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anagement of foreign bodies in the emer- a sutured wound, draining from the ear or the nose,
by a surgeon in the operating room because removal FOREIGN BODIES OF THE EAR
can potentially cause a tamponade effect and uncon- General Considerations
trollable bleeding. The external ear canal narrows in two areas: at the
junction of the cartilaginous part with the bony part and
FOREIGN BODIES OF THE NOSE then at the isthmus of the bony part. Most foreign bodies
Foreign bodies of the nose are common in children are usually found in either of these two areas. The cross-
and patients with mental disabilities. Pebbles, beads, section of the ear canal is elliptical in shapeknowing
marbles, peas, beans, nuts, button batteries, and paper this shape and the shape of the foreign body helps in
wads are the most frequently encountered foreign bod- negotiating the foreign body in the appropriate direc-
ies of the nose (Figure 1).1 Often, the patients history is tion. Every attempt should be made not to push the for-
sufficient to diagnose the presence of a foreign body of eign body into or beyond the isthmus because removal
the nose. For example, the patient may have been becomes exceedingly difficult beyond this point. Insects,
observed placing a foreign body in the nose, or the cotton, paper, jewelry, and button batteries are com-
patient may present with a history of unilateral, mal- monly encountered foreign bodies in the ear canal.
odorous, purulent discharge. Patients with undiagnosed When managing a patient who presents with a for-
nasal foreign bodies may also present with body odor.4 eign body of the ear, the physician should always check
Once the diagnosis of a foreign body of the nose is the patients hearing before and after removal of the
made, removal is indicated. This author uses and recom- foreign body and appropriately document the find-
mends the positive pressure technique, as described by ings. Also, patients with a perforated eardrum, patients
Backlin and Cohen.5,6 The positive pressure technique is with middle ear infection, and uncooperative patients
successful in removing a smooth foreign body from the should be referred to an otolaryngologist.
nose in almost all cases. This technique involves occlusion
of the uninvolved nostril and the patient forcibly exhaling Removal
through the involved nostril; either the physician or pa- Up to 80% of foreign bodies of the ear can be re-
tient can occlude the uninvolved nostril. If the patient is a moved by an ED physician. Methods of removal include
child, a parent or guardian is asked to occlude the un- suction, a right-angle nerve hook, a small alligator
involved nostril and blow air through the childs mouth, clamp, or irrigation. The irrigant can be either water or
which forces the foreign body out. In these cases, the par- saline at room temperature; isopropyl alcohol is used
ent usually needs to blow only once or twice to force the when removing organic matter or cotton, which may
foreign body out. By having the parent or guardian per- swell with water. The patient should be seated in a semi-
form the procedure instead of the physician, the child upright position. If the patient is a child, the child
remains more relaxed and is less likely to require seda- should be seated comfortably on a parents lap.
tion. If blowing into the patients mouth is unsuccessful Insects are the most common foreign bodies encoun-
or if the physician decides against the mouth-to-mouth tered in the ear canal, accounting for up to 80% of cases.7
technique, then a tight-fitting mask and a bag-valve device Shining light into the ear canal does not entice the insect
can be used to produce the positive pressure. to crawl out. This author contends that irrigation is the
If the positive pressure technique fails to expel the safest technique for insect removal. Killing the insect with
foreign body, then a long clamp and suction may also be mineral oil or lidocaine before irrigation is not necessary.
used to extract a foreign body of the nose. The physician A 20-mL syringe and butterfly needle catheter (ie, the
should pay careful attention to avoid dislodging the for- butterfly needle is cut off, leaving approximately 1 inch of
eign body posteriorly, where the object may be aspirated the catheter and the hub) are used.
into the airway. The patient should be placed in the In the case of a button battery in the ear, the foreign
Trendelenburg position to help prevent aspiration. body must be removed immediately because batteries
leak electrolyte solution. Irrigation, however, is not
Authors Experience recommended because this technique may spread the
Throughout this authors experience in EDs, a total electrolyte solution further. A right-angle nerve hook is
of six children with nasal foreign bodies were treated. recommended to remove button batteries from the ear
Five of the patients had beads in their noses. The posi- canal.
tive pressure technique was used on these children and
the beads were successfully removed. The sixth child Authors Experience
had toilet tissue in the nose, which was removed with a Thirty-six patients were treated: 30 of these patients
hemostat. were adults and six were children. The majority of adult
patients presented with the chief complaint of a foreign an eye consultation should be obtained with an ophthal-
body in the ear. Most of the adult patients had an insect mologist. While awaiting the consult, the physician
in the ear. One patient presented with the complaint of should manage the patient as follows:
dizziness, and a large cockroach was found in his right Administer a tetanus prophylaxis
ear during physical examination. All insects were
removed by irrigation. One adult patient presented Take a culture of the conjunctival sac
with a broken cotton applicator in her ear. The cotton Administer antibiotic eye dropsdo not use an
applicator was removed with a clamp. ointment, which may cause intraocular granu-
Of the six children, five had household items in their loma
ear (eg, paper, cotton, nuts). The foreign bodies were
Administer systemic, parenteral, broad-spectrum
removed either by suction or with a clamp. One child
antibiotics (eg, first-generation cephalosporin
had an earring stuck at the tympanic membrane beyond and gentamicin)
the isthmus and was referred to an otolaryngologist.
Administer an analgesic
FOREIGN BODIES OF THE EYE
Administer an antiemetic to prevent vomiting,
General Considerations which may worsen the prolapse of orbital con-
In patients presenting with a foreign body of the eye, tents
the first step is to rule out perforation of the globe of the
Keep patient from eating or drinking, in case
eye by a penetrating foreign body. The foreign body surgery is needed
may still be present as an intraocular foreign body, and
the orbital contents may have herniated through the Avoid any undue pressure on the globe, which
perforation site. The physician must always check the pa- may cause the protrusion of the orbital contents
tients visual acuity before and after removal of foreign After ruling out perforation of the globe and mea-
bodies and appropriately document the findings. A suring the patients visual acuity, a careful search for
detailed patient history and performance of a thorough, foreign bodies should be made with an ophthalmo-
methodical examination of the eye are necessary. The scope or a slit lamp. The upper lid should be everted,
physician should not stop examining after the first for- and the cornea and the anterior chamber should be
eign body is found; the examination should be contin- examined. Fluorescein dye and ultraviolet light should
ued until all foreign bodies have been located. be used to detect corneal abrasions.
foreign body is performed. The foreign body can also should be followed by daily plain radiograph of the
be endoscopically pushed into the stomach. All adult abdomen. Also stool guaiac testing should be per-
patients with steak house syndrome should undergo formed to rule out bleeding. Foreign bodies of the stom-
further diagnostic workup to rule out the presence of ach and small intestine may cause complications such as
an obstructing esophageal lesion (eg, cancer, stricture). obstruction, perforation, and bleeding. Obstruction usu-
Foreign bodies of the stomach and small intestine ally occurs at the ileocecal junction.
(Figures 4 and 5). Observation is the treatment of Although button batteries release toxic substances
choice for foreign bodies of the stomach and intestine such as mercury into the stomach, batteries less than
because most of these objects, unless extremely large or 23 mm have been observed to passed through the
sharp, pass through without any complication. Patients pylorus and gastrointestinal tract without difficulty.
(continued on page 37)
Authors Experience
The author has seen five cases of foreign bodies of
the esophagus. Two of the cases involved children with
coins in the esophagus. In both cases, the coins passed
into the stomach while the child was in the ED. One
adult patient presented with cervical esophageal perfo-
ration by a fish bone, which was confirmed by CT scan.
One case of steak house syndrome was seen. In this
case, the patient did not respond to intravenous
glucagon or oral soft drinks. A meat bolus was endo-
scopically removed by a gastroenterologist, and a
benign stricture was found at the gastroesophageal
junction. One patient presented with a fish bone in the
pharynx, which was removed by a Kelly clamp.
The author has seen six cases of foreign bodies of
the stomach or small intestine. One patient, who was
addicted to meperidine, swallowed various kinds of for- Figure 6. Swallowed sharp foreign bodies: radiograph showing
eign bodies (Figure 6) so that he could receive intra- a broken fork and a metal rod in a psychiatric patient. The for-
venous meperidine during endoscopy. This patient eign bodies were removed surgically.
underwent celiotomy for the removal of the foreign
bodies. Four other patients presented with smooth for-
eign bodies, all of which passed through the gastroin- examination, removal is often difficult because of the
testinal tract and were excreted. One child presented spasm of the sphincter or the intraluminal suction
with a staple in the stomach. Although a staple is a proximal to the foreign body. Low-lying foreign bodies
sharp object, the gastroenterologist elected to observe can be removed through an anoscope while the patient
the patient because the staple was small. The foreign is under circumanal sphincter block. Intraluminal suc-
body passed through without any complications. tion can be overcome by placement of a Foley catheter
and inflating the balloon. After removal of all rectal for-
FOREIGN BODIES OF THE RECTUM eign bodies, another erect abdominal radiograph
Foreign bodies of the rectum usually occur in indi- should be performed to again rule out free air under
viduals who engage in various anal sexual practices. the diaphragm.
After rectal and abdominal examination, an erect
abdominal radiograph should be performed to rule FOREIGN BODIES OF THE VAGINA
out free air under the diaphragm. Presence of free air Foul-smelling vaginal discharge in a patient of any
and/or signs of peritonitis are an indication for age group should alert the clinician to the possibility of a
celiotomy to remove the foreign body and for closure foreign body. In children, toilet paper is the most com-
of the perforation. Perforation is common with for- monly encountered foreign body of the vagina; in
eign bodies that are located above the peritoneal adults, the most common foreign body of the vagina is a
reflection. retained tampon. Figure 7 shows radiographs of foreign
Before manipulation of the foreign body, rectal per- bodies of the vagina (retained intrauterine devices).
foration and peritonitis must be ruled out. Although A detailed vaginal examination with a speculum in
most rectal foreign bodies are readily palpable on adults and with a vaginoscope in children should be
A B
Figure 7. Radiographs of two patients who presented with vague pelvic pain and were found to have retained intrauterine
devices.
performed. Some children may need conscious seda- medical record. Complete hemostasis, good lighting,
tion. An otoscope can be used to examine the vagina and a magnifying lens are mandatory for the successful
in children. If the foreign body is toilet paper, a vaginal removal of foreign bodies in a wound.
lavage is the best method for removal. A hard foreign All wounds, including puncture wounds, should be
body (eg, a crayon) can be felt by inserting a finger in palpated for the foreign body sensation. Inordinate
the patients rectum; a hard foreign body may also be pain, increased pain with movement, and point tender-
removed by milking it out of the vagina with the finger ness to palpation should make the clinician suspicious
in the rectum. of the presence of a foreign body in the wound. Also, a
nonhealing wound or an infected wound should raise
Authors Experience the possibility of a retained foreign body.
The author has treated five adults with foreign bod- All metal and glass objects that are larger than
ies of the vagina. Two patients presented for a miss- 2 mm and gravel larger than 1 mm can be accurately
ing tampon, two patients presented with vague pelvic seen on a plain radiograph.7 Wooden and aluminum
complaints, and the fifth patient presented with foul- foreign bodies are radiolucent. Radiographs can con-
smelling discharge. The patient with foul-smelling dis- firm a foreign body; however, this technology should
charge had a retained tampon, which was removed not be substituted for a detailed clinical examination.
under direct vision. The two patients with vague pelvic A CT scan should be ordered to visualize a wooden for-
complaints were found to have retained intrauterine eign body (Figure 8).
devices, and the other two patients failed to show any Removal of a foreign body in an uninfected wound
tampon either under speculum examination or in the is not urgent. Patients may be referred to a surgeon for
radiograph of the abdomen and pelvis. elective removal of foreign body. Meanwhile, patients
should receive tetanus prophylaxis and prophylactic
FOREIGN BODIES OF A WOUND antibiotics.
If a patient presents to the ED with either a lacera- If the foreign body is removed in the ED, the patient
tion or a puncture wound, the wound should be should be advised that there is a possibility that all for-
explored for the presence of a foreign body and the eign bodies were not found and that the patient may
exploration and findings should be documented in the have to be referred to a surgeon at a later point. All
Shank
Barb
Cut here
A
A
B
Figure 9. Illustration of A) a standard fish hook and B) a fish
hook as a foreign body of the finger. The physician should
always cut the hook at the barb before attempting to remove
the hook.
Copyright 1999 by Turner White Communications Inc., Wayne, PA. All rights reserved.