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A Nasopharyngeal Foreign Body Presenting As Adenoid

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A five year old girl presented with history of nasal obstruction, snoring, nasal discharge from last one year. X-Ray of nasopharynx showed obstruction of airway and diagnosis of Enlarged adenoid was made. Under anesthesia, before removal of adenoid, a plastic foreign body was found, which was a piece of toy.

Case Report A Nasopharyngeal foreign body presenting as adenoid M Usman Ahmed, M Riaz Akhter, Tariq M Mufti, Amanat Khan, Amna Usman From department of Otolayngology, Wah Medical College, Wah Cantt. and Shifa International Hospital, Islamabad Correspondance: Dr M Usman Ahmed, Assistant Professor of ENT Wah Medical College, Wah Cantt. Email:[email protected] Received: July 27, 2007 Accepted: August 21, 2007 ABSTRACT A five year old girl presented with history of nasal obstruction, snoring, nasal discharge from last one year. X-Ray of nasopharynx showed obstruction of airway and diagnosis of Enlarged adenoid was made. Under anesthesia, before removal of adenoid, a plastic foreign body was found, which was a piece of toy. (Rawal Med J 2007;32:203-204). Key words: Nasopharyngeal foreign body, airway obstruction, adenoids INTRODUCTION An enlarged adenoid in children is a very common condition in clinical practice. Usually, these children present with nasal obstruction, epistaxis, and nasal discharge. They have typical adenoid faces with orthodontic problems. When adenoids are enlarged they cause eustachian tube dysfunction secondary to obstruction and infection leads to serous otitis media. X-Ray of nasopharynx shows enlarged adenoid and obstruction of airway. Foreign bodies of aerodigestive tract in children are very common and every hospital encounters these emergencies. Foreign bodies are impacted in all the passages including ear, nose, and throat. But foreign bodies are very rare in nasopharynx. 1 How they are impacted is probably through nasal route and later impacted and un-noticed in nasopharynx. It is also advised that when ever a child comes with foul smell from nose until proven otherwise there is a foreign body impacted in nose. 2 X-Rays are usually diagnostic for radio opaque foreign body.3 CASE REPORT A five year girl presented in outpatient clinic with snoring, nasal obstruction and nasal discharge from last one year. There was minimal air flow through nares. Rhinoscopy was absolutely normal; endoscopy was not possible without sedation. X-Ray nasopharynx showed obstructed nasopharyngeal lumen with no air passage (fig. 1). Fig 1. Obstructed lumen of airway. A diagnosis of enlarged adenoids was made. Adenoidectomy was planned. Conventional way for adenoidectomy using oral approach was used. When mirror was placed to visualize nasopharynx, a plastic foreign body impacted in adenoids was noted. It was removed using forceps under direct vision. It was a piece of toy made of plastic (fig. 2). After removal of foreign body airway became patent. DISCUSSION Adenoid and lymphatic enlargement are very common in children. Nasal obstruction, rhinorrhea, hyponasal voice, mouth breathing and snoring are most common presentations. It is the most common cause of sleep apnea syndrome in children. This child also came to us with nasal obstruction and mouth breathing. Lateral view x-ray of soft tissue of neck showed minimal air shadow in nasopharynx. Foreign body was incidently found instead of enlarged adenoids. Fig 2. Retrieved foreign body. Foreign bodies in nose are very common.4 Every ENT department encounters it every day, but nasopharyngeal foreign bodies are very rare and it is difficult even to suspect in the absence of radio opaque foreign body. It is also suggested that if swallowed foreign bodies could not be found anywhere, nasopharynx should be examined. 5,6 Suspicion of foreign bodies in nasopharynx is strong whenever a foul smelly discharge is present or a radio opaque shadow is present on imaging. Most of the foreign bodies in the nasopharynx are found on X-Rays and were opaque.7 But in our case, there was no clue that it could be foreign body and we treated that case first conservatively, then surgery was advised for adenoidectomy. This was a very uncommon presentation. In another case report,8 foreign body of nasopharynx presented with sinusitis, was radio opaque and was found impacted in nasopharynx which was the cause of nasal obstruction. In conclusion, foreign bodies in children can be impacted anywhere and nasopharynx, which is a rare site for foreign body impaction, should be considered. REFERENCES 1. Middleton WG, Lawson VG. Fishing for foreign bodies. Otolaryngol. 1986;15:124-6. 2. Boltabaev FB. Foreign body in the nasopharynx of a 1.5-year-old boy. Vestn Otorinolaringol. 1987;(4):61 3. Baldwin CJ, Majumder S. A technique to localize the radio-opaque foreign body. Plast Reconstr Surg. 2005;115:1804. 4. Martins RH, Mano JB, da Silva EF. Foreign body in nasopharynx: an accidental radiological finding. Rev Bras Otorrinolaringol (Engl Ed). 2006;72:431. 5. Parker AJ, Bingham BJ, Osborne JE. Swallowed foreign body: Is it in the nasopharynx. Postgrad Med J. 1988;64:201-3. 6. Oysu C, Yilmaz HB, Sahin AA, Kulekci M. Marble impaction in nasopharynx following oral ingestion. Eur Arch Otorhinolaryngol. 2003;260:522-3. 7. Hameed MK. An unusual foreign body in nasopharynx. J Coll Physicians Surg Pak. 2005;15:178-9. 8. Gendeh BS, Gibb AG. An unusual foreign body presenting in nasopharynx. J Laryngol Otol. 1988;102:641-2.