Tim Young and Lance Brown
The emergency department (ED) management of foreign bodies can be simple and rewarding. There are three basic elements of management: (1) attempted removal, (2) reassurance, and (3) consultation. The plan will depend on the body cavity, the foreign body, and the clinical presentation. This chapter discusses foreign bodies of the ear, nose, airway, and gastrointestinal tract. Management of pediatric vaginal foreign bodies is discussed in Chapter 287.
EAR FOREIGN BODIES
CLINICAL PRESENTATION
Children of all ages have been described with foreign bodies in the ear canal (median age 6 years) (1,2). Presenting complaints may include pain, discomfort, decreased hearing, and bleeding (1). Ear foreign bodies include insects, paper, beads, seeds, eraser tips, earring parts, toy parts, and disk or button batteries (1–4).
DIFFERENTIAL DIAGNOSIS
It is usually easy to identify foreign bodies in the ear canal. Impacted wax and rare ear canal masses may be mistaken for foreign bodies. Chemicals released from disk or button batteries can cause an intense localized inflammation that can mimic otitis externa (3).
ED EVALUATION AND MANAGEMENT
The ED evaluation of a suspected ear foreign body is almost always straightforward and involves visual inspection of the ear canal with an otoscope. If a button battery is suspected, radiography can easily identify this metallic foreign body.
Most ear canal foreign bodies can be removed by emergency physicians in the ED (1,2). The most commonly described techniques involve grasping the object with forceps, using a hook, loop, or curette to drag the object out of the ear canal and irrigation to wash the object out (1,5). A loop may be fashioned from a paperclip when more specialized tools are not available (6). Irrigation should only be undertaken if the tympanic membrane is intact (7). Cyanoacrylate applied to the blunt end of a cotton swab may be useful to remove a round smooth object such as a bead in a child who is cooperative or sedated (8). It is critical that the child be still and that the cyanoacrylate be used sparingly to avoid applying the adhesive to the ear canal. Procedural sedation improves the chances of successful removal in the ED (1).
Button batteries in the ear canal must be removed urgently to avoid continued tissue destruction (3), In the event that an ear canal foreign body other than a button battery cannot be removed in the ED, the patient may be referred to an ear, nose and throat (ENT) surgeon for removal using an otomicroscope in the clinic or operating room (9).
NASAL FOREIGN BODIES
CLINICAL PRESENTATION
Nasal foreign bodies tend to present in young children (median age of 2 to 3 years) (1,10). These children are asymptomatic about 50% of the time (1,10). Less common complaints include a foul odor, persistent nasal discharge, pain, discomfort, and bleeding. In about 10% of cases, unilateral nasal discharge is the sole presenting complaint (1,10). The most commonly encountered nasal foreign bodies include beads, plastic toy parts, corn kernels, and beans (10). Children may also present to the ED with button batteries in their noses (4). Bilateral nasal magnets may adhere across the nasal septum causing pressure necrosis and perforation (11).
DIFFERENTIAL DIAGNOSIS
Young children with unilateral nasal discharge should be treated as if they have a nasal foreign body until proven otherwise (5). Nasal polyps may be mistaken for foreign bodies. Children who have a foul odor emanating from the mouth or nose may have halitosis, purulent pharyngitis, sinusitis, or a dental infection.
ED EVALUATION AND MANAGEMENT
A nasal foreign body can be identified by visually inspecting the nasal passages. Good lighting and a pediatric nasal speculum may be helpful.
The vast majority of nasal foreign bodies can be managed in the ED by emergency physicians (1,10). Sedation may be helpful in uncooperative children with large or adherent foreign bodies (1). The techniques for removal include grasping the object with forceps, using a hook, loop, or curette to drag the object forward, and suction applied directly to the foreign body (5). A positive pressure technique may be used whereby the parent applies pressure to the contralateral nostril and then blows into the mouth to expel the foreign body (12). Another technique is to insert a balloon catheter (such as a 6-French silicon Foley catheter or Fogarty vascular catheter) past the foreign body, inflate the balloon, and then withdraw the catheter with the balloon inflated. This is a good choice for large, round objects that are difficult to grasp and friable or fragmented materials such as clay or paper. Bilateral nasal magnets adherent across the nasal septum may be removed by placing the metal handle of a pair of forceps in each nostril to break the magnetic attraction and individually remove the magnets (13).
Essentially all children with nasal foreign bodies are discharged home (1). If a foreign body cannot be removed in the ED, outpatient referral to an ENT surgeon is appropriate in all cases except button batteries and magnets adherent across the nasal septum, which require urgent removal to avoid tissue necrosis.
AIRWAY FOREIGN BODIES
CLINICAL PRESENTATION
Although aspirated foreign bodies are uncommon (5), they are most commonly seen in toddlers, and the most common symptoms include choking or coughing (5,14). Other signs and symptoms include dyspnea, fever, and wheezing. Stridor, hemoptysis, or completely asymptomatic presentations are uncommon. The most commonly reported aspirated objects are food-related, with peanuts accounting for about one-third of cases (5).
DIFFERENTIAL DIAGNOSIS
Symptoms associated with aspirated foreign bodies are nonspecific and may describe a wide variety of common pediatric ailments including viral upper respiratory tract infections, bronchiolitis, croup, asthma, pneumonia, and hydrocarbon aspirations.
ED EVALUATION AND MANAGEMENT
Definitively determining whether a child has aspirated a foreign body can be difficult because radiography and the physical examination are insensitive diagnostic tools (15). If the object is radiopaque, a two-view chest x-ray can clearly reveal the location of the foreign body in the trachea or bronchus. Unfortunately, about 85% of aspirated foreign bodies are radiolucent. If the radiology technologist can time it properly, inspiratory and expiratory chest x-rays may be helpful, revealing a normal symmetric inspiratory study but hyperinflation on the expiratory film on the side of the foreign body. Bilateral lateral decubitus films may reveal a failure of the mediastinum to shift downward toward the affected side. However, these techniques are insensitive and have high false positive rate (15). A careful history and physical examination and re-assessments can help determine disposition in uncertain cases. Bronchoscopy is often both diagnostic and therapeutic (14).
Once an aspirated foreign body has been identified or is strongly suspected, consultation for bronchoscopy is indicated. A variety of pediatric specialists perform this procedure, including pulmonologists, intensivists, otolaryngologists, and surgeons. Aspirated foreign bodies and children with a clinical picture suspicious for aspirated foreign bodies should undergo urgent bronchoscopy.
GASTROINTESTINAL FOREIGN BODIES
CLINICAL PRESENTATION
Swallowed foreign bodies are common (16). Most children with subdiaphragmatic foreign bodies are asymptomatic, including those who ingest batteries (5,17). Developmentally delayed children may ingest large or sharp foreign bodies, present in an atypical fashion, or provide a limited history as a result of communication difficulties (18). The most widely studied esophageal foreign bodies are coins (5). More than 90% of children with esophageal coins are symptomatic before or at the time of presentation to the ED (5). Symptoms of esophageal foreign bodies include drooling, substernal pain, and a foreign body sensation. Recent years have seen an increase in magnet ingestion presentations to the ED commensurate with the increasing availability of small, high-powered rare earth magnets in the form of toys and accessories for both children and adults (19). Multiple ingested magnets can trap adjacent bowel loops and cause intestinal wall necrosis. The child may present with abdominal pain without fever, or symptoms of obstruction, volvulus, or perforation (19).
DIFFERENTIAL DIAGNOSIS
Although usually asymptomatic, subdiaphragmatic foreign bodies may present with abdominal pain or rectal bleeding (20). Conditions such as appendicitis, intussusception, Meckel diverticulum, intestinal polyps, or other rare causes of abdominal pain must be included in the differential diagnosis.
ED EVALUATION AND MANAGEMENT
A traditional approach for evaluating a child with an ingested foreign body is to obtain x-rays from the nasopharynx to the bottom of the pelvis, looking for radiopaque foreign bodies. If a foreign body is identified, the critical question is whether the foreign body is esophageal, since these typically require treatment. If a child is asymptomatic, can eat and drink without apparent pain or difficulty, and has a negative set of x-rays, a subdiaphragmatic radiolucent foreign body is assumed. If the child has persistent foreign body sensation or pain in the substernal area or neck and the x-rays are unrevealing, the child may need to undergo esophagoscopy to evaluate for esophageal abrasions or a radiolucent esophageal foreign body. The use of handheld metal detectors has also been described in the evaluation of ingested coins. When used by emergency physicians, they are highly sensitive and specific for coin presence and highly accurate for coin localization (21). When the coin is localized to the stomach or beyond, children have been discharged without adverse events (22). This approach may save time and radiation exposure.
Subdiaphragmatic foreign bodies, including sharp objects and intact batteries, pass spontaneously the vast majority of the time in children with normal anatomies (18,23). Exceptions include very large or very long and pointed objects (typically ingested by developmentally delayed older school-aged children), children with abnormal gastrointestinal anatomy (e.g., an ileostomy), with multiple magnets in the intestines (19), with intestinal batteries that could be damaged or appear to be fragmenting on x-ray (17), and symptomatic children with evidence of peritonitis.
The vast majority of ingested foreign bodies, especially those that have been confirmed to be subdiaphragmatic, can be managed expectantly without further intervention unless symptoms such as vomiting, bloody stools, or abdominal pain develop. Although it has been historically recommended that parents sift through stools until the foreign body is identified as having been passed, this process does little more than punish the parents. Children who have ingested multiple magnets typically require a laparotomy for magnet removal (19). Esophageal foreign bodies, especially button batteries, tend to need removal to avoid esophageal erosion (Fig. 273.1) (5). Coins above the thoracic outlet generally have low rates of spontaneous passage and risk airway compromise and obstruction; therefore, they should be removed urgently by a qualified specialist (24). Children with acutely ingested esophageal coins below the thoracic inlet may be observed for up to 16 hours for spontaneous passage, which occurs in up to 40% of cases (25).
FIGURE 273.1 Radiograph of a large, flat disk battery in the distal esophagus of a young child. Note the faint circular area of relative radiolucency near the periphery of the object shadow. This characteristic target appearance distinguishes this object from the more homogeneous appearance of an ingested coin. (Photograph by Lance Brown, MD, MPH.)
CRITICAL INTERVENTIONS
• Arrange for urgent removal of button batteries in the ears, nose, or esophagus.
• Consider use of sedation to remove ear foreign bodies if not accomplished easily on first attempt.
• Arrange for urgent removal of multiple magnets that may adhere across tissue planes causing pressure necrosis. This may occur across the nasal septum or in the GI tract.
Common Pitfalls
• Delaying management of a disk battery or multiple magnet ingestion.
• Failure to use procedural sedation and appropriate equipment to manage ear foreign bodies.
• Failure to consider foreign body as the cause of unilateral nasal discharge.
• Relying on radiography to rule out an aspirated foreign body.
REFERENCES
1. Brown L, Denmark TK, Wittlake WA, et al. Procedural sedation use in the ED: Management of pediatric ear and nose foreign bodies. Am J Emerg Med. 2004;22:310–314.
2. Marin JR, Trainor JL. Foreign body removal from the external auditory canal in a pediatric emergency department. Pediatr Emerg Care. 2006;22:630–634.
3. Bhisitkul DM, Dunham M. An unsuspected alkaline battery foreign body presenting as malignant otitis externa. Pediatr Emerg Care. 1992;8:141–142.
4. Sharpe SJ, Rochette LM, Smith GA. Pediatric battery-related emergency department visits in the United States, 1990–2009. Pediatrics. 2012;129:1111–1117.
5. Brown L, Dannenberg B. A literature-based approach to the identification and management of pediatric foreign bodies. Pediatr Emerg Med Reports. 2002; 7:93–104.
6. Ezechukwu CC. Removal of ear and nasal foreign bodies where there is no otorhinolaryngologist. Trop Doct. 2005;35:12–13.
7. Kumar S, Kumar M, Lesser T, et al. Foreign bodies in the ear: A simple technique for removal analysed in vitro. Emerg Med J. 2005;22:266–268.
8. Hanson RM, Stephens M. Cyanoacrylate-assisted foreign body removal from the ear and nose in children. J Paediatr Child Health. 1994;30:77–78.
9. Schulze SL, Kerschner J, Beste D. Pediatric external auditory canal foreign bodies: A review of 698 cases. Otolaryngol Head Neck Surg. 2002;127:73–78.
10. Kadish HA, Corneli HM. Removal of nasal foreign bodies in the pediatric population. Am J Emerg Med. 1997;15:54–56.
11. Shermetaro C, Charnesky M. Pediatric nasal septal perforation secondary to magnet misuse: A case report. Ear Nose Throat J. 2007;86:675–676.
12. Purohit N, Ray S, Wilson T, et al. The ‘parent’s kiss’: An effective way to remove paediatric nasal foreign bodies. Ann R Coll Surg Engl. 2008;90:420–422.
13. Brown L, Tomasi A, Salcedo G. An attractive approach to magnets adherent across the nasal septum. CJEM. 2003;5:356–358.
14. Gang W, Zhengxia P, Hongbo L, et al. Diagnosis and treatment of tracheobronchial foreign bodies in 1024 children. J Pediatr Surg. 2012;47:2004–2010.
15. Brown JC, Chapman T, Klein EJ, et al. The utility of adding expiratory or decubitus chest radiographs to the radiographic evaluation of suspected pediatric airway foreign bodies. Ann Emerg Med.2013;61:19–26.
16. Bronstein AC, Spyker DA, Cantilena LR Jr, et al. 2011 Annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 29th annual report. Clin Toxicol (Phila). 2012;50(10):911–1164.
17. Litovitz T, Schmitz BF. Ingestion of cylindrical and button batteries: An analysis of 2382 cases. Pediatrics. 1992;89:747–757.
18. Cheng W, Tam PK. Foreign-body ingestion in children: Experience with 1265 cases. J Pediatr Surg. 1999;34:1472–1476.
19. Abbas MI, Oliva-Hemker M, Choi J, et al. Magnet ingestions in children presenting to US emergency departments, 2002–2011. J Pediatr Gastroenterol Nutr. 2013;57:18–22.
20. Pinero Madrona A, Fernandez Hernandez JA, Carrasco Prats M, et al. Intestinal perforation by foreign bodies. Eur J Surg. 2000;166:307–309.
21. Lee JB, Ahmad S, Gale CP. Detection of coins ingested by children using a handheld metal detector: A systematic review. Emerg Med J. 2005;22:839–844.
22. Ramlakhan SL, Burke DP, Gilchrist J. Things that go beep: Experience with an ED guideline for use of a handheld metal detector in the management of ingested non-hazardous metallic foreign bodies. Emerg Med J. 2006;23:456–460.
23. Pellerin D, Fortier-Beaulieu M, Gueguen J. The fate of swallowed foreign bodies: Experience of 1250 instances of sub-diaphragmatic foreign bodies in children. Progr Pediatr Radiol. 1969;2:286–302.
24. Bhargava R, Brown L. Esophageal coin removal by emergency physicians: A continuous quality improvement project incorporating rapid sequence intubation. CJEM. 2011;13:28–33.
25. Waltzman ML, Baskin M, Wypij D, et al. A randomized clinical trial of the management of esophageal coins in children. Pediatrics. 2005;116:614–619.