Foreign Bodies in ENT
ENT · Head & Neck · lean revision notes
Foreign Bodies in ENT
Foreign bodies (FB) in the ear, nose, throat and oesophagus are among the commonest emergencies in clinical ENT practice, especially in children and the mentally challenged. NEET PG loves the small, sharp distinctions — when to syringe versus when not to, the button battery emergency, the level of impaction, and rigid versus flexible scope. This note gives you the high-yield framework to never lose these marks.
Overview & classification
Foreign bodies are broadly divided on two axes — site and nature. The nature determines the removal strategy and the urgency, so internalise this first.
| Axis | Categories | Examples | Clinical relevance |
|---|---|---|---|
| Site | Aural, Nasal, Pharyngeal, Oesophageal, Laryngo-tracheo-bronchial | Beads, seeds, coins, fish bone, button battery | Site dictates symptoms & approach |
| Nature | Animate (living) vs Inanimate (non-living) | Insect/maggot vs bead/pea | Animate → kill first; organic → no water |
| Composition | Organic (vegetable) vs Inorganic (metal/plastic) | Pea, seed vs bead, button battery | Organic swells with water → never syringe |
| Radiology | Radio-opaque vs radiolucent | Coin, battery, denture vs plastic, fish bone (most), aluminium ring-pull | Guides imaging utility |
High-yield: The single most-tested rule — vegetable/organic foreign bodies must NEVER be syringed, because water makes them swell, impact further and become harder to remove. Syringing is reserved for small, non-organic, non-hygroscopic foreign bodies.
A useful mental flow for ANY FB: Identify site → determine nature (animate/organic/battery?) → assess urgency → choose removal method under vision → confirm complete removal & check for a second FB.
Aural (ear) foreign bodies
Most common in children (beads, seeds, pieces of paper, parts of toys) and adults (cotton wool, broken matchsticks, insects). The external auditory canal has two narrow points — the junction of cartilaginous and bony canal (isthmus) and the region just lateral to the tympanic membrane — where FBs lodge.
Clinical features
- Often asymptomatic and found incidentally.
- Hearing loss (conductive) if canal occluded.
- Pain, especially with a live insect crawling/buzzing — intensely distressing.
- A neglected organic FB may cause otitis externa, foul discharge.
Animate FB (live insect)
The insect must be killed/immobilised before removal, otherwise its movements cause agony and may injure the tympanic membrane.
- Instil oil (liquid paraffin/olive oil), spirit, or 2% lignocaine to kill or immobilise it.
- Then remove by syringing (insect is non-hygroscopic) or with forceps/suction under vision.
High-yield: For a live insect in the ear → first kill it with oil/spirit/lignocaine, then remove. Lignocaine has the bonus of producing local anaesthesia and rapid insect death.
Inanimate FB — removal technique
| FB type | Preferred removal | Avoid |
|---|---|---|
| Small, smooth, non-organic (bead, glass) | Syringing (warm water/saline) or Jobson-Horne probe / blunt hook passed behind FB | Forceps (push it in) |
| Organic/vegetable (pea, seed) | Dry instrumentation — hook, microsuction, microforceps; under microscope | Never syringe (swells) |
| Hygroscopic & impacted | Removal under microscope ± GA | Repeated blind attempts |
| Smooth spherical objects | Blunt hook/ring curette passed beyond the FB | Grasping forceps (slips, pushes deeper) |
Key technical points:
- Use a blunt hook or Jobson-Horne probe passed beyond the FB and withdrawn — never try to grasp a smooth round object with forceps (it slips medially).
- Irregular/graspable objects (cotton, paper, matchstick) → crocodile/Tilley's forceps.
- Disc/button batteries in the ear → urgent removal (liquefactive necrosis, same logic as nose — see below).
- General anaesthesia is indicated in uncooperative children, deeply impacted or sharp FBs, or after failed OPD attempts (multiple traumatic attempts cause canal laceration & oedema).
High-yield: Contraindications to ear syringing — suspected/known tympanic membrane perforation, presence of a vegetable FB, and a grommet in situ. Syringing a perforation can drive infection into the middle ear and cause vertigo.
Nasal foreign bodies
Almost exclusively a problem of children (and the mentally subnormal). Common objects: beads, peas, buttons, paper, foam, and the dreaded button (disc) battery. Lodge usually on the floor of the nose below the inferior turbinate or just anterior to the middle turbinate.
Clinical features
- The classic triad/clue: unilateral, foul-smelling, blood-stained (sanguinopurulent) nasal discharge in a child → think nasal FB until proved otherwise.
- Unilateral nasal obstruction, sneezing.
- A long-standing neglected FB can become coated with calcium/magnesium salts forming a rhinolith.
High-yield: Unilateral foul, blood-tinged nasal discharge in a child = nasal foreign body until proven otherwise. (Bilateral discharge points away from FB.)
Button (disc) battery — the true emergency
A button battery in the nose is an ENT emergency requiring immediate removal.
- Mechanism: liquefactive necrosis from leaked alkali + low-voltage electrical current generating hydroxide at the negative pole + pressure necrosis. Damage begins within hours.
- Complications if delayed: septal perforation, synechiae, saddle nose, mucosal destruction.
High-yield: Button battery in nose (or oesophagus) → remove immediately, do not delay, do not irrigate-and-wait. Tissue necrosis can start within 1–2 hours.
Removal technique (nose)
- Position & calm the child; good light (headlight) and topical decongestant (xylometazoline) ± topical anaesthetic.
- Pass a blunt hook / Eustachian catheter / right-angled probe behind the FB and draw it forward — the safest manoeuvre.
- "Parent's kiss" / positive-pressure technique — occlude the unaffected nostril, parent blows a puff into the child's mouth → FB expelled by air. Good for soft anterior FBs.
- Balloon catheter (small Fogarty/Foley) passed beyond and inflated, then withdrawn.
- Avoid pushing the FB backwards — risk of aspiration into the airway.
- General anaesthesia if uncooperative, posterior, impacted, or first attempt failed (and to protect the airway).
High-yield: Forceps grasping a smooth round nasal FB risks pushing it posteriorly into the nasopharynx/airway → always go behind it with a hook, or use positive-pressure ("parent's kiss").
Pharyngeal foreign bodies
Usually sharp objects — fish bones, chicken bones, pins, dentures. They lodge at sites where mucosa is exposed and the lumen narrows.
Common impaction sites
- Tonsil & tonsillar pillars (commonest for fish bones)
- Base of tongue / vallecula
- Pyriform fossa
- Posterior pharyngeal wall
Clinical features
- Sharp pricking pain on swallowing, localised, often pointed to by the patient.
- Excessive salivation; the patient can usually still swallow saliva (unlike complete oesophageal obstruction).
Diagnosis & removal
- Oropharynx: inspect directly; remove tonsillar/base-of-tongue bone with Tilley's or curved forceps after topical anaesthesia.
- Hypopharynx: indirect laryngoscopy / flexible endoscopy; pyriform fossa bones removed under vision.
- Lateral soft-tissue neck X-ray may show the bone or, more usefully, secondary signs (see oesophagus). Many fish bones are radiolucent, so a normal X-ray does NOT exclude FB.
High-yield: A patient who localises a sharp pricking pain to one side of the throat after a fish meal, with a normal-looking oropharynx, needs endoscopic examination of the hypopharynx (pyriform fossa, vallecula) — don't stop at the tonsil.
Oesophageal foreign bodies
Heavily tested. Objects: coins (children), meat bolus & dentures (adults), bones, button batteries. Adults with bolus impaction frequently have an underlying oesophageal pathology (stricture, web, ring, achalasia, carcinoma) — always evaluate later.
Sites of impaction — the anatomical narrowings
The oesophagus has physiological constrictions; FBs lodge at these.
| Constriction | Distance from incisors | Notes |
|---|---|---|
| Cricopharyngeal sphincter (cricopharynx) | ~15 cm | Narrowest part & commonest site of FB impaction, esp. coins |
| Aortic arch / left main bronchus crossing | ~22–25 cm | Second site |
| Gastro-oesophageal junction (diaphragm) | ~38–40 cm | Lower site |
High-yield: The cricopharyngeal sphincter (~15 cm from incisors) is the narrowest part of the oesophagus and the commonest site of foreign-body impaction (the upper oesophageal sphincter). Coins in children lodge here.
Clinical features
- Dysphagia / odynophagia, drooling and inability to swallow saliva (complete obstruction).
- Retrosternal discomfort, pointing to the level.
- Respiratory distress / stridor if a large FB compresses the trachea (especially in infants).
- Surgical emphysema, fever, chest pain → suggest perforation.
Coin orientation — classic radiology pearl
- A coin in the oesophagus lies in the coronal plane → appears EN-FACE (round/circular) on AP (frontal) chest X-ray, and edge-on (linear) on lateral.
- A coin in the trachea lies in the sagittal plane → appears as a line/edge (sagittal) on AP film and round on lateral.
High-yield: Oesophageal coin = round/face-on on AP X-ray; tracheal coin = sagittal/edge-on (linear) on AP X-ray. (Because of the incomplete posterior tracheal cartilage and the wide-set oesophagus, the coin aligns differently.)
Investigations
- Plain X-ray neck (soft tissue lateral) & chest — first-line for radio-opaque FB (coins, batteries, dentures with metal).
- Radiolucent FB / fish bones: X-ray may be normal; look for secondary signs — prevertebral soft-tissue widening, air in the soft tissues, loss of cervical lordosis.
- Barium swallow is generally AVOIDED when endoscopy is planned (coats the FB & mucosa, risk of aspiration, and is contraindicated if perforation suspected). A cotton-wool soaked in dilute barium (cotton-wool sign) was an old method to catch a thin bone but is largely historical.
- CT scan — best for detecting non-opaque FB, complications (perforation, abscess) and planning.
- Button battery on X-ray → "double ring" / halo sign on frontal view and a step-off on lateral view (distinguishes it from a coin).
High-yield: A button battery shows a double-contour ("halo"/double-ring) sign on the AP X-ray — this differentiates it from a coin and mandates emergency removal.
Management — rigid vs flexible oesophagoscopy
This rigid-versus-flexible distinction is a favourite NEET PG point.
| Feature | Rigid oesophagoscopy | Flexible oesophagoscopy |
|---|---|---|
| Anaesthesia | General anaesthesia | Often local/sedation |
| Best for | Impacted, large, sharp FB; upper oesophagus / cricopharynx; button battery | Smooth FB, lower oesophagus, when GA risky |
| Control of sharp FB | Superior (can be withdrawn within the scope) | Limited |
| Therapeutic + airway control | Better | Less |
| Visualisation of mucosa/pathology | Good | Excellent (flexible reaches stomach) |
| Risk of perforation | Slightly higher (rigid instrument) | Lower |
General management flow: Stabilise airway → confirm site & nature (X-ray/CT) → NBM → urgent removal if battery/sharp/complete obstruction → endoscopic removal (rigid preferred for impacted/sharp/upper FB) → post-removal check for mucosal injury & re-scope to exclude a second FB / underlying pathology.
- A smooth, small, blunt FB (e.g., coin) that has reached the stomach in an asymptomatic patient can often be observed and allowed to pass per rectum (most pass within days). Serial X-rays track progress.
- Sharp objects, button batteries, magnets (≥2), and objects >5–6 cm long / >2.5 cm wide are unlikely to pass and warrant endoscopic removal.
- Multiple magnets are an emergency (attract across bowel walls → pressure necrosis, fistula, perforation).
- Meat bolus without bone: can give a short trial of conservative measures; many centres now use glucagon (relaxes lower oesophageal sphincter) — though evidence is modest; never push blindly.
High-yield: Button battery lodged in the oesophagus → emergency rigid oesophagoscopy and immediate removal, never observation — risk of full-thickness necrosis, tracheo-oesophageal fistula and aorto-oesophageal fistula (fatal haemorrhage).
Complications
- Aural: canal laceration, otitis externa, TM perforation, ossicular injury (from over-zealous instrumentation), button battery → canal necrosis & stenosis.
- Nasal: epistaxis, septal perforation & synechiae (battery), saddle nose, rhinolith, posterior displacement → aspiration.
- Oesophageal (most serious):
- Perforation → mediastinitis, surgical/cervical emphysema, retropharyngeal abscess.
- Tracheo-oesophageal fistula.
- Aorto-oesophageal fistula → massive, often fatal haematemesis (classically with batteries/sharp FB at aortic level).
- Stricture (late, post-battery or post-perforation).
Key differentials
- Unilateral foul nasal discharge in a child: FB vs choanal atresia (usually congenital, watery) vs antrochoanal polyp (older child, mucoid) vs sinusitis (usually bilateral).
- Globus pharyngeus / lingering FB sensation: a scratch from a passed fish bone can mimic a retained FB — endoscopy normal; reassure after exclusion.
- Dysphagia in adult with bolus impaction: always consider underlying stricture, web (Plummer-Vinson), eosinophilic oesophagitis, achalasia or carcinoma after removal.
- Stridor + FB: airway (laryngo-tracheo-bronchial) FB vs large oesophageal FB compressing trachea.
Recently asked / exam angle
- Narrowest part & commonest site of oesophageal FB impaction = cricopharynx (~15 cm from incisors) — repeatedly asked.
- Which FB should NOT be syringed? → Vegetable/organic (swells with water). Also TM perforation & grommet are contraindications.
- First step for a live insect in ear → instil oil/spirit/lignocaine to kill it before removal.
- Coin orientation: oesophageal = face-on (round) on AP; tracheal = edge-on (sagittal) on AP.
- Button battery in nose/oesophagus = emergency immediate removal; X-ray double-ring/halo sign; mechanism = liquefactive necrosis + electrical injury.
- Rigid vs flexible scope: rigid (under GA) preferred for impacted, sharp, upper oesophageal FB and batteries.
- Unilateral, foul, blood-stained nasal discharge in child = nasal FB.
- Most dangerous oesophageal FB complication = aorto-oesophageal fistula (with battery/sharp object).
- Smooth FB that reached stomach & asymptomatic → observe / allow to pass.
Quick mnemonics
- "VEG never gets a WASH" — VEGetable/organic FB → never WASH (syringe), it swells.
- Button Battery = "Burns in a Blink, Bring it out" — emergency, immediate removal.
- Coin: "Face the Front in the Food-pipe" — oesophageal coin is face-on (round) on the AP/frontal film.
Rapid revision
- Vegetable/organic FB → NEVER syringe (swells with water); use dry hook/suction under microscope.
- Live insect in ear → kill first with oil/spirit/2% lignocaine, then syringe or remove.
- Ear syringing contraindicated in TM perforation, organic FB, grommet in situ.
- Smooth round FB → pass a blunt hook behind it; never grasp with forceps (slips medially).
- Unilateral foul, blood-stained nasal discharge in a child = nasal FB.
- Button battery (nose/oesophagus) = emergency — immediate removal; liquefactive necrosis within hours.
- Button battery X-ray sign = double-ring/halo (frontal) + step-off (lateral).
- Cricopharynx (~15 cm from incisors) = narrowest part & commonest oesophageal FB site.
- Oesophageal coin = round/face-on on AP; tracheal coin = linear/edge-on on AP.
- Rigid oesophagoscopy (under GA) preferred for impacted, sharp, upper-oesophageal FB and batteries; flexible for smooth, lower FB.
- Smooth blunt FB in stomach, asymptomatic → observe, let it pass; sharp/battery/multiple magnets/long FB → remove.
- Worst oesophageal FB complication = aorto-oesophageal fistula (fatal haemorrhage); avoid barium if perforation/endoscopy planned.