Nasopharyngeal Foreign Bodies SOHIT KANOTRA*, MOHD. LATEEF**, SHOWKAT AHMED Abstract Nasopharyngeal foreign bodies are rare and are likely to be missed. A high index of suspicion is required for their diagnosis. While reporting three cases of nasopharyngeal foreign bodies, the problems in their diagnosis and management have been discussed. Keywords: Nasopharynx, foreign bodies, sewing needle The otolaryngologic literature is abundant with case reports of unusual foreign bodies in the upper aerodigestive tract. Of these, nasopharyngeal foreign bodies are rare. Only imagination limits the objects and circumstances that result in things getting stuck inside the nose. Sharp foreign bodies pose a greater problem as they can pierce the soft tissues of the nose and pharynx and lead to complications. The removal of such foreign bodies poses a challenge as damage to the surrounding structures can occur if these are not carefully tackled. On the other hand inert foreign bodies have been known to remain unsuspectingly in the nasopharynx for prolonged periods of time. 1 Being a blind area which is difficult to examine, especially in children who are the usual victims, foreign bodies in the nasopharynx are likely to be missed. The use of nasal endoscopes has revolutionized the otolaryngologist s ability to visualize not only the intranasal structures but also the nasopharynx, thus helping the surgeon to localize and remove foreign bodies not visible on anterior rhinoscopy. We present here three cases of nasopharyngeal foreign bodies, which illustrate some aspects of such foreign bodies. Case 1 A 4-year-old female child was brought with a history of having swallowed a match stick two hours before. The mother had seen the child gagging after putting the *Postgraduate Student **Professor and Head Registrar Dept. of ENT, Head and Neck Surgery, Govt. Medical College, Srinagar Address for correspondence Dr Sohit Kanotra, Postgraduate Student, Dept. of ENT, Head and Neck Surgery Govt. Medical College, Srinagar, Kashmir E-mail: sohit_kanotra@rediffmail.com match stick in the mouth and unsuccessfully attempted to remove the same by putting her finger in the throat of the child. In the process the child had vomited. The child had been seen by an ENT specialist who had advised an examination under general anesthesia the next day. On presentation, the child was uncomfortable and complained of pain in the throat. Oral cavity examination did not reveal any foreign body but as the patient gagged during examination, the tip of the match stick covered with mucoid secretions was seen behind soft palate. This was held with a hemostat and removed without anesthesia. Case 2 A 2-year-old child had put a plastic ring from a toy into the mouth and had an attack of choking. The mother had put her finger into her mouth to retrieve the foreign body but the child vomited and became comfortable. The child was taken to the ENT specialist who performed hypopharyngoscopy, esophagoscopy and bronchoscopy under gneral anesthesia the next day and ruled out any foreign body impaction. However, nasal endoscopy was not done due to nonavailability of the endoscope. Following this, the parents had noted that the child had started snoring heavily, and the ENT surgeon had attributed it to the presence of adenoids which was confirmed on X-ray of the nasopharynx. The child also had recurrent attacks of nasal obstruction with cough and cold which were treated with antibiotics and decongestants with partial relief. One year after the incidence, the child suddenly sneezed and brought out the plastic ring from the mouth. After this, there was marked reduction in her snoring though she continues to have recurrent nasal obstruction due to adenoids over the past one year. 392 Indian Journal of Clinical Practice, Vol. 22, No. 8, January 2012
Case 3 An 18-year-old female presented in the ENT emergency with a history of accidental lodgment of a sewing needle in her right nasal cavity four hours back. She was trying to pierce her nostril when the needle accidentally slipped into her nose. The patient was quite uncomfortable and was complaining of severe pain on the right side of nose radiating to the whole of the face. There was no history of epistaxis or any other nasal symptom. Anterior rhinoscopy did not reveal any foreign body in the nasal cavity. Posterior rhinoscopy was also inconclusive with no evidence of the needle. An oropharyngeal examination did not reveal any postnasal bleed. An X-ray skull lateral view was taken and showed the presence of the needle (Fig. 1). The needle was seen lying along the floor of the nasal cavity extending to the nasopharynx with the pointed end placed anteriorly. The patient was planned for endoscopic retrieval of the foreign body. The nasal cavity was decongested by instillation of xylometazoline nose drops followed by 10% lignocaine spray. A 0 nasal endoscope revealed the presence of the sewing needle which had pierced the posterior end of the inferior turbinate with the blunt end lying freely in the nasopharynx. A Blakesley foreceps was passed along the endoscope and the foreign body gripped under vision. The needle (Fig. 2) was then disengaged from the posterior end of the inferior turbinate by pushing it posteriorly and removed via the anterior nares with no damage to the surrounding mucosa. A check endoscopy was done. There was no bleeding and the patient was discharged after an hour of observation. Discussion Foreign bodies can reach the nasopharynx either through the nose or through the oropharynx and rarely a penetrating foreign body may lodge in the nasopharynx. Foreign bodies introduced into the nose are a common occurrence in children who out of curiosity or boredom want to explore the body orifices and thus any object small enough to enter the anterior nares has been removed from the nasal cavity. In adults, nasal foreign bodies are seen usually in mentally deranged individuals or may reach accidentally. Foreign bodies in the nose typically lodge near the floor of the nose below the inferior turbinate though these can be seen in any part of the nasal cavity. Attempts at removal of such foreign bodies by the patients themselves or those around can push them back into the pharynx and occasionally these may get lodged in the nasopharynx. Most of the foreign bodies entering the oral cavity pass into the esophagus Figure 1. Lateral X-ray nasopharynx showing the needle. Figure 2. The sewing needle after removal. and some are inhaled into the trachea. It is unusual for a foreign body taken orally to reach the nasopharynx. Various reasons for such an occurrence include attempts at digital removal, 2 regurgitation due to vomiting or coughing 3 or if the foreign body is put into the mouth in lying down position with the neck extended making the nasopharynx-dependent. 4 A large size of the foreign body has been cited as another factor. 5 In addition, animate foreign bodies like leeches can reach the nasopharynx through the nose or a round worm can get lodged in the nasopharynx during vomiting. A high index of suspicion is required for the diagnosis of nasopharyngeal foreign bodies. Adults may localize the foreign body in the nasopharynx but children may not be able to do the same. Posterior rhinoscopy where possible can be helpful. It is customary to take X-rays of the neck, chest and abdomen in children presenting with foreign body ingestion but it is important to take a lateral view of the nasopharynx also. If the foreign body cannot be found in the aerodigestive tract, a simple digital examination Indian Journal of Clinical Practice, Vol. 22, No. 8, January 2012 393
Cente
r Advt
of the nasopharynx should be performed to rule out the presence of foreign body there. In a conscious child, digital examination of the nasopharynx can be a frightening and annoying experience but in the absence of nasal endoscope, this could easily detect the presence of a foreign body in the nasopharynx. However, this is best avoided in case of sharp foreign bodies. The second case is an example where digital examination would have diagnosed the presence of the nonradio-opaque foreign body in the nasopharynx even if the nasal endoscope was not available. In children with a history of foreign body insertion into the nose, when anterior rhinosocopy with a nasal speculum or an auroscope fails to reveal the foreign body, an endoscopic examination can be performed under general anesthesia or under local anesthesia in co-operative children. Apart from examination of the nasal cavities, nasopharyngoscopy should also be performed. Regarding case No. 3, there are only a few reports in literature describing lodgment of sewing needles in nasal cavity although such foreign bodies do get impacted in the hypopharynx, 6 albeit rarely. Sewing needles have got impacted in the nasopharynx of magicians 7,8 and had to be removed under general anesthesia. An interesting case of a sewing needle reaching the maxillary antrum through a carious tooth has also been described. 9 Various methods have been described for the removal of nasal foreign bodies like instrumental removal, positive pressure technique, use of Foley s catheter or Fogarty balloon and even cyanoacrylate glue. 10 But except for the first modality, the rest of the methods can not be used for removal of nasopharyngeal foreign bodies. The basic principle in the removal of a foreign body is its adequate visualization. For nasopharyngeal foreign bodies, nasal endoscopy provides the only method of proper visualization especially for sharp foreign bodies whose retrieval can cause damage to the surrounding tissues. Perforation of the pharyngeal wall is a real threat and retropharyngeal abscess formation has been reported. 7 Direct exposure of the nasopharynx by retraction of the soft palate with catheters could be helpful in large sized blunt foreign bodies. The sewing needle located in the nasopharynx in case No. 3 could only be removed endoscopically since it could not be visualized otherwise. Use of fluoroscopy or a magnet can be other possible ways of removal of a sharp metallic needle. Conclusions One must keep in mind the nasopharynx as a site for lodgment while investigating cases of foreign body ingestion. Apart from taking X-rays of the neck, chest and abdomen, lateral view of the nasopharynx should be included in the films. In case of nonradio-opaque foreign bodies, digital palpation of the nasopharynx though annoying should be employed but should be avoided in case of sharp foreign bodies. Nasopharyngoscopy is extremely useful for diagnosis and removal of foreign bodies from the nasopharynx. References 1. Ogut F, Bereketoglu M, Bilgen C, Totan S. A metal ring that had been lodged in a child s nasopharynx for 4 years - Brief Article. Ear Nose Throat J 2001;80(8):520-2. 2. Sangeeta MM, Greval RS, Singh D. Paediatric nasopharyngeal foreign bodies. Indian J Otolaryngol Head Neck Surg 1999;51 Suppl 1:80-2. 3. Ransome J. Foreign bodies in the nose: Scott-Brown s Otolaryngology. 5th edition, Vol. 6, Kerr AG (Ed.), Butterworth: London 1987:276. 4. Majumdar PK, Sinha AK, Mookherje PB, Ganguly SN. An unusual foreign body (10 N.P. Coin) in nasopharynx. Indian J Otolaryngol Head Neck Surg 1999;52(1):93. 5. Sharma SC, Bano S. An unusual foreign body in nasopharynx. Indian J Otolaryngol Head Neck Surg 1992;1:42-3. 6. Shiv Kumar AM, Naik AS, Prashanth KB, et al. Foreign bodies in upper digestive tract. Indian J Otolaryngol Head Neck Surg 2006;58:63-8. 7. Onakoya PA, Adoga AA, Adoga AS, Galadima C, Nwaorgu OG. An unusual rhino-pharyngeal foreign body. West Afr J Med 2005;24(1):89-91. 8. Ahmed BM. Needles in the nose and pharynx: resulting from traditional magic in Maiduguri, Nigeria. Trop Doct 2005;35(1):39-40. 9. Domanskiz, Fuchs G. An unusual case of a foreign body in the maxillary sinus. Otolaryngol Pol 1997;51(4):414-7. 10. Cox RJ. Foreign Bodies Nose: e Medicine Oct. 6, 2005. 396 Indian Journal of Clinical Practice, Vol. 22, No. 8, January 2012