Introduction
ENT Foreign bodies can be intimidating to the SHO tasked with first seeing the patient and attempting removal. This quick guide will give you some useful tips and make these encounters less daunting and more successful!
Ear
Foreign bodies in the ear are a frequent presentation, particularly in paediatric cases. The classic presentation includes pain, reduced hearing, and sometimes a visible foreign object. Here are the essential steps to manage this situation effectively:
| Red Flags | Management |
| Button battery / magnets | Immediate removal, risk of necrosis. |
| Live material such as insects | Always drown insects first with water/oil for the safest retrieval. Can then try to flush out with warm water. |
History/Examination
- May present with persistently, discharging ear and/or reduced hearing.
- In children common foreign bodies – toys, seeds, beads.
- In adults common foreign bodies – hearing aids, cotton buds, earrings, silicon ear plugs.
- Perform otoscopy, ensure to do both ears
Management Steps
Step 1
Irrigation: warm water in a syringe attached to a cannula with the needle removed. Aim superiorly when irrigating. This is contraindicated in any materials that may expand such as vegetative material.
Step 2
If foreign body is seen anteriorly any of the following can be used to try and retrieve it:
Referral to ENT: If unable to retrieve the foreign body, refer to ENT for prompt and safe removal, this can be done under microscope / utilising microsuction / general anaesthetic.
Nose
Foreign bodies in the nasal passages are another common presentation, especially in children. They can result in nasal pain, bleeding, or difficulty breathing. Here’s what you need to know:
| Red Flags | |
| Button battery / magnets | Immediate removal, risk of necrosis. |
| Aspiration | All nasal foreign bodies pose the theoretical risk of aspiration. |
History and Examination
- May present with unilateral foul smell from the nose, sometimes the foreign body is not visualised with anterior rhinoscopy due to the posterior location in the nasal cavity.
- Children – toys, seeds, beads, rocks, nuts
- Adults – nose piercings
- Elevate nasal tip to visualise into nostril.
- Ensure to look into both nostrils to avoid missing any further foreign bodies.
| Management setup | |
| Environment | Environment is key in trying to optimise your chances of removing the foreign object |
| Children | Swaddle children and keep them calm often in the arms of parents. Gather allied health professional support Remember – with children first attempt is usually best shot anyone will get! |
| Avoid | Pushing the item in further risk of aspiration. Damage to nasal mucosa. |
Management Steps
Step 1 – Mother/Father’s kiss
Instructions:
- Place your mouth over the child’s open mouth, creating a secure seal as you would during mouth-to-mouth resuscitation.
- Use a finger to block the unaffected nostril.
- Exhale until you sense resistance, which occurs when the child’s glottis is closed.
Deliver a quick, forceful exhalation to release a short burst of air into the child’s mouth. This air will pass through the nasopharynx and exit through the unblocked nostril.
 Step 2Â
If the foreign body is seen anteriorly, any of the following can be used to try and retrieve it:
Referral to ENT: If unable to retrieve the foreign body, refer to ENT for specialist review and removal (+/- under general anaesthetic) or If unable to visualise the foreign body but remain highly suspicious refer to ENT for further assessment i.e. flexible nasendoscopy/examination under anaesthetic
Throat
Depending on the location, foreign bodies in the throat can be a life-threatening emergency.
If in the larynx/trachea, patients can present with stridor and respiratory distress.
If the foreign body is in the upper oesophagus, patients can present with dysphagia, odynophagia and regurgitation. It is important to remove these foreign bodies as they can cause oesophageal perforation.
Immediate action and escalation are crucial in these cases:
| Red Flags | |
| Acute airway compromise | Move patient to Resus, A-E assessment |
| Contact anaesthetics and ENT urgently | |
| Button battery / magnets | Need immediate removal due to risk of erosion / necrosis. |
| Suspected oesophageal perforation | Symptoms include severe neck/chest/back pain, surgical emphysema, tachycardia, fever. |
History/examination
- History from the patient if possible or detailed collateral to determine the nature of the foreign body and the location it is lodged.
- Children – Small toys, coins, food
- Adults – bones (fish, chicken), dentures, meat
- A-E assessment
- Assess the oropharynx, try to make an assessment to determine if the foreign body is in the oral cavity, pharynx (above or below vocal cords) or oesophagus
Investigations
- Soft tissue neck X-ray: lateral + AP views
- CT neck
| Management setup | |
| Environment | Manage such patients in RESUS due to risk of airway deterioration. |
| Children | Important to keep children calm and avoid anything that may distress the child, this can lead to sudden deterioration of airway. |
| Avoid | Blind finger sweep – can push things further down. |
Management steps
Step 1Â
A-E assessment – call anaesthetics and ENT team early
Encourage coughing
Consider Heimlich manoeuvre/back blows/chest thrusts/abdominal thrusts
Step 2
Examine oropharynx.
avoid blind finger sweep – can push things further down
Step 3
Medical management options in cases of food bolus (do not delay OGD for medical treatment)
- IV hyoscine butylbromide 10-20mg boluses 30 minutes apart, maximum 5 doses – relaxes lower oesophageal sphincter.
- Glucagon IV 1-2mg – relaxes lower oesophageal sphincter
- Metoclopramide 10mg IV – empties stomach
- Fizzy drinks – release c02 in the oesophagus which raises the intraluminal pressure against a closed upper oesophagal sphincter. (Do not use in absolute dysphagia due to risk of aspiration)Â
General principles for emergency Endoscopy:Â
| Immediate | Urgent | Non-urgent |
| Acute airway compromise | Absolute dysphagia | Asymptomatic patients |
| Signs of perforation | Sharp object / food bolus | Object has passed into stomach |
| FB above the level of the vocal cords | Soft food bolus |
Referral For ENT: If unable to retrieve foreign body, refer to ENT for specialist review +/- removal
| Surgical options | Team | What is it |
| Oesophagoscopy | ENT | Done under general anaesthetic, examination into the upper oesophagus with rigid metal tube. |
| Largyngoscopy | ENT / Anaesthetics | Done under local or general anaesthetic, examination into the larynx and hypo-pharynx using a laryngoscope. |
| Pharyngoscopy | ENT | Done under general anaesthetic, examination of the pharynx (nasopharynx + oropharynx + hypo pharynx) with rigid metal tube. |
| Rigid bronchoscopy | ENT | Done under general anaesthetic examination into the bronchi of the lungs with rigid tube. |
| Bronchoscopy | Respiratory | Done under sedation, examination into the trachea and main bronchi of the lungs with flexible tube. |
| Oesophago-gastro-dueodenoscopy (OGD) | Gastroenterology | Done under sedation, examination of the digestive tract from oesophagus to duodenum with a flexible tube. |
Conclusion
Dealing with foreign bodies in the ear, nose, and throat can be challenging, especially for foundation doctors. Remember that a cautious approach is often the safest one. Always prioritise patient safety; if in doubt, don’t hesitate to seek help from the on-call ENT team. Following the steps outlined in this quick reference guide can ensure the best possible outcome for your patients facing these common ENT emergencies.
References
www.bsg.org.uk/wp-content/uploads/2020/11/flgastro-2020-101450.full_.pdf
www.teachmesurgery.com/ent/throat/foreign-bodies
www.entsho.com
Written by Melanie Suseeharan CT2 ENT & reviewed by Dema Motter ST3 ENT
