A metal ring that had been lodged in a child's nasopharynx for 4 years.

Abstract

A considerable number of articles on foreign-body ingestion and inhalation have been reported in the literature. Of these, nasopharyngeal foreign bodies are rare. Unless they cause total obstruction, symptoms typically appear late. Foreign bodies, especially metal ones, can lodge in soft tissue, and their removal can be rather complicated. In this article, we describe the case of a 4-year-old girl who had had a gold ring lodged in her nasopharynx. The history led us to determine that the ring had been there since the child was 3 months old. A flexible fiberoptic nasopharyngeal examination revealed that the ring was embedded in the nasal surface of the soft palate and was enclosed by a thin layer of mucosal membrane. With the patient under general anesthesia, we were able to remove the foreign body with a 0[degrees] endoscope.

Introduction

Many cases of foreign-body ingestion and inhalation have been reported in the literature. [1-5] The management of these cases varies greatly according to the object's composition, location, and depth of penetration. Embedded foreign bodies that are made of inert material such as gold can remain asymptomatic for a long period of time. Their removal can be challenging, especially when they are embedded in soft tissues. In this article, we describe the case of a child who had had a metal ring lodged in her nasopharynx for approximately 4 years.

Case report

A 4-year-old girl was referred to our department for an evaluation of halitosis. During the history-taking, her mother said that she remembered seeing her daughter put a gold ring to her mouth when she was 3 months old. At that time, the infant experienced an immediate but short period of respiratory distress and cough. Because the attack resolved quickly, the parents did not admit the girl to the hospital at that time. However, 15 days later, after intractable cough had returned, the mother brought the child to the hospital. Physical examination and chest x-ray revealed no pathologic findings. The girl had become asymptomatic after being treated with classic therapy for upper respiratory tract infection.

Symptoms again became evident shortly thereafter, and the patient had been treated many times by different physicians who prescribed different kinds of medications. She also experienced halitosis of 2 years' duration. Prior to her visit to our department, the mother had never mentioned the incident with the ring to any of the other physicians who had treated her daughter.

The results of our routine otorhinolaryngologic examination were normal. However, Waters'-view and lateral-cervical-view x-rays revealed the presence of a ring in the nasopharyngeal area (figure 1). During a flexible fiberoptic nasopharyngeal examination, we found that the ring was embedded in the nasal surface of the soft palate and was covered with a thin layer of mucosal membrane. The stone of the ring was oriented downward.

The patient was placed under general anesthesia, and the thin mucosal layer covering the ring's stone was peeled off with a 0[degrees] endoscope. A forceps was used to push the foreign body from the nasal cavity toward the oropharynx. The ring, with its imitation reddish stone still attached, was then extracted from the oral passage with another forceps (figure 2). The patient's postoperative period was uneventful, and she was discharged the following day. No recurrence of symptoms has been noted during followup.

Discussion

Fish and chicken bones are the most common foreign bodies found lodged in the airway and food passage. [6] The inhalation or ingestion of metallic foreign bodies is less common but not rare, especially in children. Only a few cases of foreign bodies embedded in the nasopharynx have been published. [7,8]

In adults, a clinical evaluation of the oropharynx, nasopharynx, and hypopharynx can be easily accomplished with topical lidocaine anesthesia and a laryngeal mirror. But in children, it is necessary to use a fiberoptic endoscope. Once lodged, foreign bodies that are made of inert material such as gold can become embedded in soft tissue and remain silent and unnoticed for a substantial period of time. [6]

In cases of foreign-body aspiration, the lower respiratory tract is usually examined in its entirety. However, an aspirated foreign body can be missed if it migrates toward the upper respiratory tract following an attack of cough or hiccups. Such a foreign body might later move back down from the upper respiratory tract and cause a total or partial obstruction of the lower respiratory tract. We believe this is what happened to our patient. Therefore, if there is any suspicion at all of a foreign-body aspiration, care should be taken to examine the upper as well as the lower respiratory tract.

References

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(2.) Rimell FL, Thome A, Stool S, et al. Characteristics of objects that cause choking in children. JAMA 1995;274:1763-6.

(3.) Ryan CA, Yacoub W, Paton T, Avard D. Childhood deaths from toy balloons. Am J Dis Child 1990;144:122]-4.

(4.) Bhatia PL. Problems in the management of aspirated foreign bodies. West Afr J Med 1991;10:158-67.

(5.) Panieri E, Bass DH. The management of ingested foreign bodies in children--a review of 663 cases. Eur J Emerg Med 1995;2:83-7.

(6.) Braverman I, Garfunkel AA, Rosenmann E, et al. A metal ring embedded in the hypopharynx. J Otolaryngol 1997;26:201-2.

(7.) Sabirova MM, Khidirov BK, Abdusamatova SA. [A signet ring of the nasopharyax in a 3-year-old child]. Vestn Otorhinolaringol 1998;(6):64.

(8.) Lopatin BS, Larikov EM. [A foreign body of the nose and ethmoid labyrinth extending to the nasopharynx]. Vestn Otorhinolaringol 1997;(1):59-60.