Foreign Body in ENT
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Direct answer
Unilateral foul-smelling nasal discharge in a child is a foreign body until excluded. Ear, nose, airway and oesophagus each have their own classic patterns and removal rules, but two principles govern them all: a button battery anywhere is an emergency because alkali leakage liquefies tissue within hours, and blind or forcible removal pushes objects deeper — into the nasopharynx or, worse, the larynx. Most nasal and aural foreign bodies come out in the clinic under vision; inhaled or swallowed objects that endanger the airway or oesophagus need rigid endoscopy under anaesthesia.
What you must remember
- Nose: children insert beads, paper, food; presentation is unilateral foul discharge, obstruction and epistaxis — bilateral symptoms argue against a foreign body.
- Button battery in the nose or ear: necrosis of the septum or canal within hours; remove immediately under anaesthesia if needed, and irrigate to neutralise alkali.
- Nasal removal options: positive-pressure "mother's kiss" (parent blows into the mouth with the contralateral nostril closed), a blunt hook passed beyond the object, or alligator forceps — never push posteriorly.
- Ear: kill a live insect first by drowning it with warm oil or lignocaine, then remove; syringe smooth objects, grasp irregular ones, and never syringe a vegetable seed (it swells) or a battery.
- Airway: choking and sudden cough; the right main bronchus, wider and more vertical, is the commonest resting site; a valve effect gives obstructive emphysema, complete obstruction gives collapse, and oil-containing peanuts cause lipoid pneumonia.
- Oesophagus: coins lodge at the three classic narrowings — cricopharyngeus, compression by the aortic arch, and the diaphragmatic hiatus; drooling and dysphagia in a child with a history of swallowing demands an X-ray that includes the neck.
- Disc battery or multiple magnets in the oesophagus: mucosal injury begins within an hour and perforation follows — emergency rigid oesophagoscopy, not observation.
Site by site: how the pathway runs
Start in the nose. A three-year-old with three days of one-sided foul discharge has a grey mass in the vestibule; suctioning reveals a rolled paper bead. Apply topical lignocaine with adrenaline, and try the parent's mouth-to-mouth positive pressure first. If that fails, pass a blunt hook behind the bead and draw it forward. Success means a discharge that clears over days; failure or an uncooperative child means removal under short anaesthesia, the same sitting ruling out a second, forgotten object.
Move to the ear. An adult with a buzzing insect in the canal is in agony; kill the intruder with warm oil dripped in, then suction or extract the still body with alligator forceps. A child's smooth plastic bead can be flushed by syringing; an irregular piece of foam is grasped, never irrigated deeper. The battery rule overrides all comfort: any disc battery seen in any orifice is removed within the hour.
Now the dangerous end. A toddler choked while eating peanuts, then developed a wheeze; the chest is hyperinflated on one side on expiration — a ball-valve obstruction, the expiratory film showing air trapping of the affected lung. Rigid bronchoscopy under anaesthesia removes the peanut; the rigid scope remains the instrument of safety. Finally the swallowers: a coin at the cricopharyngeus causes drooling and refusal to feed; a plain radiograph including the neck locates it, and uncomplicated blunt objects may be observed briefly if already in the stomach, but an object at any of the three narrowings, any battery, any magnet pair, or any sharp body goes for rigid oesophagoscopy. The unifying habit across all four sites is the same: vision, restraint and the right instrument.
Where students slip
The recurring errors are the irrigation errors: syringing a seed (it swells and impacts) and syringing or delaying with a battery (alkali continues to burn). The second family is the push-back error: extracting a nasal foreign body posteriorly converts a nuisance into a laryngeal emergency, which is why the hook and positive pressure exist. The third is attribution error: weeks of unilateral discharge or hearing loss treated as sinusitis while the bead sits undisturbed — persistent unilateral symptoms in a child deserve a look, not another prescription.
Frequently asked questions
Why is a button battery an emergency in ENT?
It generates hydroxide at the negative pole, causing liquefaction necrosis of the septum, canal or oesophageal wall within hours, with perforation and stenosis following.
How is a live insect in the ear canal managed?
Kill it first by drowning with warm oil (or lignocaine), which immediately relieves pain, then remove the dead insect by suction or forceps.
Which bronchus most often retains an inhaled foreign body, and why?
The right main bronchus, because it is wider, shorter and more vertical than the left.
At which sites do swallowed objects lodge in the oesophagus?
The three physiological narrowings: the cricopharyngeus, the crossing of the aortic arch, and the diaphragmatic hiatus.
What is the positive-pressure technique for nasal foreign bodies?
The "mother's kiss": the carer blows into the child's mouth while occluding the unaffected nostril, expelling the object — a first-line, instrument-free method.