ENT Foreign Bodies: An Experience

Foreign Bodies in Pediatric Otorhinolaryngology: A Review

Foreign bodies (FBs) in pediatric otorhinolaryngology represent up to 10% of cases in emergency departments (ED) and are primarily present in children under five years old. They are probably the result of children's curiosity and tendency to explore the environment. Aural and nasal FBs are the most common and accessible, and the removal methods differ depending on the exact location and type of FB, which can be organic or inorganic. A fish bone stuck in one of the palatine tonsils is the most common pharyngeal FB. Laryngopharyngeal FBs can obstruct the upper respiratory tract and thus become acutely life-threatening, requiring an urgent response. Aspiration of FBs is common in children between 1 and 4 years old. A history of coughing and choking is an indication of diagnostic and therapeutic methods to rule out or confirm a tracheobronchial FB. Regardless of the availability of radiological diagnostics, rigid bronchoscopy is the diagnostic and therapeutic method of choice in symptomatic cases. Radiological diagnostics are more significant in treating esophageal FBs since most are radiopaque. Flexible or rigid esophagoscopy is a successful method of removal. A delayed diagnosis, as with tracheobronchial FBs, can lead to fatal consequences.

Intraoperative Ultrasound for Removal of a Fishbone Foreign Body Embedded in the Tongue

Background

Ultrasound (U/S) is a dynamic imaging modality with many applications in medicine. In Otolaryngology, U/S is used routinely in the clinic with several evolving applications intraoperatively. Case Report. A 53-year-old male presented to the emergency department with dysphagia, odynophagia, hoarseness, and sensation of foreign body after ingesting fish. A CT scan identified an approximately 2 cm horizontally-oriented foreign body consistent with a fishbone embedded in the left posterolateral tongue. Intraoperative U/S was used to localize and remove the fishbone without complications.

Results

The patient recovered well after surgery and was discharged home on postoperative day 2. No residual foreign body was found on the repeat CT scan.

Conclusion

Our case demonstrates the effectiveness of intraoperative U/S for removal of fishbone foreign bodies from the tongue and serves to inspire future applications of this modality in Otolaryngology.

Analysis of Ear Nose Throat Consultations Requested From the Pediatric Emergency Service in a Tertiary Hospital

OBJECTIVE

The aim of this study is to examine the reasons and the methods of approach to the patients for the ear nose and throat (ENT) consultations requested from the patients who applied to the pediatric emergency department.

METHODS

The files of 351 patients who applied to the pediatric emergency outpatient clinic and were asked for consultation from the ENT clinic were reviewed retrospectively. Demographic data, complaints on admission, diagnostic examinations, diagnoses, treatment methods, and hospitalizations were recorded.

RESULTS

Of the patients included in the study, 190 (54.1%) were female and 161 (45.9%) were male. The median age of the patients was 4.0 years (3.0-8.0 years). The most common diagnoses after ENT examination are; 120 patients (34.2%) had foreign body (FB) in the nose, 58 patients (16.5%) had FB in the ear, 16 patients (4.6%) had FB in the throat, 16 patients (4.6%) had epistaxis, and 15 patients (4.3%) had Bell's palsy. According to age group, it was determined that FB in the nose and ear was more common in the 0- to 5- and 6- to 11-year age group, and Bell's palsy, FB in the ear and epistaxis were more common in the 12- to 17-year age group. A normal examination was also an important finding in 83 of the patients (23.6%).

CONCLUSIONS

Foreign bodies are the most common reason for admission to the emergency services in children, and it is frequently seen between 0 and 5 years of age. Informing and raising awareness of parents on this topic will reduce both unwanted complications and ENT consultations along with admission to pediatric emergency services.

General Anesthesia in Early Childhood Significantly Reduces Asthma Incidence and Clinical Visits: A Nationwide Population-Based Cohort Study

Few studies have focused on the consequence of exposure to general anesthesia (GA) in children’s early life with the risk of asthma and disease outcomes. The present study examines the correlation between exposure to GA under three years old and the subsequent course of asthma in a nationwide population-based cohort study. Our cases were acquired from Taiwan’s National Health Insurance Research Database (NHIRD). Children under three years old with either GA exposure or not during in-patient treatment from 1997 to 2008 were included. The study group was age- and sex-matched with a ratio of 1:2 to create the control group for comparison. The cohort included 2261 cases with GA and 4522 cases without GA as a control group. The incidence of asthma onset was significantly reduced in patients with GA exposure under 3 three years old (hazard ratio 0.64 (95% confidence interval 0.57~0.72), p < 0.001). In addition, regardless of whether the asthmatic clinical visits were before or after GA exposure, asthma onset patients before GA exposure have significantly fewer clinical visits than those without GA exposure (both p < 0.001, respectively). Using the Kaplan–Meier method, we also demonstrated that GA exposure was associated with favorable clinical visits in patients with asthma, whether their asthma was onset before GA (p = 0.0102) or after GA exposure (p = 0.0418) compared to non-GA-exposed controls. In the present study, we demonstrated that children with early GA exposure under three years old were at a reduced risk of developing asthma compared to the general population. Furthermore, we first reported that GA exposure significantly reduced clinical visits in patients with asthma regardless of whether their asthma onset was before or after GA exposure. It is indicated that GA exposure at a younger age could have potential clinical benefits for asthma than non-GA-exposed controls.

Factors associated with complications of foreign body ingestion and/or aspiration in children from a Peruvian hospital

Objective

To determine the factors associated with complications of foreign body ingestion and/or aspiration in children from a hospital in the Peruvian social security program.

Materials and methods

An observational, retrospective, analytical, and transverse study was undertaken. Medical records of patients under the age of 14 years old, who were admitted to the National Hospital Edgardo Rebagliati Martins between January 2013 and May 2017, and treated with a diagnosis of foreign body in the digestive or respiratory tract, were selected. Variables that characterized the foreign body ingestion and/or aspiration were assessed. STATA v11.1 was used for all subsequent statistical analyzes.

Results

A total of 322 cases met the inclusion criteria and the median age of the cohort was 4 years old (interquartile range: 2-6). The most frequently ingested foreign bodies were coins (∼59%) and batteries (∼10%). Fifty-four cases (∼17%) were classed as having a complication. In the multivariate analysis, we observed that the frequency of complications increased when the ingested object was a battery (adjusted prevalence ratio (aPR): 2.89; 95% confidence interval (CI): 2.52-3.32; p-value<0.001), when the time elapsed prior to diagnosis was 8-16 h (aPR: 2.23; 95% CI: 2.18-2.28; p-value<0.001), and when the child was male (aPR: 1.85; 95% CI: 1.24-2.74; p-value = 0.002). However, the frequency decreased in cases where foreign bodies were lodged in the nose (aPR: 0.97; 95% CI: 0.97-0.98; p-value<0.001).

Conclusions

Whilst the most frequently ingested foreign bodies in this study were coins, complications were more common in cases of battery ingestion and in those where the diagnosis was made after 8 h.

Removal of external auditory canal foreign bodies in the pediatric emergency department - A retrospective comparison study

INTRODUCTION

The removal of foreign bodies from the external auditory canal (EAC) is a common cause of referral to the pediatric emergency department (PED). The attempt at removal of foreign bodies can lead to complications ranging from mild canal injuries and through severe inner ear damage. The removal requires knowledge and expertise. Ear, Nose and Throat (ENT) physicians are considered the most qualified to remove these foreign bodies. The decision of when the ENTs need to be involved is debated.

METHODS

A retrospective analytical comparison study was conducted. The study included all children admitted to the PED for EAC foreign body removal, between the years 2009-2019.

RESULTS

A total of 333 children were included in the study. The mean age was 6.53 years. Success rate of the procedure on the first attempt performed by pediatricians was 82.4% and when performed by ENT physicians the success rate was 96.1%. However, when those with a previous attempt of removal were removed from the study the success rates of PED physicians were 93.9% and of ENT physicians were 96.8%.

CONCLUSION

This single center study shows that with correct case evaluation, the PED physician can and should succeed in EAC FB removal with minimal complications and comparable to ENT performance. If a first attempt failed, an ENT consult is warranted.

Ear, Nose, and Throat Foreign Bodies in the Paediatric Population: Did the COVID-19 Lockdown Change Anything?

Background

In the pediatric population, the ear, nose, and throat (ENT) foreign body is a common presentation for emergency departments (ED) and ENT units. COVID-19 has led to a significant impact on the health care system and the overall mental well-being of the general population. With the health care system under significant strain, we noted a continued presence of children with foreign bodies, with some requiring removal under a general anesthetic.

Aim

We aimed to assess if lockdown measures increased or decreased the incidence of children presenting to the hospital with ear, nose, and throat foreign bodies and to evaluate their management by the ED and ENT specialties.

Method

A retrospective data of children presenting with a foreign body in the ear, nose, and throat from March 2020 to August 2020 was compared with the data for the same period in 2019.

Results

Our study showed an overall decrease in children presenting with foreign bodies in 2020 compared to 2019 (n=90 and n=106, respectively). However, the number of children needing general anesthetic remained the same, and those presenting with foreign bodies in the upper aerodigestive tract were higher in 2020.

Conclusion

Children with foreign ear, nose, and throat bodies continued to present to the hospital during the COVID-19 lockdown. Our study shows an overall decrease in the number of children presenting with Ear, Nose, and Throat foreign body during the lockdown, but not statistically significantly different.

Satisfaction with an In-House Nasal Foreign Body Removal Manikin: A Randomized Controlled Trial

Introduction

Nasal foreign bodies can lead to life-threatening conditions. Hence, it is a necessity that physicians be well trained in the appropriate procedures for removal of nasal foreign bodies. However, training on real patients is not only unpractical it is also too dangerous, due to risk of foreign body aspiration during the procedure. Therefore, our goal was to construct a manikin, with a specific design, to serve all possible needs for training.

Methods

We developed an in-house manikin from 2 materials; these being flexible polyurethane foam and silicone. Silicone, which has elasticity similar to nasal alae, was used to develop the detachable nose and nasal cavity, whilst polyurethane foam, which is light and easy to carry, was used to develop the head. The in-house manikin was compared with a commercial manikin for satisfaction after a nasal foreign body removal procedure was performed in both groups, by 37 physicians, after conducting a randomized controlled trial with a crossover design.

Results

The satisfaction scores of the in-house manikin were statistically significantly higher than the satisfaction scores of the commercial manikin for 6 dimensions: proper size, ease of use, ease of maintenance, flexibility of nasal alae relative to actual anatomy, similarity of the nasal cavity relative to actual anatomy and confidence that the manikin can upskill the medical students ability to practice on real patients (p value < 0.05).

Conclusion

This in-house nasal foreign body removal manikin design had high satisfaction for training and could be used to develop further nasal foreign body removal manikins in the future.

Intranasal foreign bodies: A 10-year analysis of a large cohort, in a tertiary medical center

BACKGROUND

Nasal foreign bodies (NFB) are commonly seen in pediatric patients seeking medical attention in the emergency department (ED). We aim to describe the occurrence, clinical presentation and management, of these cases, and to assess various risk factors for complications.

METHODS

A retrospective analysis of a computerized patient directory of 562 children admitted to the emergency department during a 10-year period, with NFB, in a tertiary pediatric hospital.

RESULTS

Upon admittance, most of the children (82%) were asymptomatic. Among the symptomatic children (18%), the primary symptoms were nasal discharge (10%), epistaxis (8%) and pain (4%). Younger children (under 4 years) were more likely to insert organic materials, compared to older children. Younger children were also admitted sooner to the emergency department and were more likely to present with nasal discharge. The overall complication rate was 5%. None of the children had aspirated the foreign body. Complications included infection (2%), necrosis (0.7%), septal perforation (0.5%), deep mucosal laceration (1.5%) and loss of foreign body (1.9%). Significantly higher rates of symptoms and complications were associated with button batteries. Increased risk for complications were observed according to type of foreign body, multiple attempts to remove it, posterior insertion and left-side insertion.

CONCLUSIONS

Nasal foreign bodies in children are common. Mostly, patients are asymptomatic, therefore a high index of suspicion is required, for quick diagnosis and safe removal, without complications.

A prickly situation: an attempted Caterpillar ingestion - case report

Background

Foreign body ingestion is a common problem in pediatrics. Each foreign body can present its’ own unique challenges during removal, and we present the management of an ingested Spotted Tussock Moth (Lophocampa maculata), more commonly known as a caterpillar.

Case presentation

An 18-month-old boy presented to the emergency department with difficulty handling secretions and odynophagia. It was reported he had placed a caterpillar in his mouth and then spat it out. On examination, hundreds of miniscule filaments (setae) were seen embedded in his lips and tongue. Our service was consulted out of concern for airway involvement. The patient was taken to the operating room where a direct laryngoscopy under general anesthesia with spontaneous ventilation was performed to confirm the setae were confined to the anterior tongue and lips. Once we were satisfied the airway was stable, the airway was secured, and we then began to remove the setae. The initial method used was to use Adson-Brown forceps to remove the setae, however this proved difficult and time-consuming given the volume of setae and how thin the setae were. Ultimately, a more effective technique was developed: a 4 × 4 AMD-RITMES® gauze was applied to the mucosa in order to dry up any secretions and then a piece of pink, waterproof BSN medical® tape was applied to the mucosa. After 3 s of contact it was removed. This technique was then repeated and was used to remove the vast majority of the setae.

Conclusion

To our knowledge, we have described the first technique to remove the caterpillar setae from the oral cavity mucosa in a fast, safe and efficient manner.

Rhinitis 2020: A practice parameter update

This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR.

The aural foreign body space: A review of pediatric ear foreign bodies and a management paradigm

PURPOSE

We aim to describe and review the management of pediatric aural foreign bodies (FBs).

METHODS

We performed an observational study and retrospective chart review with statistical analysis of management for patients presenting with aural FBs to the Emergency Department (ED) with or without ENT consultation, or presenting directly to the ENT clinic.

RESULTS

There were 166 objects in the ears of 155 children. Paper and beads were the most common objects. Micro-alligator forceps and small right-angle hooks were the most commonly used instruments for removal. 60% of patients had attempted removal prior to referral to Otolaryngology, who removed 72% of the FBs in the outpatient setting, 23% in the operating room, and 2.5% in the ED.

CONCLUSION

Taking into account certain characteristics of the object reflects an efficient manner in which to determine referral of difficult removals to Otolaryngology. Providers should determine if the FB is very hard or very soft and spherical or cylindrical with secondary consideration of cost to the patient and hospital in order to properly navigate treatment. Soft and irregular objects may be extracted without need for referral to Otolaryngology. Patients with aural FBs that are hard or round, in instances which previous attempts have failed, and/or where there is trauma to the ear should be referred to Otolaryngology to avoid worsening the position of the FB and increasing the chances of requiring removal in the operating room.

Not 'just' a foreign body in the ear canal

Foreign bodies are commonly seen by the Ear, Nose and Throat emergency team with cotton wool being the most common aural foreign body seen in the adult population. Most complications secondary to aural foreign bodies described in the literature are minor and rarely require any surgical intervention. Here, we present two cases with impacted cotton wool as aural foreign bodies which resulted in suppurative labyrinthitis and osteomyelitis causing profound sensorineural hearing. These cases highlight the importance of considering aural foreign bodies in the differential diagnosis in those presenting with unilateral symptoms as significant complications, although rare, can occur, particularly in those with delayed diagnosis.

Nasal foreign bodies in the paediatric emergency department

BACKGROUND

Nasal foreign body(-ies) (FB) cause local irritation, inflammation, and mucosal erosion and carry a potential risk of aspiration. The aim is to describe the management of nasal FBs in our Emergency Department (ED).

METHOD

A retrospective study of 100 sequential suspected nasal FB presentations to a tertiary paediatric ED. Patient age, gender, FB typology, doctor/nurse seniority, sedation/analgesia usage, removal method, ENT referral rate, extraction time and disposition were collected. Data was inputted to Microsoft Excel®.

RESULTS

One hundred cases were encountered over 16 months: 51 males and 49 females. Median age was 3.4 years (range 0.8-10). Of the 73 FB visualised in the ED, 78% (57/73) were successfully removed by ED staff. Sixteen visualised in ED required ENT removal. Of those 16 FBs, 7 were removed at OPD while 9 were removed by ENT in ED.

DISCUSSION

The ED physician/advanced nurse practitioner successfully managed most children with a nasal FB in the ED. The goal of the management should be to minimise complications/repeated attempts. Formation of a national guideline to assist in ED removal and timely care will hopefully improve patient's experience. It will include guidance on topical anaesthetic use, performing radiographs for radiopaque objects not initially visualised and limiting ED staff extraction attempts.