Manipulated foreign body Nasopharynx? A case report

Introduction

A foreign body (FB) is any object in a region it is not meant to be, where it can cause harm by its mere presence if immediate medical attention is not sought. It can be found lodged in the ear, nose, throat, digestive or respiratory tracts, FB may be classified as animate (living) or inanimate (nonliving). The inanimate FBs can further be classified as organic or inorganic and hygroscopic (hydrophilic) or nonhygroscopic (hydrophobic). The presence of FBs in the ENT region is one of the most common causes of otolaryngologic emergencies. FBs can be introduced spontaneously or accidentally in both adults and children. FBs are generally more common in younger children. This may be due to various factors such as curiosity to explore orifices, imitation, boredom, playing, mental retardation, insanity, and attention deficit hyperactivity disorder, along with availability of objects and absence of watchful caregivers.

Foreign bodies in aerodigestive tract are a common entity.In nasopharynx however it is very rare to find an impacted foreign body (FB). The anatomical structure of nasopharynx prevents any lodgement of foreign body. It is capacious and has a nasopharyngealsphincter which prevents regurgitation of FB from oropharynx. Through nasal cavity FB cannot travel to nasopharynx as the former is narrower. Most of the FB gets impacted as a result of forceful emesis, coughing, penetrating trauma or manoeuvre for removal of FB from oropharynx.

 

Case Report

A 4-year-old male child was brought to the emergency department at Sharda hospital with history of ingestion of a one rupee coin an hour previously. The informant being the mother of the child reported that she had made efforts to remove the ingested coin, manipulating it towards the nasopharynx. The child did not have any history of breathing difficulties or vomiting. There was no significant history of excessive crying, cough reflex, nasal obstruction, nasal discharge, epistaxis, hematemesis, hemoptysis, or loss of consciousness.

On examination, the child was thin built, well hydrated, conscious and oriented to time, place and person. All anthropometric measures were within normal limits for his age, general condition was fair and his vitals were stable. On otorhinolaryngological examination, oral cavity was normal with a mild bulge of the soft palate mildly restricting its movements. There was mild congestion of the posterior pharyngeal wall. Examination of both the ears revealed no abnormalities.

On anterior rhinoscopy the septum and lateral wall was found to be normal. Beyond some serous discharge in both nasal cavities, there were no other abnormalities. The nasal cavity was suctioned using disposable plastic non-traumatic 8 FG catheters to clear the discharge. Direct nasal endoscopy showed floor of bilateral nasal cavities to be clear with hypertrophy of bilateral inferior turbinates. The nasopharynx was visualized. Adenoids were found to be enlarged almost completely obscuring the posterior choanae. No further manipulation was possible in the unsedated child. Furthermore, to establish the location of the foreign body an immediate X-ray skull with neck lateral view was taken and a radiopaque foreign body (coin) was visualised in nasopharynx.

Management

After the confirmation of the lodged foreign body in the nasopharynx, an emergency endoscopic removal of the foreign body was planned under general anaesthesia. Appropriate pre-anaestheic clearance and a written informed consent was obtained. All the biochemical parameters were found to be within normal limits.

Direct Nasal endoscopy was repeated under general anaesthesia with oro-tracheal intubation. On slight manipulation of the adenoids blocking the left posterior choana, the coin was discovered, embedded in the tissue of the adenoids at a slight angle to the saggital plane. Boyles-Davis mouth gag was introduced and fixed. The soft palate was elevated using Negus forceps and the coin was visualised. It was then extracted under observation. Hemostasis was achieved. The retrieved foreign body was handed over to the attendants.The postoperative period was uneventful. The patient was discharged after twoâ??days of observation. At the follow-up on the seventh day, the child was well with no voice change, nasal regurgitation or difficulty in swallowing.

Discussion

Foreign bodies in aero-digestive tract, especially, the nasal cavity are very common. The presence of foreign bodies in the airway depends on their nature, size and location. Every otorhinolaryngology department faces it on a day to day basis. Nasopharyngeal foreign bodies however are rare and mostly asymptomatic making its identification a difficult unless specifically suspected. It is recommended that if an ingested foreign bodyis not recovered in the aerodigestive tract, the nasopharynx ought to be examined. Foreign bodies in the nasal cavity and nasopharynx may cause purulent nasal discharge, nasal obstruction, chronic rhino sinusitis, persistent coughing or may remain asymptomatic. Most often nasopharyngeal foreign bodies are accidental findings on radiology. When inhaled, they may lodge in bronchi leading to pneumonia, atelectasis and bronchiectasis, often a complication of delayeddiagnosis. The history of foreign body inhalation is positive in approximately 70% of cases and of these only 60% seek medical help within the first 24â??h. It is difficult to diagnose a nasopharyngeal foreign body, more so in children.

Techniques of foreign body removal have improved greatly over the past few decades. They can be removed with the help of speculum and forceps. Endoscopic removal or removal through oral cavity can also be done.

 Foreign body in nasopharynx should be kept in mind as a differential diagnosis in case of a suspected hidden FB which may have dire complications if not removed promptly. It may dislodge from the site during coughing, sneezing or digital manipulation and cause obstruction in the larynx and even subsequent respiratory arrest.

Complications may arise due to the foreign body itself or during the procedure for its removal.There maybe bleeding, pulmonary complications, retropharyngeal abscess and localized infection. Complication rates of 12.6% in adults and 4.6% in children have been reported by Singh B et al .Pulmonary complications were more common in children and whereas retropharyngeal abscess was found more frequently in adults, which was mostly due to sharp objects.

The objective of this case report is to encourage suspicion and identification of the site of a lodged foreign body presenting with no symptoms. A careful history of a sudden onset nasal regurgitation or change in voice should raise suspicion of a foreign body in the nasopharynx. Symptoms like difficulty in swallowing along with clinical signs is also very important. If a foreign body in the upper aero-digestive tract is suspected, endoscopic and radiological examination should be done promptly. Nasopharyngoscopy should also be part of the investigation as the suspected nasopharyngeal foreign body may not be radiopaque. In addition to X-ray of the chest , X-ray neck and skull lateral view including nasopharynx should also be done as these are diagnostic for radiopaque foreign bodies.

Author(s): Sama Rizvi

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