Introduction:Foreign bodies in the ear, nose, airway and esophagus sometimes occur in children. Foreign bodies refer

to any object that is placed in the ear, nose, or mouth that is not meant to be there and could cause harm without immediate medical attention. Foreign bodies can be classified as either inorganic or organic. Inorganic materials are typically plastic or metal. Common examples include beads and small parts from toys. These materials are often asymptomatic and may be discovered incidentally. Organic foreign bodies, including food, rubber, wood, and sponge, tend to be more irritating to the nasal mucosa and thus may produce earlier symptoms.Etiology:Young children comprise the most common age group for foreign body obstruction because of the following:

– They lack molars for proper grinding of food.– They tend to be running or playing at the time of aspiration.– They tend to put objects in their mouth more frequently.– They lack coordination of swallowing and glottis closure.– Curiosity, boredom

Dignosis – the history is given by a parent who has seen the child with an object in his or her mouth and suspects the

child might have swallowed it.– ABG analysis– Administer the test in conjunction with an assessment of appearance, voice, speech, vital signs, physical

examination, and pulse- oximetry.– Chest radiography– CT scanning– Fluoroscopy– Barium or Gastrografin swallow

Foreign bodies in the ear: Foreign bodies of the ear are relatively common in emergency medicine. They are seen most often but not

exclusively in children.Various objects may be found, including toys, beads, stones, folded paper, and biologic materials such as insects or seeds.Clinical features

May be asymptomatic Some may cause pain in the ear, redness, or drainage. Hearing may be affected if the object is blocking the ear canal.

Treatment:Emergency department care

Patients in extreme distress secondary to an insect in the ear require prompt attention. The insect should be killed prior to removal, using mineral oil or lidocaine (2%). EMLA cream has also been reported as being effective to kill the insect as well as provide local

anaesthesia. Methods of removal

o Irrigation is the simplest method of foreign body removal, provided the tympanic membrane is not perforated.

o Irrigation with water is contraindicated for soft objects, organic matter, or seeds, which may swell if exposed to water.

o Suction is sometimes a useful means of foreign body removal. Suction the ear with a small catheter held in contact with the object.

o Grasp the object with alligator forceps. Place a right-angled hook behind the object and pull it out. Form a hook with a 25-gauge needle to snag and remove a large, soft object such as a pencil eraser.

o Avoid any interventions that push the object in deeper.

Nasal foreign bodies (NFBs)These are commonly encountered in emergency departments. Although more frequently seen in the

pediatric setting, they can also affect adults, especially those with mental retardation or psychiatric illness. Children's interests in exploring their bodies make them more prone to lodging foreign bodies in their nasal cavities. In addition, they may also insert foreign bodies to relieve preexisting nasal mucosal irritation or epistaxisPathophysiologyNasal foreign bodies,

Damage to the nasal cavity and surrounding structures.

They can produce local inflammation, which may result in a pressure necrosis.

Mucosal ulceration and erosion into blood vessels producing epistaxis.

Obstruction to sinus drainage

Secondary sinusitis.

Firmly impacted and unrecognized foreign bodies can in time become coated with calcium, magnesium, phosphate, or carbonate and become a rhinolith. 

Organic foreign bodies tend to swell and are usually more symptomatic than inorganic foreign bodies.Clinical features:

A thorough history from the patient and his or her primary guardian Unilateral nasal discharge.

Nasal irritation, epistaxis, sneezing, snoring, sinusitis, stridor, wheezing, or fever.  Unusual patient presentations, such as irritability, halitosis, or generalized bromhidrosis (body malodor).  The physical examination - otorhinolaryngologic examination. Sedation is often helpful in the pediatric

population.¾ positioning children younger than 5 years in a supine lying position and older children in a sitting

"sniffing" position to allow optimal visualization. ¾ A nasal speculum may also help to view the nasal cavity.

Planning/Pretreatment

Repeated attempts at nasal foreign body (NFB) removal are likely to be successively more difficult, and the object may become more deeply lodged. Therefore, careful planning is important to maximize the likelihood of removal on the first attempt. 

Having the necessary instruments at the bedside is essential In addition, emergency airway supplies should be readily available in the event that manipulation of the

foreign body results in aspiration.Pharmacological vasoconstriction of the nasal mucosa can facilitate both examination and removal of a NFB. Anesthesia and mucosal vasoconstriction can be accomplished by applying several drops of 1% lidocaine (without epinephrine) and 0.5% phenylephrine to the affected nostril.

Specific Removal Techniques

For easily visualized nonspherical and nonfriable objects, most clinicians prefer direct instrumentation. If the object is poorly visualized, spherical, or unsuccessfully removed by direct instrumentation, balloon-

catheter removal is a preferred method. For large, occlusive NFBs, positive pressure techniques are commonly used.  All attempts at removal can be complicated by mucosal damage and bleeding. 

Direct instrumentation   This technique is ideal for easily visualized, nonspherical, and nonfriable foreign bodies.

Friable and spherical foreign bodies are particularly difficult to remove by this technique: friable objects may tear, and spherical objects may be difficult to grasp and result in posterior displacement.

Instruments include hemostats, alligator forceps, or bayonet forceps ,hooked probes (ie, right-angle hook) can be used for objects that are easily visualized but difficult to grasp. 

The hook is placed behind the NFB and then rotated so the hook angle is behind the bulk of the object. The object is then pulled forward.

Balloon catheters  This approach is ideal for small, round objects that are not easily grasped by direct instrumentation. Foley catheters (ie, 5, 6, or 8) and the Katz Extractor oto-rhino foreign body remover.  First, the balloon is inspected, and the catheter is coated with 2% lidocaine jelly. Then, it is inserted past

the foreign body and inflated with air or water (2 mL in small children and 3 mL in larger children). After inflation, the catheter is withdrawn, pulling the foreign body with it.

Positive pressure   Large and occlusive foreign bodies are especially amenable to the positive pressure technique. Techniques to expel the NFB out "forced exhalation," can be accomplished by occluding the unaffected

nostril and asking the child to blow hard out his or her nose.  If this fails, the positive pressure can be applied by either the parent's mouth ("parent's kiss" ) or a bag-

valve-mask.  With either method, a tight seal is formed around the child's mouth, while avoiding the nose.  The unaffected nostril is then occluded, and a forceful puff of air is provided.  A potential complication unique to positive pressure techniques is barotrauma to the lungs or the

tympanic membranes. However, to date, no cases of this have been reported.Suction  

This technique is ideal for easily visualized smooth or spherical foreign bodies. The catheter tip is placed against the object, and suction is turned on to 100-140 mm Hg (readily supplied

by standard medical suction equipment). Posterior displacement 

Rarely, a foreign body may be so posterior that the above techniques will not work. In these cases, after consultation with a specialist, it may be necessary to induce further posterior displacement of the object into the oropharynx for removal. 

Of course, this would require general anesthesia, endotracheal intubation, and esophageal occlusion.Magnet 

A case report demonstrated successful removal of a loose ball bearing from a nasal cavity using a household magnet

Irrigation This technique has been strongly criticized for carrying a significant risk of aspiration or choking.  The authors do not recommend use of this method; however, it will be reviewed so that clinicians can be

aware of its existence.  The irrigation technique is performed by forceful squeezing of a bulb syringe filled with 7 mL of normal

saline into the unaffected naris.Foreign body airway obstruction

Can be partial or complete blockage of the breathing tubes to the lungs due to a foreign body (e.g., food, a bead, toy, etc.). The onset of respiratory distress may be sudden with cough. There is often agitation in the early stage of airway obstruction. The signs of respiratory distress include labored, ineffective breathing until the person is not longer breathing (apneic). Loss of consciousness occurs if the obstruction is not relieved.Degrees of airway obstructions

Partial obstruction Good air exchange : forceful cough, wheezing, talking do not interfere Poor air exchange : weak ineffective cough, high pitched breath sounds, cyanotic, clutches

throat (universal distress signal) manage as complete obstruction

Complete obstruction Unable to speak, breath, or cough Clutches neck (unversal distress signal) Cyanotic (bluish color)

Treatment of airway obstruction due to a foreign body includes: Children over 1 year of age: A series of 5 abdominal thrusts (a children's version of the Heimlich

maneuver Infants under 1 year of age: A combination of 5 back blows (with the flat of the hand) and 5 abdominal

thrusts (with 2 fingers on the upper abdomen). Almost all aspirated foreign bodies can be extracted bronchoscopically.– If rigid bronchoscopy is unsuccessful, surgical bronchotomy or segmental resection may be necessary. – Chronic bronchial obstruction with bronchiectasis and destruction of lung parenchyma may require

segmental or lobar resection

Esophageal foreign bodyForeign bodies in the upper GI tract are usually swallowed, purposefully or accidentally. After reaching

the stomach, a foreign body has greater than a 90% chance of passage. Coins reaching the stomach are very likely to pass into the small bowel. Objects larger than 2 cm in diameter are less likely to pass the pylorus, and objects longer than 6 cm may become entrapped at either the pylorus or the duodenal sweep. Symptoms of Esophageal Foreign Bodies

Oropharyngeal foreign bodieso Patients with oropharyngeal foreign bodies normally present with a foreign body sensationo Variable degrees of discomfort, from minor to more severe.o inability to swallow secretions.o Rarely, patients may have airway compromise o Patients can usually localize the foreign body sensation in the oropharynx.

Esophageal foreign bodieso 35% of children with esophageal foreign bodies are asymptomatico Gagging, vomiting, and neck or throat pain are common presentations.

Children with chronic esophageal foreign bodies may have– Coughing– Blood in saliva– Gagging– Drooling– Dysphagia – Failure to thrive– Fever– Food refusal– Foreign body sensation in throat

– Irritability– Pain in neck, throat, or chest– Recurrent aspiration pneumonia– Respiratory distress– Stridor – Tachypnea or dyspnea – Vomiting– Wheezing

Stomach/small intestine foreign bodieso Patients with foreign bodies in the stomach or small intestine may present with a history of

swallowing an object, which has passed through the esophagus.o Patients may present with vague symptoms such as fever, abdominal pain, or vomiting.

Management Endoscopy - GI foreign body Smooth-muscle relaxation agents may be used to relax the LES, thereby allowing the passage of

foreign bodies lodged in this location. 

Dignosis

– the history is given by a parent who has seen the child with an object in his or her mouth and suspects the child might have swallowed it.

– ABG analysis– Administer the test in conjunction with an assessment of appearance, voice, speech, vital signs,

physical examination, and pulse- oximetry.– Chest radiography– CT scanning– Fluoroscopy– Barium or Gastrografin swallow

Complications – Local inflammation– Edema– cellular infiltration– Ulceration and granulation tissue formation may contribute to airway obstruction– The airway becomes more likely to bleed with manipulation;– the object is more likely to be obscured and becomes more difficult to dislodge Mediastinitis Distal to the obstruction, air trapping may occur, leading to– Local emphysema, atelectasis,– Hypoxic vasoconstriction– Post obstructive pneumonia– And the possibility of volume loss– Necrotizing pneumonia or abscess– Suppurative pneumonia or bronchiectasis.

Entrapment of object within a Meckel's diverticulum Perforation leading to peritonitis and advanced sepsis Acute or sub-acute small-intestinal obstruction Metal poisoning (coins)

Nursing management – Recognise the signs of aspiration– Immediate measures to relive the symptoms– Parental education as prevention – Patient Education

Educate parents, and other caregivers about providing foods of appropriate size and texture, based on the patient's ability to chew and swallow.

Train caregivers in methods of clearing the airway (eg, Heimlich maneuver, finger sweep).BIBLIOGRAPHY:

1. Wong D.L etal . Essentials Of Paediatric Nursing. 6th edition. Missouri: Mosby;20012. Marlow D.R. Redding B. Textbook of Paediatric nursing. 1st edition.Singapore: Harwourt Brace &

company; 19983. Judith S.A. Straight A’s in Pediatric Nursing. 2nd edition.Lippincott Williams and Wilkins:Philadelphia;

20084. Parthasarathy IAP textbook of Paediatrics. 2nd edition. jaypee: NewDelhi; 20025. Hatfield N.T. Broadribb’s introductory Paediatric nursing. 7th edition. Wolters Kluwer: New Delhi;

20096. http://emedicine.medscape.com/article/763767-overview 7. http://www.amazon.com/Delmars-Textbook-Basic-Pediatric-Nursing/dp/08273771778. http://emedicine.medscape.com/article/776566-treatment

Foreign body

obstruction

Submitted to: Submitted by:Ms. G. Laviga Ms. Shesly P . Jose

Lecturer II MSc (N)

NUINS NUINS