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Is the emergency department management of ENT foreign bodies successful? A tertiary care hospital experience in Australia.

Abstract

We evaluated the role of the emergency department (ED) in the management of ear, nose, and throat foreign bodies in an Australian tertiary care hospital. We retrospectively reviewed all cases of ENT foreign-body presentations in the ED over a 2-year period. We identified 168 such cases, a large proportion of which involved pediatric patients. In addition to demographic factors, we also collected data on the nature of the foreign bodies, the specific sites involved, the rate of successful treatment by the ED staff, the seniority/rank of the treating clinician, and complications. Foreign bodies in the ear accounted for 49% of all cases, the nose for 43%, and the throat for 8%. The ED staff attempted to remove the foreign body in 89%> of cases, while the rest were referred to the ENT team. The rate of successful removal of all foreign bodies attempted by the ED team was fairly high--78%; success rates were 86% for nasal foreign bodies, 72% for aural objects, and 67% for those lodged in the throat. No major complications occurred; minor bleeding episodes after removal occurred in 8% of cases. Most ENT foreign-body presentations were managed safely and entirely by the ED team; most of the ENT referrals were to outpatient clinics.

Introduction

Presentations of a foreign body in the ear, nose, and throat are a common occurrence in the Emergency Department (ED). Most cases are managed by the ED staff, while some others require referral to an ENT specialist. Protracted or multiple attempts at removal can result in inadvertent local trauma or other delayed complications, such as infection.

In this article, we describe our study of outcomes in the management of ENT foreign bodies by ED physicians, trainees, and nurses in an Australian tertiary care hospital.

Patients and methods

We conducted a retrospective review of all ENT foreign-body presentations to a single ED at the Royal Hobart Hospital in Australia over a 2-year period. Our exclusion criteria were:

* cases of foreign bodies lodged in the esophagus, hypopharynx, or laryngotracheobronchial area, since they were referred directly to the ENT specialist team; and

* cases in which a foreign body was suspected but not found on examination in the ED; these, too, were referred to the ENT team.

A total of 168 cases met our eligibility criteria. In terms of age, patients ranged from infants to elderly persons. Most cases involved pediatric patients (figure 1). The male-to-female ratio was 1:1.

In addition to demographic data, we collected information on the site of foreign-body impaction, the nature and type of foreign body, whether the case was managed in the ED or referred to the ENT team (and in the latter case, whether the episode was managed as an outpatient procedure, as an inpatient procedure with general anesthesia, or as an urgent procedure), and the seniority/rank of the treating healthcare provider.

Site of impaction. Among the 168 cases, 82 (49%) involved the ears, 72 (43%) the nose, and 14 (8%) the throat.

Nature of the foreign body. Of the 168 cases, 113 (67%) involved nonorganic objects, including batteries, beads, small plastic and rubber items, paper, cotton buds, pebbles, sponges, buttons, hearing aid pieces, ear plugs, earphone buds, and crayon fragments, among others. Among the 55 organic cases (33%) were 11 episodes of fish bone impaction; the remainder involved seeds, peas, pieces of fruit, insects, etc. Of the 2 cases of battery impaction, 1 occurred in the ear and 1 in the nose.

Specialty. The ED staff attempted the initial foreign-body removal in 150 of the 168 cases (89%). The remaining 18 cases (11%) were referred to the ENT team. The reasons for the referrals included a deep-seated location, an inability to adequately visualize the foreign body, previously unsuccessful attempts at removal by a general practitioner, an uncooperative patient, and a lack of appropriate instruments for removal.

ED staff experience. Consultant- and Registrar-level staff members were each primarily involved in roughly one-third of cases (31% and 38%, respectively). Nurse practitioners managed about 16% of cases, residents 11%, and interns 4%.

Primary outcomes measures. Ourprimary outcomes measures pertained to the ED staff. They included the removal success rate in the ED, the number of attempts at removal, the need for referral to the ENT team after attempts at removal in the ED had failed, and complications.

Ethical considerations. Approval for the study protocol was granted by the hospital's Research Ethics Committee.

Results

Success rates. Of the 150 cases initially seen in the ED, 117 (78%) were completed successfully (figure 2). More than two-thirds of these successful cases were handled by those at the Consultant and Registrar level.

Number of attempts. In most of the cases managed in the ED, either 1 or 2 attempts at removal were made. There were 5 cases that involved 4 or more attempts; of these, 2 of 3 cases in the ear canal and 1 of 2 in the nasal passage were successfully treated.

ED referral to ENT. Of the 150 cases initially managed in the ED, 33 (22%) had to be referred to the ENT service because of difficulties encountered by the ED clinicians. Only 1 of these 33 cases required that the ENT team remove the foreign body with the use of general anesthesia.

Complications. No major complications were observed. Minor bleeding occurred in 12 cases (8%) (figure 3). There were 9 cases of epistaxis after attempts at nasal foreign-body removal and 3 cases of ear canal bleeding after aural foreign-body removal. All of the nasal bleeding complications resolved spontaneously without the need for any further intervention. One of the 3 aural cases featured a small skin tear that had occurred during multiple attempts at removal; the other 2 cases were caused by minor abrasions during 2 or 3 attempts at removal.

Discussion

In our study, well over half of all cases involved children, particularly those aged 5 years and younger. Young children are curious, and they often insert objects into their ears and noses, usually with items found at home. (1) Most of the ear and nose foreign bodies seen in our study were beads, pieces of plastic, parts of toys, paper, seeds, and other small items found in a household. Most of the throat foreign bodies were fish bones, and these were seen most often in adults.

Regardless of what technique is used to remove a pediatric foreign body, the clinician usually has only one or two chances before a child loses patience and becomes uncooperative. (2) Further attempts with an uncooperative child can lead to complications, as well as patient and parental distress. (2)

Aural foreign bodies accounted for almost half of all the cases in our study, and nasal foreign bodies were only slightly less common. The quantitative data on foreign bodies in the throat (8% of cases) were limited, since we excluded cases of foreign bodies lodged in the esophagus, hypopharynx, or laryngotracheobronchial area. The primary reasons for these exclusions were the inaccessibility of the foreign body and/or the inability of an emergency clinician to visualize it. These cases were immediately referred to the ENT specialist team.

Overall, the ED clinicians' success rate in removing ENT foreign bodies was 78%. They successfully removed 86% of the nasal foreign bodies, 72% of the aural foreign bodies, and 67% of the throat foreign bodies. Senior staff (i.e., Consultants and Registrars) appeared to be more successful than their junior counterparts, but since it was not possible to reliably establish whether the cases seen by the senior and the junior staff were directly comparable in terms of difficulty, little importance can be placed on what was a comparatively minor difference.

No major complications were observed in our study. The most common minor events were self-limiting epistaxis and aural bleeding secondary to mechanical trauma. We cannot comment on any delayed complications because follow-up was not routinely sought in this patient group.

Of all the cases that were referred to the ENT team, either directly or after ED attempts at removal, most were managed on an outpatient basis. In fact, urgent ENT attention was sought only in the few cases of impaction by a battery or vegetative foreign body. Only 3 patients required ENT hospital admission and removal under general anesthesia.

Our conclusion that most aural foreign bodies can be successfully removed in the ED is in contrast to findings by Mackle and Conlon in Ireland. (3) They found that their ED successfully removed only 4 of 58 aural foreign bodies (7%). Their ED success rate for nasal foreign bodies was much higher (65% [53/82]), but still substantially below our rate. Ngo et al reviewed 353 cases of ENT foreign bodies in Singapore and found that 50.1% were successfully managed in the ED. (4)

Our rigorous search of the literature found only three other articles on ENT foreign bodies based in Australia. (5-7) In 2004, Kumar summarized the management of ENT foreign bodies and concluded, among other things, that in less-than-ideal conditions, most of them do not require immediate removal; instead, removal can be undertaken the next day in a more suitable environment if need be. (5) In 2006, Ryan et al studied 330 cases of aural foreign bodies and delineated the differences in treating adults and children. (6) In 2015, Craig et al provided an overview of the removal of ENT foreign bodies in children in the emergency setting, including information on the use of procedural sedation and a description of various instruments to aid in removal. (7)

Our study had a few limitations. We could not deter mine the methods of foreign-body removal because of the retrospective nature of our review of the documentation. It might be reasonable to expect that some techniques maybe more successful than others. Moreover, the shape and texture of the foreign bodies were not specified.

In conclusion, we found that most ENT foreign-body presentations can be successfully managed by the ED staff. Nasal foreign bodies were the easiest to remove. Removal of aural foreign bodies can be difficult without adequate instrumentation and microscopic visualization. Foreign bodies in the throat that are hidden within the mucosal walls require specialist evaluation with the aid of a flexible endoscope. Complications are encountered most often when multiple attempts at removal are made, so this should be avoided. ENT specialist help should be sought if any doubt or concerns exist about the patient's safety.

Acknowledgment

We thank Dr. Emma Huckerby, an emergency physician and director of the Emergency Department at Royal Hobart Hospital, for her general advice on our research.

References

(1.) Balbani AP, Sanchez TG, Butugan O, et al. Ear and nose foreign body removal in children. Int J Pediatr Otorhinolaryngol 1998;46(13):37-42.

(2.) DiMuzio J Jr., Deschler DG. Emergency department management of foreign bodies of the external ear canal in children. Otol Neurotol 2002;23(4):473-5.

(3.) Mackle T, Conlon B. Foreign bodies of the nose and ears in children. Should these be managed in the accident and emergency setting? Int J Pediatr Otorhinolaryngol 2006;70(3):425-8.

(4.) Ngo A, Ng KC, Sim TP. Otorhinolaryngeal foreign bodies in children presenting to the emergency department. Singapore Med J 2005;46(4):172-8.

(5.) Kumar S. Management of foreign bodies in the ear, nose and throat. Emerg Med Australas 2004;16(l):17-20.

(6.) Ryan C, Ghosh A, Wilson-Boyd B, et al. Presentation and management of aural foreign bodies in two Australian emergency departments. Emerg Med Australas 2006;18(4):372-8.

(7.) Craig SS, Cheek JA, Seith RW, West A. Removal of ENT foreign bodies in children. Emerg Med Australas 2015;27(2):145-7.

Ritesh Gupta, MBBS, MS(ENT); Rugare Percy Nyakunu, MBBS, BMedSci; Jorian Russell Kippax, MBChB, FACEM

From the Department of ENT, Princess Marina Hospital, Gaborone, Botswana (Dr. Gupta); and the Department of Psychiatry (Dr. Nyakunu) and the Emergency Department (Dr. Kippax), Royal Hobart Hospital, Hobart, Australia. The study described in this article was conducted at Royal Hobart Hospital.

Corresponding author: Dr. Ritesh Gupta, Department of ENT, Princess Marina Hospital, Gaborone, Botswana. Email: riteshgupta19@ gmail.com
Figure 1. Chart shows the distribution of ages (N = 168).

>65 yr           4%
0 to 5 yr       51%
6 to 10 yr      11%
11 to 25 yr     13%
26 to 45 yr     12%
46 to 65 yr      9%

Note: Table made from pie chart.

Figure 2. Graph compares the number of successful and unsuccessful
ED foreign-body removals according to site (n = 150). The success
rates were 72% in the ear, 86% in the nose, and 67% in the throat.

             Success (78%)   Failure (22%)

Ear 72%      56              22

Nose 86%     57              9

Throat 67%    4              2

Note: Table made from bar graph.

Figure 3. Graph shows the total number of cases attempted in the
ED at each site and the number of complications, all of which were
minor (n = 150). Complications occurred in 4% of the aural cases,
14% of the nasal cases, and in none of the throat cases.

         Cases attempted   Complications

Ear      78                9
Nose     66                9
Throat   6                 0

Note: Table made from bar graph.
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Article Details
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Title Annotation:ORIGINAL ARTICLE
Author:Gupta, Ritesh; Nyakunu, Rugare Percy; Kippax, Jorian Russell
Publication:Ear, Nose and Throat Journal
Article Type:Report
Geographic Code:8AUST
Date:Mar 1, 2016
Words:2173
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