An unusual foreign body in the floor of the mouth presenting as a gradually growing mass

Foreign bodies in the upper aerodigestive tract represent one of the most common ENT emergencies, but patients with foreign bodies in the floor of the mouth rarely present to the otolaryngologist. Only a very small number of these foreign bodies are embedded under normal mucosa and can result in lethal complications. In this article, we report the case of a 3-year-old girl with a gradually enlarging mass in the floor of the mouth. On physical examination at admission, there was a 2×3-cm, elastic, tender mass on the left side of the floor of the mouth, with the overlying mucosa intact and normal in color. Taking the palpable lymph nodes into consideration, a congenital lesion or a pediatric malignancy was suspected initially. A blue pen cap with a surrounding pneumatocele was found intraoperatively. After a careful reevaluation of a previous MRI, a check valve mechanism at the possible site of entry was detected, leading to a pneumatocele, thus explaining the constant growth of the mass. This is a unique case of a foreign body in the floor of the mouth, mimicking a congenital lesion or a pediatric malignancy. Thus, the possibility of a foreign body should not be underestimated when evaluating a child with swelling in the floor of the mouth.     

Parapharyngeal space foreign body

We present a case of an unusual toothbrush foreign body in the parapharyngeal space in a 1.5-year-old child. Children are most affected by this kind of trauma. Quicker and exact diagnosis guarantee proper treatment and recovery. The toothbrush had broken and one-third (about 6 cm) of it was left in the child’s mouth, causing some swallowing problems. We do not observe any injury of neurovascular structures or inflammation complications. Under general anesthesia, neck exploration was undertaken and the toothbrush removed. External exploration of the neck is the method of choice in the treatment of big parapharyngeal space foreign body as we demonstrated in our case. This method guarantees a good exposure of the neurovascular structures of the neck.     

2例特殊类型儿童气管异物的临床分析

目的：分析儿童气管异物误诊原因，减少临床误诊率。方法：对2例诊断为儿童气管异物的病例进行回顾性分析。结果：1例无明确异物吸入史的患者证实为鼻腔脓性痂皮致主气管异物，1例高度怀疑为气管异物患儿最终诊断为有机磷中毒。结论：对疑似气管异物的儿童患者，应仔细采集病史，注意特有体征，减少误诊。     

Ingested foreign bodies: patient-guided localization is a useful clinical tool.

We prospectively studied the latest 60 patients who presented to the ENT Departments of St Mary's and St George's Hospitals with ingested foreign bodies. Localization of the foreign body by the patient was compared to the actual site of the foreign body at removal and graded accordingly. Localization was better the higher the object. When compared with objects above the cricopharyngeus muscle items impacted below this level were poorly localized (P < 0.0001) and lateralized (P < 0.0001). This suggests that for a patient who is able to lateralize a presumptive foreign body within the cervical region, then that object is likely to be above cricopharyngeus and on the side indicated. Further, it is likely to be visible on indirect laryngoscopy and amenable to removal in the casualty department. We hypothesize that the pharyngeal innervation by the vagus and glossopharyngeal nerves provides better sensation than in the oesophagus which is innervated less densely by the vagus and cervical sympathetic nerves.     

Unusual presentation of laryngeal foreign bodies — report of two rare cases

Aspiration of a foreign body into the respiratory tract is a common and serious problem in childhood but is rare in adults. Two interesting cases in which the diagnosis of foreign body in the larynx was not suspected preoperatively are being reported. A three and half year old female child was diagnosed as a case of bronchitis and was later found to have a metallic spring in the supraglottic region which was removed by direct laryngoscopy under general anesthesia. The other patient, a 32-year-old male, was diagnosed to have a fibrous lesion in the larynx one year previously, and on laryngoscopy a vegetable, spiculated foreign body was found after excising the fibrous lesion on the left false cord. Both the cases are symptom free 18 months after endoscopy.     

Flexible bronchoscopic removal of a distal bronchial foreign body with cinefluoroscopic guidance

A 15-year-old girl presented to the emergency department with cough and bloody sputum. A chest radiograph demonstrated a radiopaque foreign body (a tongue stud) in the right lower lobe. Rigid and flexible bronchoscopy failed to localize the foreign body. Under fluoroscopic guidance, the foreign body was identified in a right lower lobe distal bronchus; it could be visualized from a distance with a 3.5-mm flexible bronchoscope. An endobronchial biopsy forceps was passed through the suction port of the bronchoscope, but the view of the foreign body was obstructed by the biopsy forceps. The bronchoscope could not be advanced closer to the foreign body, because its diameter was greater than that of the bronchus. Under cinefluoroscopic guidance, the endobronchial biopsy forceps was then used to remove the foreign body. A chest radiograph obtained after removal was normal. The patient was discharged home the following day. Removal of distal bronchial foreign bodies can be challenging, because the bronchial diameter may preclude the advancement of the bronchoscope. Cinefluoroscopy is a relatively safe therapeutic adjunct that may avert the need for thoracotomy.     

Unique presentation of a bronchial foreign body in an asymptomatic child.

A child who aspirates a foreign body may present in many ways. We present the case of an 8-year-old boy whose initial presentation consisted only of his preoccupation with his lost toy and his gesturing toward his oral cavity. There was no witnessed coughing or choking episode, and there were no initial physical examination findings of note, and no abnormalities on appropriate radiographic studies. The patient was transferred to our institution for further evaluation and management. Our careful examination revealed a slight wheeze at the left upper lobe. Endoscopy was immediately performed, and bronchoscopy revealed a yellow, tubular, plastic foreign body in the left main bronchus through which the patient was breathing freely. This was removed without incident by means of optical graspers. The physical characteristics of this foreign body, including its small size, relatively inert material, and large lumen, allowed this patient to present relatively asymptomatically. This case demonstrates the need for a high index of suspicion in the evaluation and management of foreign bodies in the aerodigestive tract.     

Ingested foreign bodies: patient-guided localization is a useful clinical tool

We prospectively studied the latest 60 patients who presented to the ENT Departments of St Mary's and St George's Hospitals with ingested foreign bodies. Localization of the foreign body by the patient was compared to the actual site of the foreign body at removal and graded accordingly. Localization was better the higher the object. When compared with objects above the cricopharyngeus muscle items impacted below this level were poorly localized (P0.0001) and lateralized (P0.0001). This suggests that for a patient who is able to lateralize a presumptive foreign body within the cervical region, then that object is likely to be above cricopharyngeus and on the side indicated. Further, it is likely to be visible on indirect laryngoscopy and amenable to removal in the casualty department. We hypothesize that the pharyngeal innervation by the vagus and glossopharyngeal nerves provides better sensation than in the oesophagus which is innervated less densely by the vagus and cervical sympathetic nerves.     

Unusual case of the long term presence of esophageal foreign body (non-radiopaque coin) in children

The authors report an unusual case of a foreign body in the esophagus of a child present for longer than 2 years. As an infant this child had repair of esophageal atresia. She was examined and assessed 2 years ago for suspected foreign body swallowing. Chest and abdominal xrays did not show the presence of any foreign body. Now this child was re-admitted with a foreign body in the esophagus, a piece of meat. X rays showed narrowing at previous anastomosis site and dilatation proximally. At esophagoscopy after removal of the piece of meat, a coin was removed as well (50 Hungarian fills). This coin has low radiopacity so did not contrast well in soft tissue. It is worth pointing out that despite having a foreign body this child did not have any difficulty with swallowing and development was normal.     

食管内异物并发症的危险因素分析

摘要：目的寻找可能导致食管内异物患者发生并发症的危险因素,为预防并发症的发生提供循证医学证据。方法总结2012年9月~2016年9月收治住院的食管异物患者235例的相关临床资料。通过对患者年龄、性别、异物种类、大小、形状、滞留时间及处理方式进行统计学分析。结果食管内异物并发症的发生与就诊是否及时,是否有强行努力吞咽动作病史,异物的形状,异物的滞留轴向有关;与患者的年龄、性别、异物的大小、异物的种类、异物的滞留部位、麻醉方法及取出方式等无关。结论食管内异物患者并发症的发生率较高,一旦误吞异物,尽量不要强行吞咽动作,并尽早就诊取出异物或能降低并发症的发生几率。     

经口吹气治疗幼儿鼻腔异物45例疗效分析

目的 探讨经口吹气取鼻腔异物的临床实践,为临床提供参考。 方法 回顾性分析2013年4月~2015年5月诊治的125 例儿童鼻腔异物的临床资料,分析两种治疗方法的有效性及安全性。 结果 经口吹气组45例患者中有6例患儿异形硬质异物、瓜子未取出(后通过其他有创方式取出),其余异物均顺利取出,无一例患儿出现鼻黏膜出血、鼻腔损伤及异物后坠等风险;使用鼻腔异物钩、枪状镊等器械组85例患者中1例患儿在取异物过程中发生异物后坠,后经检查坠入支气管内经全麻手术取出;5例患儿鼻腔表面麻醉后仍不能配合,后改为全麻下取出。由于患儿配合情况不同,出现不同程度鼻黏膜损伤致鼻腔少量出血者7例,鼻出血较严重经压迫止血者1例。 结论 经口吹气是针对婴幼儿的一种简单、有效、无损伤的取鼻腔异物方法,尤其是对表面光滑、无明显棱角的异物效果确切,值得临床推荐。     

The effect of the training given to the child development students about foreign body aspiration upon their knowledge levels

Objective

This study was semi-experimentally conducted in order to determine knowledge levels of child development students about foreign body aspiration and to explore the effect of the training given to these students about foreign body aspiration upon their knowledge levels.

Methods

The research was conducted with a total of 231 students who studied at the department of child development of two high schools and one vocational higher school in Erzincan Province located in the east of Turkiye between May 2011 and February 2012. The data were gathered using a questionnaire form of 38 questions. The training on foreign body aspiration (Power point presentation, video presentation and practice on a dummy) was provided in three phases. For the data evaluation; percentages, chi-square test and Mc Nemar test were used.

Results

It was found out in the study that 91.8% of the students did not take any training/course about foreign body aspiration and 55% confronted situations of foreign body aspirations (ear, nose, airway).After the training about foreign body aspiration; it was noted that the number of the students who knew risky behaviors for foreign body aspiration increased and the increase in the number of the students was at the highest level among high schools (p < 0.05). It was seen that the training was most effective among the university students in terms of knowing first-aid intervention in case a foreign body would obstruct airway among the children aged < 1 year (p < 0.05).

Conclusion

It was noted that the training which was applied on the dummy by using visual aids about foreign body aspiration increased the knowledge level of the students. Based on this finding, it may be recommended that nurses should perform their counseling and educator roles more actively for the families and those who are responsible for the baby care about foreign body aspiration by playing a more active role in the health care team.     

Unusual complication of an ingested foreign body

Migration of a foreign body from the mouth and throat to the subcutaneous tissue of the neck is very rare. We present a case of a migrating foreign body (a piece of straw) from the floor of the mouth to the neck. To our knowledge, this is the second case reported in the English literature.     

301例食管异物患者临床诊治分析

目的回顾性分析301例食管异物患者的临床资料,探讨食管异物的临床特征,以提高诊治率。方法收集2000年1月～2011年12月收治经x线食管吞钡棉等检查确诊的食管异物患者301例,其中288例患者有明确的异物史,患者均表现为吞咽困难和疼痛;术前均行X线食管吞钡棉明确异物部位,并根据异物所处部位采取不同的手术方式。结果281例患者通过硬质食管镜取出异物,10例患者通过电子胃镜取出异物,4例合并下咽后壁脓肿患者行颈侧切开取出异物,6例患者入院后自行呕出或进入胃内,1例患者术后失血过多而死亡。结论对于食管异物患者应早诊断、早治疗,同时应根据异物的性质及所处部位采用不同的手术方式,避免并发症的发生。     

Esophageal perforation and neck abscess from ingested foreign bodies: treatment and outcomes

Over a 6.5-year period, 5,848 patients who had ingested a foreign body were admitted to the ENT unit at the Prince of Wales Hospital in Hong Kong. Potentially serious complications developed in 12 patients (0.21%). Eight patients had an esophageal perforation; three had clinical evidence that their injury had been caused by the foreign body itself and five were deemed to have been injured iatrogenically during esophagoscopy. One of the latter group eventually developed an abscess. Four patients originally presented with an abscess. Three of these patients and the patient who later developed an abscess were treated with neck exploration and surgical drainage. One of the patients who initially presented with an abscess refused surgical treatment and was treated conservatively. Conservative treatment was also initiated for all patients who had a perforation. Patients on the conservative regimen were administered intravenous broad-spectrum antibiotics and were not permitted to take any food or liquids by mouth; they received their nutrition via either enteral feeding or total parenteral nutrition. Conservative treatment was successful in all seven patients with a perforation and no abscess and in the one patient with an abscess who refused surgery. Moreover, all four patients who underwent surgical treatment recovered. Our experience demonstrates that esophageal perforation related to an ingested foreign body can be safely treated by conservative means if the diagnosis is made before significant contamination occurs. Conversely, abscesses (cervical or mediastinal) related to an ingested foreign body should be explored and surgically drained.     

Sekundäre Erblindung nach orbitaler Holzfremdkörperverletzung

We report a 68-year-old male who had orbital trauma from a bicycle accident. His vision was initially normal but deteriorated over 8 days to complete blindness. After 13 days, when he first consulted a physician, clinical investigation revealed total ophthalmoplegia, ptosis, and chemosis. Computed tomographic scan showed fractures of the medial orbital wall, orbital floor, and posterior ethmoid with dislocation into the orbital apex near the optic nerve. The patient was sent to our department for optic nerve decompression. Clinical examination showed induration and an already healed infraorbital entry wound suggesting an orbital foreign body, which was confirmed by ultrasound. Renewed analysis of CT scans in different window settings could clearly demonstrate a wooden foreign body in the lower eyelid. Additionally, a diffuse inflammation in the orbital apex was diagnosed. The foreign body was removed and decompression of the orbita and optic nerve was performed. Antibiotics and corticosteroids were administered i.v. Unfortunately, no visual improvement could be achieved.     

Mediastinal tuberculosis in a 10-month-old child

We report a rare case of mediastinal tuberculosis in a child who presented as a possible inhaled foreign body. A 10-month-old girl was admitted with a five-month history of cough, wheeze and problematic feeding, thought initially to be due to asthma. A clinical deterioration and subsequent X-rays suggested an inhaled foreign body. However, at direct laryngotracheobronchoscopy no foreign body was found and subsequent investigations revealed a subcarinal mediastinal mass. She underwent a thoracotomy and excision of the mass, the histological analysis of which revealed it to be of tuberculous origin. When a patient presents with symptoms of upper airway obstruction which are highly suggestive of a foreign body, other causes such as mediastinal tuberculosis must be borne in mind when no foreign body can be found. Although rare, cases of tuberculosis are apparently increasing and the otolaryngologist must be aware of its various manifestations and submit specimens for appropriate analysis. We also briefly review mediastinal lymphadenopathy due to tuberculosis.     

A prolonged buried fish bone mimicking Ludwig angina

Most migrated foreign bodies in the neck were removed immediately in patients with persistent symptoms. It is a rare condition that a fish bone was buried for a prolonged time in the tongue with little discomfort. We report a unique case of an ingested fish bone lodged in the tongue for 16 months until infection ensued. Ludwig angina was considered first because the patient had fever, odynophagia, swelling of the tongue, and mouth floor. The fish bone buried in the tongue was incidentally found on the computed tomography scan and successfully removed by surgical exploration. Although dental infection is the most common underlying cause in Ludwig angina, embedded foreign body should be considered as one of the pathogenesis. On the other hand, computed tomography scan can be useful in identifying extraluminal migration of fish bones in the neck.     

食管异物并发食管穿孔及颈部脓肿临床分析

目的：探讨食管异物并发食管穿孑L及颈部脓肿的临床特点及治疗方法,以期提高对该病的诊治水平。方法：24例食管异物并发食管穿孔及颈部脓肿患者均在全身麻醉下行食管镜检查异物取出术,其中经食管镜取出异物14例,开胸后取出义齿3例,颈侧切开取出异物5例;余2例未见异物。结果：24例患者中并发脓肿16例,其中食管周围脓肿10例,颈部脓肿4例,纵隔脓肿2例;治愈21例,死亡1例,1例因血糖高转内分泌科,1例转胸外科继续治疗。结论：早期诊断、早期治疗是处理食管异物并发食管穿孔的关键。对于食管异物并发食管穿孔及颈部脓肿患者行薄层CT扫描具有极高的诊断及鉴别诊断价值。颈部脓肿一经确诊,应及时行脓肿切开引流术,合理应用抗生素,有效控制感染及并发症的发生,加强营养支持治疗可提高治愈率。     

The interesting case -- case no. 69

This report presents the case of a 28-year-old patient who was referred to our department for having swallowed a metallic foreign body accidentally. Initial X-ray investigation showed a bent needle, localized in the upper esophagus. While removal of the object in question was being planned, we just in time got information concerning the patient's far-reaching psychiatric history. By interviewing him again it turned out that he had been swallowing multiple bent pins intending to commit suicide. Abdominal X-ray demonstrated at least 12 bent metallic pins in different segments of the gastrointestinal tract. Subsequently the young man was admitted to the local psychiatry department. All foreign bodies were excreted per vias naturales within a few days. This case shows that the ingestion of "atypical" foreign bodies needs very careful anamnesis. The patients' psychiatric background and past history should always be taken into consideration.