are beads, plastic toys, popcorn kernels, and pebbles.[16] Live insects in the ear canal are commonly found in older children.[16] The most common location for FB in the ear is the bony part of the external auditory canal, as in our study. In the ear, the most common FB was the insect in this study.

The FBs of the nasal cavity are often found in the floor of the nasal passage below the inferior turbinate or in the upper part of the nasal cavity anterior to the middle turbinate.[17] Commonly seen nasal FBs are buttons, beads, pebbles, toy parts, food, candle wax, paper, button batteries, and cloth.[17] In this study, vegetable seeds are the most common FB found in the nose. Children with nasal FBs often present with unilateral foul-smelling nasal discharge as in our study.[18] In this study, the majority of the children with ear and nose FB presented late after 24 h of intake.

The FB in the throat (pharynx and LTB airway) is often considered as a medical emergency. The throat or pharynx is bounded by above by the base of the skull and below by the lower border of the cricoid cartilage. The hypopharynx is adjacent to the larynx and upper inlet of the trachea and esophagus. LTB airway FBs in children are more hazardous than the nose and ear FBs as the airway may be compromised. In this study, vegetable seeds are more common than any other type of FBs in LTB. Aspiration of the safety pin is considered as dangerous FB in LTB airway, and in this study, two such cases were found. Complete obstruction of the airway may occur during the aspiration and leading to sudden respiratory distress where patients need emergency intervention. Children with partially blocking FB in the throat often cause chocking, dysphagia, and odynophagia or dysphonia.[13] Pharyngeal or throat FBs are suspected in the case of children with undiagnosed cough, stridor, or hoarseness.[19] In this study, all the children with FB at the food passage and LTB airway presented early within 24 h. This may be due to the difficulty and pain during swallowing; however, the late presentations in some cases may be due to delayed presentations of the symptoms, negligence by the caretakers or parents, painless clinical features, and outreach location of the villages.[20] The diagnosis of the FB in ear and nose is usually done based on clinical presentations; however, the FB in LTB, pharynx, and esophagus are confirmed by imaging. The diagnosis of the FB insertion in the ear, nose, and throat among children may be delayed because the causative events are often unobserved and also the symptoms are nonspecific. Hence, initially, there may be misdiagnosis. Flexible or rigid endoscopic examination is often required for confirmation of the diagnosis. Imaging results may be normal in several cases. Pediatricians or pediatric otolaryngologists have a high index of suspicion in the case of FB in pediatric patients with unexplained upper airway symptoms. Majority of the FBs are removed by skilled otolaryngologists in the office without much complication. The success of the FB removal depends on various factors such as site of the FB, type of the FB material, graspable or nongraspable FBs, clinician dexterity and co-operation of the patient.

The common techniques such as forceps, suction catheter, and water irrigation are useful to remove the FB from the nose and ear. Ear syringing is avoided in case of vegetable FB or with the previous history of instrumentations causing otitis externa or perforated tympanic membrane. The FBs at the pharynx, larynx, trachea, and bronchi are considered as medical emergencies which need surgical consultations. The first attempt for FB removal is often critical as the success rate falls after the initial attempt. There is also increasing of the complications as the number of failed attempts increases.[21] Attempting for removal of the FB is often painful, and so can lead to injury and bleeding, which causes limiting of the visualization, so causing difficulty for accessing the FB. Live FB of the ear canal such as insects can be killed immediately by instilling 2% lidocaine, alcohol or mineral oil into the external auditory canal. This instillation should be done before removal of the live FB but should not be used when the ear drum is perforated.[22] In one study, approximately 30% of the children required general anesthesia for removal of the FB from the ear and majority of the children were younger than 7 years of age.[16] In the majority of children, nasal FBs are easily removed at the outpatient department or emergency unit. Before removal of the FB from the nose, 0.5% phenylephrine can be instilled into the nostril for reducing the mucosal edema whereas the application of the topical lidocaine give analgesia. There are different techniques utilized for removal of the nasal FBs such as removal with forceps under direct visualization or with curved hooks, cerumen loops, or suction catheters. Sometimes, the tip of the Foley catheter (5 or 6 French size) is passed beyond the FB, inflating the balloon and pulling the inflated catheter balloon anteriorly so pull the FB into the anterior part of nasal cavity and then complete removed outside.[23] Sometimes, the nasal FBs are expelled by simply nasal blowing while blocking the other nostril. If this technique fails or child is not co-operative, positive pressure ventilation can be provided through the mouth. FBs in the esophagus need immediate removal under general anesthesia with the help of endoscope. Rigid bronchoscopies with different size of forceps, including optical forceps are ideal for FB removed from the LTB airway.[24] In this study, the FBs from LTB were removed by rigid bronchoscopy with help of optical forceps under general anesthesia. Complications of the throat FBs include airway obstruction, laryngeal edema, and pushing down of the FB into subglottis, tracheal and also to esophagus. There are certain complications associated with FB, such as anesthetic complications, perforation of the tympanic membrane in the case of ear canal FB and perforation of the esophagus in the case of esophageal FB. Long-standing FB in the esophagus may lead to the erosion of the esophageal wall and later on cause mediastinitis or late complications as esophageal stricture. In this study, there were no complications found in rigid esophagoscope. These complications are managed conservatively but may require surgical intervention.


  Conclusion Top


Ear, nose, and throat FBs are often found in children. The study of ear, nose, and throat FB often present with regional peculiarities. Pediatric otolaryngologists usually deal with such FB at ear, nose and throat. The types of FB vary with age group. The food material constitutes the common type of FB in ear, nose, and throat with additional parts of the toys in children. There must be awareness among the parents and caregivers regarding the risk of FB insertion in ear, nose, and throat and its preventive measures. Proper visualization, appropriate equipment, cooperative parents of the children, and skilled clinicians are keys to the successful removal of the FB. The shape of the FB, site of the impaction, and size of the FB are important for planning for managing the FB of ear, nose, and throat among children.

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Conflicts of interest

There are no conflicts of interest.



 
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Jyothi AC, Shrikrishna BH, Sanjay G, Sandeep SG, Chaitanya V. A clinical study regarding foreign bodies in aerodigestive tracts. Odisha J Otolaryngol Head Neck Surg 2011;5:9-15.  Back to cited text no. 12
    
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Ngo A, Ng KC, Sim TP. Otorhinolaryngeal foreign bodies in children presenting to the emergency department. Singapore Med J 2005;46:172-8.  Back to cited text no. 13
    
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Brown L, Denmark TK, Wittlake WA, Vargas EJ, Watson T, Crabb JW. Procedural sedation use in the ED: Management of pediatric ear and nose foreign bodies. Am J Emerg Med 2004;22:310-4.  Back to cited text no. 14
    
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DiMuzio J Jr, Deschler DG. Emergency department management of foreign bodies of the external ear canal in children. Otol Neurotol 2002;23:473-5.  Back to cited text no. 15
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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