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Long lasting nasopharyngeal foreign body
Long lasting nasopharyngeal foreign body FARDIN EGHTEDARI,
MD,
Shiraz, Iran
An
8-year-old boy was referred to our ENT outpatient department with the complaint of halitosis, rhinorrhea, and mouth-breathing. Patient had no history of epistaxis or fever. He had been treated medically for a long period without significant improvement. Physical examination revealed foul-smelling nasal breathing, postnasal drip, and a moderate degree of bilateral mucopurulent nasal secretion. There was no obvious foreign body in the nose; the patient, however, was not cooperative enough for adequate suctioning and further nasal examination. Examination found that the ears and tonsils were normal. Radiographs showed the para nasal sinuses were normal. Due to the chronicity of the patient’s problem and the lack of benefit obtained after various medications, he was scheduled for examination under general anesthesia for better evaluation of possible nasal foreign body or chronic adenoiditis. There was no significant abnormality found in the nose except for some secretions and secondary inflamed mucosa. No foreign body was found in the nasal cavities, but some whitish material was seen deeply in the nasopharynx. Digital palpation was positive for a large, hard mass, which was impacted in the nasopharynx. With the use of a clamp, the mass was grasped and extracted. This foreign body was presumed to be a child’s toy (a small plastic tree) with some debris attached to it (Fig 1). The nasopharynx was otherwise normal. After showing the object to the parents, they remembered a transient choking episode when the child was playing with this plastic toy when he was 1.5-year-old. Follow-up examination showed complete improvement of patient’s complaints and findings of the nasopharynx.
From the Department of Otolaryngology, Khalili Hospital, Shiraz University of Medical Sciences. Reprint requets: Fardin Eghtedari, MD, 253, Lane 22, Eram St., Shiraz, 71437 Iran; e-mail, [email protected] Otolaryngol Head Neck Surg 2003;129:293-4. Copyright © 2003 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2003/$30.00 ⫹ 0 doi:10.1016/S0194-5998(03)00471-6
Fig 1. Nasopharyngeal foreign body.
DISCUSSION This case has been reported as a presentation of a foreign body with 4 unusual aspects: 1. A foreign body in the nasopharynx is a rare entity. This condition is more often seen in patients with a palatal defect or after a penetrating trauma.1,2 This entity is encountered more frequently in veterinary medicine.3 In children the diagnosis of a nasal foreign body is not difficult, because it presents with a typical history of unilateral fetid rhinorrhea. Bilateral rhinorrhea, however, makes the physician think of differential diagnosis other than foreign bodies. 2. After a choking spell, the foreign body has been impacted in the nasopharynx instead of more usual anatomic areas such as the esophagus or laryngopharynx. We know that foreign body aspiration and ingestion are more common entities after oral manipulations of small size objects by children. These 2 entities have their specific presentations, such as respiratory difficulty or dysphagia, which is more easily recognized by physicians.4 Nasopharyngeal impaction of an object may be silent and presents with sign and symptoms that may lead the physicians to think of more common conditions, such as allergic rhinitis or denoid hypertrophy. 293
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294 EGHTEDARI
3. The long duration of presence of the foreign body before diagnosis and removal: about 6.5 years! This long period of undiagnosed foreign body in the upper airway is interesting. It has been reported that in a quarter of pediatric patients with aspiration of a foreign body, a positive history cannot be obtained. In nearly one third of children ingesting foreign bodies, the event is not witnessed.5 However, in our case, the parents had forgotten the choking episode until remembered by seeing the foreign body probably because their child had not developed significant symptoms in the early or intermediate period of time. 4. No development of significant local complication such as epistaxis or otitis media despite prolonged impaction. This may be due
to the inert nature of this inorganic foreign body and to the shape of this foreign body, which had permitted air passage through its leaves and branches. REFERENCES
1. Walby AP. Foreign bodies in the ear or nose. In: Kerr AG, editor. Scott-Brown’s Otolaryngology, 6th ed. Oxford: Butterworth-Heinemann; 1997. p. 6/14/1-6. 2. Gendeh BS, Gibb AG. An unusual foreign body presenting in the nasopharynx. J Laryngol Otol 1988;102:641-2. 3. Dodd DC. Nasopharyngeal foreign body. J Am Vet Med Assoc 1993;202:1042. 4. Murray AD, Mahoney EM, Holinger LD. Foreign bodies of the airway and esophagus. In: Cummings CW, Frerickson JM, Krause CJ, et al, eds. Otolaryngology head and neck surgery, 6th ed, vol 5. St Louis: Mosby Inc; 1998. p. 377-87. 5. Cohen SR, Herbert WI, Lewis GH, et al. Foreign bodies in the airway: a five-year retrospective study with special reference to management. Ann Otol Rhinol Laryngol 1980;89:437-42.
MD,
Shiraz, Iran
An
8-year-old boy was referred to our ENT outpatient department with the complaint of halitosis, rhinorrhea, and mouth-breathing. Patient had no history of epistaxis or fever. He had been treated medically for a long period without significant improvement. Physical examination revealed foul-smelling nasal breathing, postnasal drip, and a moderate degree of bilateral mucopurulent nasal secretion. There was no obvious foreign body in the nose; the patient, however, was not cooperative enough for adequate suctioning and further nasal examination. Examination found that the ears and tonsils were normal. Radiographs showed the para nasal sinuses were normal. Due to the chronicity of the patient’s problem and the lack of benefit obtained after various medications, he was scheduled for examination under general anesthesia for better evaluation of possible nasal foreign body or chronic adenoiditis. There was no significant abnormality found in the nose except for some secretions and secondary inflamed mucosa. No foreign body was found in the nasal cavities, but some whitish material was seen deeply in the nasopharynx. Digital palpation was positive for a large, hard mass, which was impacted in the nasopharynx. With the use of a clamp, the mass was grasped and extracted. This foreign body was presumed to be a child’s toy (a small plastic tree) with some debris attached to it (Fig 1). The nasopharynx was otherwise normal. After showing the object to the parents, they remembered a transient choking episode when the child was playing with this plastic toy when he was 1.5-year-old. Follow-up examination showed complete improvement of patient’s complaints and findings of the nasopharynx.
From the Department of Otolaryngology, Khalili Hospital, Shiraz University of Medical Sciences. Reprint requets: Fardin Eghtedari, MD, 253, Lane 22, Eram St., Shiraz, 71437 Iran; e-mail, [email protected] Otolaryngol Head Neck Surg 2003;129:293-4. Copyright © 2003 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2003/$30.00 ⫹ 0 doi:10.1016/S0194-5998(03)00471-6
Fig 1. Nasopharyngeal foreign body.
DISCUSSION This case has been reported as a presentation of a foreign body with 4 unusual aspects: 1. A foreign body in the nasopharynx is a rare entity. This condition is more often seen in patients with a palatal defect or after a penetrating trauma.1,2 This entity is encountered more frequently in veterinary medicine.3 In children the diagnosis of a nasal foreign body is not difficult, because it presents with a typical history of unilateral fetid rhinorrhea. Bilateral rhinorrhea, however, makes the physician think of differential diagnosis other than foreign bodies. 2. After a choking spell, the foreign body has been impacted in the nasopharynx instead of more usual anatomic areas such as the esophagus or laryngopharynx. We know that foreign body aspiration and ingestion are more common entities after oral manipulations of small size objects by children. These 2 entities have their specific presentations, such as respiratory difficulty or dysphagia, which is more easily recognized by physicians.4 Nasopharyngeal impaction of an object may be silent and presents with sign and symptoms that may lead the physicians to think of more common conditions, such as allergic rhinitis or denoid hypertrophy. 293
Otolaryngology– Head and Neck Surgery September 2003
294 EGHTEDARI
3. The long duration of presence of the foreign body before diagnosis and removal: about 6.5 years! This long period of undiagnosed foreign body in the upper airway is interesting. It has been reported that in a quarter of pediatric patients with aspiration of a foreign body, a positive history cannot be obtained. In nearly one third of children ingesting foreign bodies, the event is not witnessed.5 However, in our case, the parents had forgotten the choking episode until remembered by seeing the foreign body probably because their child had not developed significant symptoms in the early or intermediate period of time. 4. No development of significant local complication such as epistaxis or otitis media despite prolonged impaction. This may be due
to the inert nature of this inorganic foreign body and to the shape of this foreign body, which had permitted air passage through its leaves and branches. REFERENCES
1. Walby AP. Foreign bodies in the ear or nose. In: Kerr AG, editor. Scott-Brown’s Otolaryngology, 6th ed. Oxford: Butterworth-Heinemann; 1997. p. 6/14/1-6. 2. Gendeh BS, Gibb AG. An unusual foreign body presenting in the nasopharynx. J Laryngol Otol 1988;102:641-2. 3. Dodd DC. Nasopharyngeal foreign body. J Am Vet Med Assoc 1993;202:1042. 4. Murray AD, Mahoney EM, Holinger LD. Foreign bodies of the airway and esophagus. In: Cummings CW, Frerickson JM, Krause CJ, et al, eds. Otolaryngology head and neck surgery, 6th ed, vol 5. St Louis: Mosby Inc; 1998. p. 377-87. 5. Cohen SR, Herbert WI, Lewis GH, et al. Foreign bodies in the airway: a five-year retrospective study with special reference to management. Ann Otol Rhinol Laryngol 1980;89:437-42.