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Paediatric nasopharyngeal foreign bodies

1999, Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India

Two unusual cases of foreign bodies, a metallic whistle and a wooden gutty with a threaded screw, lodged in the nasopharyngeal region are reported. The rare feature of absence pf symptoms inspite of impaction for long duration in the paediatric age group is recorded.

Paediatric Nasopharyngeal Foreign Bodies Manish Munjal, Sangeeta, R. S. Greval, Daljit Singh, Faculty of Otorhinolaryngology and Head Neck Surgery Anaesthesia and Paediatric Medicine Dayanand Medical College and Hospital, Ludhiana, Abstract Two unusual cases of foreign bodies, a metallic whistle and a wooden gutty with a threaded screw, lodged in the nasopharyngeal region are reported. The rare feature of absence of symptoms inspite of impaction for long duration in the paediatric age group is recorded. 0 80 IJO & HNS, August 1999 (Special Number, EB,) Paediatric Nasopharyngeal Foreign Bodies ---Manish Munjal et al T h e nasopharynx or the post-nasal space is the clinically inaccessible space behind the nasal cavity and above the uvulopalatal region. With respect to foreign bodies the significance of this region is that a relatively less sensitive mucosa lines it and the foreign body may be retained undetected for a long duration. Moreover if the size and shape of the extraneous object is such that it does not fall down into the oropharynx and laryngopharynx, it is lodged precisely at this site. The route of entry is the oral cavity and the oropharynx. The child usually is playing with a toy or object which can be grasped and it is innocuosly inserted in the mouth. An adult witnessing the event would catch the child at this juncture and with their index finger sweep out the foreign body, with an accompanying thump on the back. Case I A 3 year old male child was brought to the casualty of Dayanand Medical College and Hospital, Ludhiana. The tense parents gave a history of something behind the nose. Thudicum anterior rhinoscopy did not indicate any obstructive pathology in accessible nasal cavity. Auscultatory hiss was equal and present bilaterally. There was absence of crackle of stagnant secretions. Index finger digital palpation was not permitted by the anxious parents and the child. Sometimes a sibling tries to clear the oral cavity simulating his elders but accidently forces the foreign body into the nasopharynx. The victim may sometimes inadvertently push the foreign body in his own nasopharynx. Out of sheer fear of reprimand, the matter is not reported to the parents. Blood in oral secretions or epistaxis is a late presentation which occurs due to pressure necrosis. We report two children below five years of age who revealed quite late to their parents about something stuck behind their nose. Radiograph nasopharynx and neck lateral projection exhibited a silhoutte of a 'flying saucer", type of foreign body. (Fig. 1.) The child and the parents immediately identified it be a metallic whistle fitted in a pressure toy doll gifted to the, which was missing for the last one month. Case H A carpenter's four year old grand-daughter was "admitted to casualty with the complaint of something black coluured hanging behind the uvula. There was no complaint of recurrent rhinorrhea, mucoid or sanguinous, nor any bleed per os. A check radiograph nasopharynx and neck lateral projection revealed an impacted foreign body in the nasopharynx and neck Lateral projection revealed an impacted foreign body in the nasopharynx. IJO & fINS, August 1999 (Special Number, EB.) [] 81 Paediatric Nasopharyngeal Foreign Bodie --Manish Munjal et al (Fig. II.) The father described it as a wooden gutty with a threaded metallic screw. A gutty is a wooden block fixed in the wall for fitting wall hangings. In his professional work, the grandfather used to have such blocks lying around his place which the child must have picked up and inserted in her mouth. This happened during her visit to her grand-parents two months earlier. Management Under general anaesthesia administered via an endotracheal tube, bilateral red rubber catheters were inserted transnasally and withdrawn via the oropharynx. The uvulopalatal region was retracted and the foreign bodies were visualised wedged in the nasopharynx. The sharp edge of the whistle was prised carefully out of the fossae of Rosenmuller. The gutty was extracted by latching the universal Lucs forceps on to the screw and with gradual withdrawl with a rotational torque. The post operative period was uneventful. Minimal bleed per os halted with five minute pressure compression and instillation of 0.05% oxy zylometazoline. Antibiotics and antiinflammatory medication were administered orally for a period of seven days. Discussion The paediatric age group is notorious for association with insertion of anything and for that matter everything within reach, in the oral cavity. Sanowski, 1987. Peanuts, buttons, coins, rings, whistles etc, constitute the common inanimate extraneous objects which lodge in the aerodiogestive tract. Unawareness or ignorimg such an accident on the part of the parents leads to delay in seeking medical attention, or out of sheer fear the child may not disclose the accident, Bhargavae, 1992. A pterygopalptine fossa impacted foreign body has been described by Ghosh. 1978. A pterygopalptine fossa impacted foreign body has been described by Ghosh. 1978. This foreign body had pierced the lateral pharyngeal wall and was hidden from view. An upward ascent of an oral foreign body into the nasopharynx and its asymptomatic retention for more than a month is a rare presentation. Sharma and Bano, 1992. Similar two such cases were encountered by us, and in both the period of retenion was more than a month. In both patients the history was taken seriously and they were not sent off, after dispensing antihistamincs or analgesics, as is the usual practise. A radiographic assesment modality was resorted too and a definite diagnosis was made. Thereby we conclude that radiography lateral projection must be a requisite investigation in dealing with paediatric patients, who do not pemit digital assesment for where the narrow nasopharyngeal isthmus permits periscope mirror examination. References I. Sanowski, R.A. (1987) : Foreign body extraction, in the gastrointestinal tract. In : Sivak M. E, ed. Gastroenterological Endoscopy. Philadelphia : WB Saunders and Company, pp321-331. 2. Bhargavae, S.K. (192) : Rare foreign bodies in Laryngo-tracheo-bronchial tree with preventive profile, lndian Otolaryngol. Head Neck 1 (2) : 83 - 85. 3. Sharma, S. C., Bano. S. (1992) : An unusual foreign body in nasopharynx. Indian Journal of Otolaryngology, Head and Neck, Vol 1, March. 4. Ghosh, L. M., and Pal, P.K. (1989) : An unusual foreign body in neck. lndian Journal of Otolaryngology 41 : 150. 5. Ghosh, LM, Roy, P., Dandapath, A, Nandi, D. : Foreign body in the pterygopalatine fossa. Indian Journal of Otolaryngology, 30 (3) : 118. 82 IJO & HNS, August 1999 (Special Number, EB )