People often present to an emergency room, or urgent care setting with a foreign body lodged in an orifice. When the patient presents they will have a sense of urgency, and feel that it needs to “come out now”. This may or may not be the case. In order of most to least common, non-traumatic foreign bodies can become lodged in the throat, ears, nose, vagina, rectum and urethra. Patients may be adult or pediatric. Kids will often stick beads or buttons in their ears or nose, and will swallow just about anything. Adults may have an insect in their ear, esophageal food impaction, or engage in foreign body insertions during sexual practices. In this blog we will talk about HEENT/Esophageal foreign bodies.
Adults may present with food swallowing difficulty, and children may present after a witnessed or reported foreign body ingestion. In either case, performing and documenting a good history and physical exam is crucial. Remember, A and B of the ABC’s are airway and breathing. Document the presence or absence of drooling, trismus, stridor, wheezing, or respiratory distress. The presence of these findings merits emergent consultation. Any esophageal impaction merits emergent consultation with gastroenterology.
Adults will often complain of feeling a chicken or fish bone in their throat above the larynx. This symptom often is the result of a minor abrasion and this causes a foreign body sensation. Soft tissue x-rays of the neck will generally rule out a bony foreign body, and if the patient is speaking, breathing, eating, and drinking well, reassurance and outpatient referral to ENT is appropriate.
Other patients will complain of food being stuck “right here” while pointing to the lower sternum. Some adults will have a history of previous food impaction or esophageal dilations. Often food will impact at the distal esophagus, sometimes due to a poorly chewed food bolus stuck at the lower esophageal sphincter (LES), or abnormal thickening known as a Schatzki ring, or esophageal webbing or strictures, often associated with GERD. The key to these patients is breathing and drinking. Most true food impaction patients will present with a container for their frequent spitting due to inability to pass secretions through the impaction. If food impaction is suspected, a trial of glucagon is recommended.
Glucagon, a medication used to raise blood sugar by promoting the release of stored glycogen, also relaxes smooth muscle. IV glucagon, usually 1-2 mg, has been shown to resolve food impactions in up to 50% of cases (this number varies widely from study to study). Use IV glucagon in conjunction with a carbonated beverage and anti-nausea medications. If this attempt fails, and the patient is not passing their secretions (evidenced by frequent spitting or vomiting) then gastroenterology should be consulted for emergent endoscopy.
Kids love to swallow all kinds of things, particularly coins. These show up great on plain films. Always obtain a two view study. A major pitfall is failure to obtain 2 view x-rays. Esophageal coins will look round in AP films, and flat on lateral views. The opposite is usually true for tracheal foreign bodies (see image 1). A foreign body in the trachea is more dangerous, and requires a pulmonologist, rather than a gastroenterologist, for removal. Tracheal foreign bodies, thankfully, are less common. With tracheal foreign bodies, the patients complaints will be primarily respiratory, with coughing, wheezing, and possibly respiratory distress.
Figure 1. Tracheal vs. esophageal foreign coins.
Button batteries have a distinctive look on lateral view (see image 2). This impaction is important because necrosis of the esophagus can begin rapidly. If a button battery impaction is suspected or confirmed, immediate transfer to a facility capable of pediatric endoscopy is indicated. Sharp items, such as thumbtacks, also represent a higher danger of esophageal perforation, thus, a higher level of urgency.
Figure 2. Lateral view of a button battery.
In general, any pediatric foreign body in the esophagus is considered impacted and requires removal as soon as possible. These patients should not be discharged home. Once a foreign body is visualized in the stomach or below, it will usually pass without incident. Monitoring should include surveillance of the stools, and possibly repeat plain film imaging in 1-2 days. Pitfall: with the popularity of magnetic toys, multiple ingested magnets could attract across different segments of small bowel and remain lodged, requiring surgical removal.
Ears and Nose
With ear canal foreign bodies, just like any other patient, obtain a good history and perform a physical exam. Pediatric patients will often present with a bead or bean in the ear, adults may have an insect, or parts of a cotton swab. There are many devices available, including alligator forceps, ear curettes, and balloon catheters (see image 3). Suction and irrigation are also options. There are several factors for success, including the type of foreign boy, and patient cooperation. Have the patient lie in the lateral decubitus position, pull the pinna superiorly and posteriorly to straighten and open the canal. For living insects, instill lidocaine into the canal, which will kill the insect and partially numb the canal. If irrigating the canal, make sure to use warm water. Begin the irrigation slowly until the canal is filled, then apply more pressure. This will avoid perforating the tympanic membrane, and is less painful than starting with high pressure. An 18 gauge angiocatheter and a 20 or 60 cc syringe is best.
In children always examine the nares and opposite ear canal. Avoid damage to the canal or tympanic membrane. If the item is not coming out after a reasonable attempt, or if the patient is fighting the attempt too vigorously, refer the patient to ENT. There are very few dangerous ear foreign bodies, and the last thing our ENT colleagues want is a frightened, angry child presenting to their office after a prolonged, traumatic emergency room visit. If you are successful at removal of the foreign body, examine and document the ear exam post-removal.
Figure 3. Katz Extractor for ear canal foreign bodies.
Nasal foreign bodies are generally much easier to remove due to the larger diameter of the passageway. Patients will generally be pediatric, or adults with developmental or psychiatric disorders. Often patients will have a history of nasal discharge, and previous foreign bodies. Again, the item to rule out is a button battery. These cannot be left in the nares. Imaging with plain films or CT may be needed if a foreign body is suspected but cannot be visualized on exam. Procedural sedation may be required for patients that are not cooperative with removal techniques using regular or alligator forceps.
A great technique for smooth items is positive pressure. Have the parent give an open mouth “kiss” to the child, while closing the un-affected nares. Another very successful technique is using high flow oxygen with a common suction tube (without the suction yankauer). Place the tubing on the un-affected nares. The patient will often struggle, closing the soft palate, creating a strong loop of pressure, extruding the foreign body, often with dramatic effect (ie. shooting across the room).
In summation, always remember the ABC’s. If a patient is discharged, always give them a referral to the appropriate specialist with strict return precautions for fever, increased pain, difficulty swallowing/breathing, or any other concerns they may have.