Key Facts

Foreign bodies in the ear, nose, and throat are among the most common ENT emergencies, particularly in the paediatric population. Most can be managed in the emergency department or primary care, but certain foreign bodies (button batteries, airway FBs) constitute true emergencies requiring immediate intervention.

Epidemiology

• Nasal FB: peak age 2-5 years; accounts for up to 25% of paediatric ENT emergencies
• Ear FB: common across all ages; children (beads, small toys), adults (cotton buds, insects)
• Inhaled (airway) FB: peak 1-3 years; significant cause of paediatric mortality (NICE)
• Ingested FB (throat): common in adults (fish bones) and children (coins)

Aetiology

• Nasal: beads, buttons, peas, tissue paper, button batteries, magnets
• Ear: beads, insects, cotton bud tips, stones, hearing aid parts, button batteries
• Throat/oesophagus: fish bones, coins, food bolus, dentures
• Airway (laryngotracheal/bronchial): peanuts (most common), small toy parts, food items

Pathophysiology

• Nasal FB: causes unilateral mucopurulent rhinorrhoea, mucosal irritation, infection
• Button batteries: generate electric current causing alkaline burns, tissue necrosis, septal perforation within 2 hours
• Ear FB: may impact against TM, cause otitis externa, or be asymptomatic
• Airway FB: partial or complete airway obstruction; ball-valve effect may cause unilateral hyperinflation, atelectasis, or pneumonia
• Oesophageal FB: may cause dysphagia, pain; perforation risk with sharp or button battery objects

Nasal Foreign Body

• Unilateral foul-smelling nasal discharge (most common presenting feature)
• Nasal obstruction
• Epistaxis
• Child may be unaware or deny insertion

Ear Foreign Body

• Ear pain or discomfort
• Hearing loss (if EAC obstructed)
• Buzzing (if insect — live insect causes extreme distress)
• Otorrhoea
• May be asymptomatic (incidental finding)

Inhaled (Airway) Foreign Body

• Acute: choking episode, coughing, stridor, wheeze, respiratory distress
• Chronic (missed aspiration): recurrent pneumonia, persistent cough, unilateral wheeze
• Witnessed choking event (often not reported by the time of presentation)

Throat/Oesophageal Foreign Body

• Sensation of something stuck in the throat
• Odynophagia
• Drooling (complete obstruction)
• Sharp pain localised to neck

Red Flags

• Stridor or respiratory distress (airway FB — emergency)
• Button battery in nose or oesophagus (tissue necrosis emergency)
• Complete airway obstruction (back blows, abdominal thrusts)
• Drooling with inability to swallow (oesophageal obstruction)
• Sharp object (perforation risk)

Bedside

• Anterior rhinoscopy or otoscopy: direct visualisation of FB
• Flexible nasendoscopy: for posterior nasal or pharyngeal FB
• Oropharyngeal examination with tongue depressor and headlight
• Respiratory assessment (chest auscultation for inhaled FB: unilateral reduced air entry, wheeze)

Imaging

• X-ray (AP and lateral): for radio-opaque objects (coins, batteries, metallic items)
  • Lateral neck X-ray: for oesophageal or pharyngeal FB (disc battery appears as 'double ring' sign)
  • Chest X-ray: inhaled FB — unilateral hyperinflation, mediastinal shift, atelectasis
  • Inspiratory/expiratory CXR or lateral decubitus films: air trapping on affected side
• CT: if FB location unclear or complications suspected

Special Tests

• Rigid bronchoscopy: diagnostic and therapeutic for inhaled FB
• Rigid oesophagoscopy: for oesophageal FB removal
• Flexible nasendoscopy: to visualise pharyngeal/laryngeal FB

Nasal Foreign Body

• Positive pressure technique ('mother's kiss'): parent occludes unaffected nostril, delivers sharp puff of air into child's mouth — may dislodge FB
• Instrumented removal: Jobson-Horne probe, crocodile forceps, suction, balloon catheter (Fogarty) passed behind FB
• Button battery: remove IMMEDIATELY under direct vision; do NOT irrigate; apply honey to anterior nares if delay anticipated (shown to reduce tissue damage)
• ENT referral if failed removal after 1-2 attempts; removal under GA if needed

Ear Foreign Body

• Insects: kill first with olive oil or 2% lidocaine drops, then remove
• Removal with Jobson-Horne probe, crocodile forceps, or suction
• Irrigation: effective for smooth, non-organic objects with intact TM; AVOID for organic material (swells), button batteries, or perforated TM
• ENT referral: impacted objects, failed removal, uncooperative child, suspected TM damage

Inhaled (Airway) Foreign Body

• Complete obstruction: back blows (infant <1 year), abdominal thrusts (Heimlich, >1 year and adults) — BLS protocol
• Partial obstruction, stable: do NOT intervene; keep calm, allow coughing, transport to hospital
• Definitive: rigid bronchoscopy under GA for removal (paediatric/ENT surgeon)
• Flexible bronchoscopy may be used in adults

Throat/Oesophageal Foreign Body

• Visible fish bone: remove with Magill forceps or Tilley forceps under direct vision
• If not visible: flexible nasendoscopy to locate
• Oesophageal FB: rigid or flexible oesophagoscopy under GA
• Button battery in oesophagus: EMERGENCY removal (risk of aorto-oesophageal fistula)

Referral Criteria

• Emergency: airway FB, button battery (nose or oesophagus), sharp object, respiratory distress
• Urgent ENT: failed removal, impacted FB, suspected complications
• All children with suspected inhaled FB: paediatric ENT/respiratory for bronchoscopy

• Most FBs in ear and nose: excellent prognosis with appropriate removal
• Button battery: if removed within 2 hours, minimal damage; delayed removal causes septal perforation (nose) or oesophageal perforation/fistula (oesophagus)
• Inhaled FB: prompt bronchoscopic removal: excellent outcome; delayed diagnosis increases risk of pneumonia, bronchiectasis, lung abscess
• Oesophageal FB: risk of perforation (sharp objects, batteries); mediastinitis if perforated
• Complications of removal: mucosal trauma, bleeding, TM perforation (ear), laryngospasm (airway)
• Prevention: parental education about choking hazards in young children is essential

Button Battery Emergency Protocol

Foreign Body Removal Techniques