Foreign Bodies: Throat, Ear, and Nose

Part 1: Foreign Bodies in the Throat

Clinical Presentation

A careful history is the foundation of management. Two distinct clinical presentations exist:

Significant obstruction / true foreign body: The patient reports eating a bony fish or other meat and developing immediate inability to swallow, clearly localised pain, and marked distress. They may appear as though they are choking and cannot swallow their own saliva — you will find them constantly spitting. This history strongly suggests a foreign body that is genuinely lodged, most likely below the base of the tongue, in the piriform fossa, or at the cricopharyngeal sphincter (the upper oesophageal sphincter). Any progressively worsening difficulty with swallowing also belongs in this category — this may indicate an impacted foreign body with secondary oedema.

Mucosal scratch / minor injury: The patient reports eating fish or chicken and experiencing a sudden localised pain on swallowing. They may have vomited initially but are now generally well. They are able to eat and drink, but every swallow causes a vague, persistent, localised pain that worries them. This presentation is consistent with a small scratch or laceration to the upper oesophageal or hypopharyngeal mucosa from a bone that has already passed — not a retained foreign body. However, clinical examination and investigation are required to confirm this, as a small foreign body can be easily missed.

Examination

Oral cavity inspection: Most fish and chicken bones initially lodge in the tonsils or at the base of the tongue. Examine these areas very closely with a headlight — the bones can be extremely thin (almost translucent) and may be mistaken for a strand of saliva. Look systematically and rule everything out. If a bone is visible in the oral cavity, remove it carefully with Magill's forceps or a Burkitt's straight forceps, taking care not to cause additional mucosal trauma.

If the base of the tongue is difficult to visualise, try lying the patient's head over the edge of the bed and looking as an anaesthetist would, using a curved laryngoscope. Pressing down on the base of the tongue suppresses the gag reflex (Xylocaine spray also helps).

Flexible fibreoptic nasendoscopy (FNE): If nothing is found on oral inspection and the history is strongly suggestive of a retained foreign body, flexible nasendoscopy allows direct visualisation of the nasopharynx, oropharynx, larynx, and hypopharynx. Special hiding places include the valleculae (the recesses between the base of tongue and the epiglottis) and the piriform fossae (recesses on either side of the larynx, often where thin fish bones lodge). With experience, the scope can be advanced gently into the upper oesophagus by asking the patient to swallow. Only advance the scope when you can see where you are going. Any bone identified at or below the base of the tongue requires removal under general anaesthesia.

Imaging

Lateral soft tissue neck X-ray: Useful for identifying radio-opaque foreign bodies (some chicken bones, fish bones — particularly those with calcification, metal objects) in the soft tissues of the neck and hypopharynx. However, interpretation is difficult — the heterogeneous calcification of the laryngeal cartilages (particularly in older patients) can simulate a foreign body and fool even experienced radiologists. A negative lateral neck X-ray does not exclude a foreign body. Cartilaginous bones (herring, salmon, and many freshwater fish) are often radiolucent and will not be visible on plain films.

CT neck and chest (soft tissue protocol): If clinical suspicion is high but plain X-rays are negative or inconclusive, a CT scan is the investigation of choice. It provides excellent visualisation of radio-opaque foreign bodies, associated soft tissue swelling, and any complications (e.g. perforation, abscess). Request CT with contrast if perforation is suspected.

If No Foreign Body is Found

If you have examined thoroughly (including flexible nasendoscopy if available) and are confident there is no foreign body, these patients can be discharged with:

• Analgesia: paracetamol and ibuprofen
• Antibiotics (amoxicillin) if there are signs of mucosal infection
• Advice that a mucosal scratch can cause symptoms for 3 to 5 days and will resolve spontaneously
• Safety-netting advice: return immediately if symptoms worsen, if they develop fever, or if they are unable to swallow fluids

Meat Bolus Impaction

An impacted meat bolus (a soft food bolus stuck at the cricopharyngeus or upper oesophagus) is different from a bony foreign body. A patient who cannot swallow anything and is drooling or spitting saliva with a history of eating meat has a bolus impaction until proven otherwise. Try the following in sequence:

• If the patient can swallow any fluid, try a carbonated drink (cola or sparkling water) — belching from carbonation can sometimes dislodge a soft bolus.
• Hyoscine butylbromide (Buscopan) 20 mg IV — a smooth muscle antispasmodic that relaxes the cricopharyngeus and upper oesophageal sphincter, given with diazepam 2.5 to 5 mg IV or oral for additional muscle relaxation. This combination can allow the bolus to pass spontaneously.
• Admit the patient overnight — sleep and positional changes sometimes allow a soft bolus to pass.
• If none of the above works, the patient requires endoscopy under general anaesthesia to remove the bolus using rigid oesophagoscopy or a flexible gastroscope. Do not delay this if the patient is at risk of aspiration or regurgitation.

Part 2: Foreign Bodies in the Ear

Aural foreign bodies (foreign bodies in the ear canal) are common, particularly in children. There is a fundamental principle that cannot be overstated:

Most aural foreign bodies are not immediately dangerous (provided there is no active infection or battery involvement) and can be managed at next-day ENT clinic review rather than emergency removal.

Types and Specific Management

• Hard inorganic objects (beads, stones, small toys): Attempt removal with micro-suction under direct vision using an operating headlight and an aural speculum in a cooperative patient. Alternatively, a right-angled hook (Jobson Horne probe) can be used to hook behind the foreign body and draw it outward — never try to grab a smooth round object with forceps, as this pushes it deeper. In children, or where the foreign body is deep or very close to the tympanic membrane, arrange removal under general anaesthesia.
• Vegetable matter (peas, beans, corn): Do NOT use water syringing — vegetable matter absorbs water and swells, causing pain and worsening impaction, and can cause significant mucosal trauma. Remove with forceps or hook under direct vision. These also require ENT review if not removable at first attempt.
• Live insects: A live insect moving in the ear canal is extremely distressing (the noise and movement in the enclosed canal are alarming). First, drown the insect by instilling olive oil, mineral oil, or eardrops into the ear canal. Once the insect has stopped moving (usually within a few minutes), it can be removed with micro-suction or syringing with warm water. Do not attempt removal of a live insect — it will attempt to escape and may damage the tympanic membrane or dig deeper.
• Button battery: A button battery (lithium disc battery) in the ear canal is a true emergency. The battery generates a current that causes electrolytic liquefactive necrosis of surrounding tissue within hours, potentially eroding through the tympanic membrane and causing ossicular chain damage, facial nerve injury, or labyrinthine involvement. Contact ENT immediately for emergency removal — this cannot wait until the next morning.
• Organic matter (cotton wool, sponge): These can be fragmented during removal attempts — care is needed. Forceps under direct vision are preferred over hook instruments, as organic material can be grasped more easily.

Part 3: Foreign Bodies in the Nose

Nasal foreign bodies occur predominantly in young children, who insert small objects (beads, peas, small toy parts, folded paper) into their nostrils out of curiosity. Adults occasionally present with nasal foreign bodies (usually traumatic, or after sneezing out displaced nasal packing material), but they are generally able to remove objects themselves.

Clinical Presentation

The classic presentation in a child is unilateral purulent nasal discharge (often green or blood-stained) with an unpleasant odour. This is the result of secondary infection around the foreign body. Any child with a persistent unilateral nasal discharge must be assumed to have a nasal foreign body until proven otherwise. Other presentations include unilateral nasal obstruction and epistaxis. The child may not volunteer the history of having inserted something.

Removal Technique

As with aural foreign bodies in children, there is generally only one attempt without general anaesthesia:

• "Mother's kiss" technique: The parent occludes the unaffected nostril with a finger and places their mouth over the child's mouth, then gives a firm puff of air. The positive pressure in the nasopharynx may expel the foreign body from the nose. This is well tolerated and should be tried first in young children.
• Blow-nose technique: Occlude the unaffected nostril and ask the child to blow through the nose firmly. In cooperative children, this may be sufficient to expel the foreign body. Having the child blow against a tissue makes this technique more effective.
• Positive pressure balloon catheter: A small balloon catheter (or a modified Foley catheter) is passed beyond the foreign body, the balloon inflated, and the catheter withdrawn, dragging the foreign body with it. This is particularly useful for smooth, round objects that cannot be hooked.
• Jobson Horne probe or right-angled hook: Pass the probe beyond the foreign body under direct vision (using a headlight and nasal speculum), rotate it to hook behind the object, and withdraw. Do not use this technique for friable objects (which will fragment) or for objects very close to the choanae (which may be pushed posteriorly into the nasopharynx and aspirated).
• Forceps: For graspable objects (soft materials, irregular objects). Avoid pushing round, smooth objects further in.

If the foreign body cannot be removed at first attempt in a child, book the child for removal under general anaesthesia. Advise the parents to keep the child NBM from midnight and contact the ENT on-call to arrange an urgent theatre slot. Opinions differ about whether these children should be admitted overnight (risk of aspiration if the object migrates posteriorly) — check your local protocol.

Button Battery in the Nose