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18.2 Acute Emergency ofSystem
Table 18.26 D/D of dysphagia based on the history
Type of dysphagia or symptoms Diagnosis
Progressive dysphagia Neuromuscular dysphagia
Sudden dysphagia Obstructive dysphagia
Difculty initiating swallow Oropharyngeal dysphagia
Food stuck after swallow Oesophageal dysphagia
Cough early in swallow Neuromuscular dysphagia
Cough late in swallow Obstructive dysphagia
Weight loss in elderly with dysphagia Carcinoma
Dysphagia with weight loss with regurgitation Achalasia
Intermittent symptoms Rings and web, diffuse oesophagal spasm, nutcracker
oesophagus
Pain made worse by solid food only Obstructive dysphagia
Pain made worse by solid and liquid Neuromuscular dysphagia
Regurgitation of old food Zenker diverticulum
Weakness and dysphagia CVA, muscular dystrophy, myasthenia gravis, multiple
sclerosis
Halitosis with dysphagia Achalasia
Dysphagia made worse with cold food Neuromuscular motility disorder
493
– Tachycardia, cyanosis, accessory mus-
cle use, jaundice, pallor and koilonychia should be noted.
– Observing the patient swallowing a
variety of liquids and solids can be
helpful. The patient should demonstrate enough neuromuscular control
to chew food, mix it into a bolus with
saliva and propel it to the posterior
pharynx without choking or coughing.
– Elevation of the larynx during the
swallowing reex protects the airway
and opens the upper oesophageal
sphincter. Normal laryngeal ascent can
be palpated by placing the index nger
above the patient’s thyroid cartilage
when the patient swallows. The cartilage should move cephalad against the
physician’s nger.
– Laryngeal crepitus—This is a normal
crepitus sound felt on moving the larynx against the cervical vertebra.
• Systemic examination
– Neurologic evaluation—It should
include assessments of the patient’s
mental status, motor and sensory functioning, deep tendon reexes and cranial nerves, and a cerebellar
examination. Patients with impaired
cognitive functioning and those who
are under sedation should be carefully
assessed, because these neurologic
states can interfere with swallowing.
Motor and sensory examinations may
reveal a new stroke or identify a longterm illness. Special attention should
be focused on the cranial nerves that
are associated with swallowing, particularly the motor components of cranial nerves V, VII, IX, X and XII and
sensory bres from cranial nerves V,
VII, IX and X.A decreased gag reex
is associated with an increased risk of
aspiration. A ‘wet voice’ may suggest
long-term laryngeal aspiration, while a
weak, breathy voice may indicate
vocal cord pathology.
– Examination of the respiratory sys-
tem—Crackle sounds, A widened
anteroposterior chest diameter and distant breath sounds are signs of COPD,
which could be caused by long-term
aspiration.
– Examination of GIT—The patient’s
abdomen should be examined for
masses and organomegaly.
494
18 History andExamination ofNon-traumatic Emergency ofENT, Head, Neck andSkull Base
• Local examination
– Oral cavity examination—It includes
the mouth opening, appearance of
the mucosa and adequate saliva production, which results in a pink,
well- hydrated oral cavity (certain
medications induce xerostomia, preventing adequate mixing and propulsion of the food bolus into the
posterior oropharynx), tongue movement, a tongue blade and handheld
mirror allow indirect inspection of
the soft palate and vocal cord mobility. Physicians who are skilled in
nasopharyngoscopy can directly
view the vocal cords and hypopharynx. Bimanual palpation of the oor
of the mouth, tongue and lips with a
gloved hand detects masses and
abnormal motor function.
Examination of the teeth can reveal
signs of inammation or other structural disorders.
– Oropharyngeal examination.
Gag reex
Tonsillar hypertrophy
Bulging of lateral oropharyngeal
wall
– Larynx and laryngopharyngeal
examination.
– Indirect laryngoscopy—Pooling of
saliva, mass lesion, vocal cord
movement.
– Examination of neck
Neck swelling.
Laryngeal crepitation—The
absence of laryngeal crepitus indicates a retropharyngeal abscess and
post-cricoid tumour.
Laryngeal tenderness—This is the
sign of perichondritis.
Examination of thyroid gland—
Thyroid masses and lymphadenopathy that cause obstructive
dysphagia can be palpated on examination of the neck.
(c) Causes of dysphagia
• Causes of dysphagia based on duration
(Table18.27).
– Local causes.
– Systemic (remote/distant) causes—
Paralysis of the palate, pharynx, vagus
nerve (diphtheria, lead palsy), hysteric
spasm, hydrophobia, tetanus, myasthenia gravis, polio.
• Causes of dysphagia on site of lesion
(Table 18.28).
• Causes of dysphagia (Table 18.29).
• Medication associated dysphagia
(Table 18.30).
Table 18.27 Local causes of dysphagia based on duration
Acute and painful Chronic and painless
Local causes inside lumen—Stomatitis, Ca post 1/3 of
the tongue, acute tonsillitis, reux esophagitis, peptic
ulcer of the oesophagus, corrosive injury, FB impaction
Local cause outside lumen—Acute submandibular
sialoadenitis, cervical lymphadenitis, acute thyroiditis,
acute suppurative pericarditis, acute mediastinitis
Local causes—Laryngeal TB, pharyngeal pouch,
pharyngeal carcinoma, localized muscular spasm
(Plummer-Vinson syndrome), congenital stricture,
simple stricture (due to swallowed poison, reux
esophagitis, Schatzki’s ring, tubular stricture,
carcinoma)
Local causes outside lumen—Ca thyroid, metastatic
lymph node, mediastinal tumour, aortic aneurysm
18.3 Bleeding inENT, Head Neck andSkull Base
Table 18.28 Site-specic causes of dysphagia
Oral Oropharyngeal Oesophageal
Disturbance in motility of
tongue—Paralysis of the tongue,
painful ulcer, tumours, surgery
Defect in palate—Cleft palate,
oroantral stula
Lesion of buccal cavity and oor
of mouth—Stomatitis, Ludwig’s
angina
Table 18.29 Causes of dysphagia
Anatomic Neurological Muscular
Zenker diverticulum, Tumour,
enlarged thyroid, osteophytes, head
neck surgery, Web, abscess
Neurological disorders—These
include multiple sclerosis, muscular
dystrophy, Parkinson’s disease
Brain stem tumour, myasthenia
gravis
Neurological damage—Stroke,
brain injury, CVA
Obstructive—Cervical spondylosis,
anterior mediastinal mass, Zenker’s
diverticulum, carcinoma base of the
tongue, trauma
CVA, post-polio syndrome, radiation
injury, parkinsonism, multiple
sclerosis, CNS tumour, botulism,
supranuclear palsy, myotrophic
dystrophy, ALS
Lumen—Atresia, oesophageal
stricture
Oesophageal tumours
FB
Wall—Esophagitis, GERD
Hyomotility disorders (achalasia,
scleroderma, ALS)
Hypermotility disorders (diffuse
oesophageal spasm, cricopharyngeal
spasm)
Others—Oesophageal ring
Eosinophilic esophagitis, dysphagia
lusoria
Radiation therapy
Chemical induced
Medication induced
Polymyositis, myasthenia gravis,
muscular dystrophy, radiation injury
495
18.3 Bleeding inENT, Head Neck
andSkull Base
18.3.1 Bleeding fromNose: Epistaxis
1. Surgical anatomy—The nose has two arterial
plexuses, anterior is Kiesselbach’s plexus
and posterior is Woodruff’s plexus.
Kiesselbach’s plexus is formed by the superior labial artery, anterior ethmoidal artery,
posterior septal artery and greater palatine
artery.
2. Presentation/history of epistaxis—It is impor-
tant to obtain a detailed description of the epistaxis, including:
(a) What are the chief complaints—Bleeding
from nose or mouth.
(b) Laterality/side—Unilateral or bilateral.
(c) Duration of the bleed—It may be either
acute or chronic.
(d) Frequency of bleed.
(e) What the patient was doing just before
the epistaxis started.
(f) Site of epistaxis—Which side the bleed
originated from, and whether it began
anteriorly or posteriorly; asking whether
the patient has noticed the sensation of
blood dripping down their throat may
help to distinguish between anterior and
posterior bleeds.
(g) Severity—How much blood was lost
(h) Age of patient (age below 10 or above
65)—Young children frequently experi-
ence epistaxis, due in part to high rates of
digital trauma and recent viral upper respi-
ratory tract infections. The increased risk
in elderly patients may be due to a higher
prevalence of vascular comorbidities such
as atherosclerosis and hypertension.
(i) Inquire about precipitating or aggravat-
ing factors and relieving factors.
(j) Associated symptoms
496
Table 18.30 Medication causing dysphagia
Medication causes oesophageal injury
Ferrous sulphate, quinine gluconate,
theophylline, ascorbic acid, potassium
chloride tab, zidovudine, alendronate,
NSAIDs, clindamycin, tetracycline,
doxycycline
18 History andExamination ofNon-traumatic Emergency ofENT, Head, Neck andSkull Base
Reduced lower oesophageal
sphincter tone Medication associated xerostomia
Butylscopolamine,
theophylline, nitrates,
calcium antagonists, alcohol,
fat, chocolate
Anticholinergic, alpha-blockers, ACE
enzyme inhibitors, angiotensin II receptor
blockers, antiarrhythmic, disopyramide,
ipratropium bromide, antihistamine,
diuretics
• Determine whether the bleeding
occurs after exercise or during sleep
or is associated with a migraine.
• Determine whether haematemesis or
melena has occurred because posterior bleeding in particular may present
in this fashion.
• H/O trauma—Most nosebleeds are
reported as spontaneous events and
are frequently related to nose picking
or other trauma.
• H/O risk factors.
– Rhinitis, both allergic and
non-allergic
– Viral or bacterial sinusitis
– High ambient temperature
– Septal deviation
– Bleeding disorders
– Decompensated heart failure
– Cocaine use
– Trauma with facial injury
– Hepatic or renal impairment
– Anticoagulant or antiplatelet drugs
– Frequent use of intranasal steroids
– Alcohol and illicit drug use
(k) Past history—H/O previous epistaxis,
hypertension, hepatic or other systemic
disease, easy bruising, prolonged bleeding after minor surgical procedures, frequent recurrent nosebleeds treatment
already performed to stop the bleeding,
whether this has occurred before and if
so, is it similar to those episodes.
(l) Treatment history—General medical his-
tory (e.g. profuse post-operative bleeding, easy bruising, multiple blood
transfusions), concerning relevant medical conditions and current medications,
like aspirin, NSAIDs, warfarin, heparin,
ticlopidine, anticoagulant and antiplatelet drugs, intranasal sprays.
(m) Personal history—Smoking and drinking
habits.
(n) Family history—Family history of bleed-
ing disorders or leukaemia (e.g. rst or
second-degree relative with bleeding
diathesis).
3. Examination of patient
(a) General examination—General con-
sciousness, pallor, tachycardia, hypertension, tachypnoea.
(b) Systemic examination—CNS and CVS to
be examined.
(c) Local examination
• External examination of the nose—Signs
of trauma like swelling and laceration.
• ARS—(Internal examination of nose).
– Deviated septum.
– Site of epistaxis—There are two
types of nose bleeding depending
on the site posterior and anterior.
Anterior sites—Septum (little’s
area), inferior turbinate.
Posterior sites (lateral wall of
the nose at the posterior end of
middle turbinate—Woodruff’s
plexus).
– Severity of epistaxis
Mild—Crusting, nose picking,
FB in the nose
Moderate—Rhinosporidiosis,
microaneurysm, granulation,
trauma to nose, septum
Severe—JNA, maxillary artery
tear, anterior ethmoidal artery
tear, etc.
18.3 Bleeding inENT, Head Neck andSkull Base
497
– Mass lesion
Septum—Rhinosporidiosis,
haemangioma, microaneurysm
(b) Causes in adult (Table 18.32)
(c) Causes in geriatric (Table18.33)
(d) Causes in pregnancy (Table18.34)
Sphenopalatine area on the lateral wall—JNA
Middle meatus—Angiomatous
polyp
Inferior meatus—Rhinosporodiosis
• Oral cavity
– Bleeding—Present or absent
4. Causes of epistaxis
(a) Causes of epistaxis in children (Table
When to Seek Physician Consultation
High blood pressure
Nosebleed has not stopped after 20min
Trouble breathing through your mouth
A large amount of blood
Nosebleeds frequently
Swallowed a lot of blood and vomited
Fever or chill
18.31)
Table 18.31 Causes of epistaxis in children and their presentation
Epistaxis with associated symptoms Signs Diagnosis
U/L nasal obstruction + U/L mild epistaxis+foul
smelling discharge
Anterior bleed+history of nasal picking Anterior bleeding Nose picking
B/L severe bleeding+history of previous epistaxis Bruises Haematological disorder
Nasal obstruction+epistaxis Nasal mass (strawberry like) Rhinosporidiosis
Nasal obstruction+adolescent age+M gender
FB in nose Foreign bodies in the nose
Nasal mass +/− bulging of
palate
Juvenile nasopharyngeal
angiobroma
Table 18.32 Causes of epistaxis in adults with clinical presentation
Epistaxis with associated symptoms Signs Diagnosis
Nasal obstruction+epistaxis Deviated nasal septum Deviated nasal septum
Nasal obstruction+epistaxis+nasal mass Strawberry-like nasal mass
Red mass
Epistaxis+nasal obstruction+foul smell nasal
discharge
Epistaxis+H/O trauma Deviated nose, laceration Nasal trauma
Table 18.33 Causes of epistaxis in geriatric
Epistaxis with associated symptoms Signs Diagnosis/causes
Posterior epistaxis+high BP+ Posterior nasal bleeding Hypertension
Nasal obstruction + nasal mass + nasal bleeding
(mild to severe) +
Table 18.34 Causes of epistaxis in pregnancy
Symptoms in pregnancy Signs Diagnosis
Bleeding+cold Signs of acute rhinitis Acute rhinitis
Bleeding+H/O high blood pressure High BP hypertension
Nasal obstruction+nasal bleeding Nasal mass Pyogenic granuloma
Nasal secretion + Rhinolith
Nasal mass+nasal
swelling+bleed on touch
Rhinosporidiosis
Haemangioma
FB in the nose
Carcinoma
498
18 History andExamination ofNon-traumatic Emergency ofENT, Head, Neck andSkull Base
18.3.2 Bleeding fromEar
• History of ear bleeding—Bleeding is a common ear infection symptom. Bleeding can be
presenting symptoms of trauma to carcinoma
of the ear.
– Duration of bleeding
– Acute (short duration)—Trauma, self-
inicted trauma, ASOM, FB in ear
– Chronic (long duration)—CSOM (squa-
mous type), granulation, haemangioma,
maggot, glomus tympanicum, bleeding
disorders
– Mode of onset
– Sudden onset—ASOM, trauma
– Insidious—CSOM, cholesteatoma, granu-
lation, maggots, bleeding disorders, malig-
nant tumour
– Amount of bleeding
– Small—Granulation, maggots, CSOM,
ASOM
– Copious—Bleeding disorders, JNA,
Schwannoma, Trauma
– Continuity
– Continuous—Bleeding disorders, trauma
– Intermittent—Haemangioma, granulation,
cholesteatoma
– Associated symptoms—Ear discharge, ver-
tigo, tinnitus, hearing loss, ear mass, ear
growth, H/O ying or diving, trauma (slap,
head trauma, accidental trauma with object,
self-cleaning or cleaning of ear), H/O—FB
in ear (insect, etc.)
• Examination
– General examination—It includes pallor,
other injuries, other bleeding sites,
consciousness.
– Local examination—Discussed in ear
(Chap. 3)
• Causes (Table18.35)
18.3.3 Bleeding fromThroat
• Clinical presentation—It can be presented as
blood from the mouth with cough or without
cough.
– Type of blood—Clot, mixed with sputum
or fresh blood
– Colour of blood—Black (haematemesis,
clot) or red (bleeding)
– Duration—Acute (trauma, acute tonsillitis,
epistaxis), chronic—(TB and COPD)
– Bleeding or blood-stained sputum with
cough suggestive lower airway diseases
– Spontaneous bleeding—It suggests local
causes like trauma, tonsillitis
– Associated history of throat pain, dyspha-
gia and odynophagia
• Examination—The examination should
include a mouth examination, nose examination, nasopharynx examination, examination
of the oropharynx, examination of the larynx
and examination of the chest.
• Causes (Table18.36)
Table 18.35 Causes of bleeding from the ear
Symptoms Signs Causes
H/O—Cleaning ear, scratching ear, accidental insertion of an
object, H/O FB, H/O head trauma, bleeding from ear
Earache, ear discharge, H/O URI, fever, ear pain Perforation of TM,
Bleeding with ear mass or growth with or without facial palsy Bleeding mass Haemangioma EAC,
Ear discharge, hearing loss, blood-stained discharge Granulation,
H/O head trauma, dizziness, nausea and vomiting, tinnitus Clot in EAC Head trauma
H/O ying or diving, hyperbaric oxygen therapy, exposure to
explosive blast ear pain, pressure in the ear, tinnitus, hearing loss
Perforated TM with
irregular margins, clot
in EAC
redness
cholesteatoma
Perforated TM Barotrauma
Injury or cut, ruptured
TM
ASOM
granuloma, SCC
Cholesteatoma
18.4 FB inENT, Head andNeck
Table 18.36 The causes of bleeding from the throat
Anticoagulant
medication/
Trauma Infection
Blow to chest
Mouth trauma,
maxillofacial
trauma
Pharyngeal or
laryngeal trauma
Tonsillitis,
bronchiectasis,
bronchitis, TB,
pneumonia
bleeding dis. Other health condition
Warfarin,
Aspirin
Bleeding
disorders
499
COPD, cystic brosis, lung cancer, gum disease,
haemangioma (tongue, glottis, subglottis),
carcinoma (oropharynx, oral cavity,
nasopharynx, larynx), oesophageal varices
18.3.4 Oral Bleeding
Bleeding from the mouth is usually from the
gum, tongue, lip, cheek and any sites of the oral
cavity.
It can be caused by trauma, bleeding disorders, neoplastic disorders, vascular, mouth ulcers,
gum diseases and tumours. Oral bleeding can be
presented with blood mixed with saliva or bleeding from the mouth. The patient with lung diseases and nasal bleeding can also be presented as
oral bleeding.
18.4 FB inENT, Head andNeck
There are various sites in the head and neck
region where a FB can be lodged and need
removal.
Oesophagus
Tracheobronchial tree
Nose and nasopharynx
Oropharynx
Larynx and laryngopharynx
Neck
Ear
Other areas
18.4.1 FB intheOesophagus
Food and a variety of other swallowed objects
can become impacted in the oesophagus from the
cricopharynx to the lower oesophageal junction.
Oesophageal foreign bodies cause dysphagia and
sometimes lead to perforation. Diagnosis is clini-
cal, but imaging studies and endoscopy may be
needed. Key factors to consider in assessing
patients with ingested foreign bodies include
type and number of objects, location, time since
ingestion and presenting signs and symptoms.
These factors help to determine whether the
object needs to be retrieved emergently and
urgently or if the patient can be safely managed
with observation and follow-up. The most frequent lodgement site in children is at the level of
the cricopharyngeus muscle (which is the narrowest part of the oesophagus), and in adults, it is
at the lower oesophageal sphincter or at the site
of any predisposing lesion. A wide variety of
oesophageal foreign bodies are seen in clinical
practice. Coins are the commonest overall and
the commonest single type in children, while
bones comprise the bulk of FBs in adults. Other
objects regularly seen include meat, cartilage,
dentures, bezoars, fruit stones, toys, batteries and
buttons. Among the more dangerous ones are batteries, needles, safety razors, dentures with wires,
spring coils and pieces of glass.
1. Presenting complaints of impacted/ingested
foreign body—Foreign bodies in the upper
oesophagus are more accurately localized by
the patient, while impactions of foreign bodies in the mid or lower oesophagus are presented as vague discomfort such as ache or
chest pain. Patients with FB in the lower and
mid-oesophagus and infants, younger children, mentally impaired or prisoners may be
unable or unwilling to provide history and
require a high index of suspicion. Symptoms
typically develop in minutes to hours; the
patient may have mild symptoms and is in
stable condition. Infants and young children
500
18 History andExamination ofNon-traumatic Emergency ofENT, Head, Neck andSkull Base
may present with gagging, poor feeding,
drooling or irritability.
(a) What are the chief complaints/
symptoms?
• Dysphagia (difculty swallowing)—It
is due to obstruction.
• Odynophagia—This may indicate
more serious problems such as oesophageal laceration or perforation.
• H/O choking—It may be transient.
• Excessive salivation—It is due to the
inability to swallow.
• Pain—This is a common symptom of a
sharp FB in oropharynx, larynx and
laryngopharynx.
• H/O FB sensation.
• Other symptoms include hypersalivation, retrosternal fullness, regurgitation, gagging, choking, hiccups and
retching.
• Time since ingestion—The time
should be noted.
• H/O accidental ingestion of a known
object and time of ingestion may be
given by most adults and older children but not by small children.
• Type of foreign body—There are two
types of FB.
– Less risk of complications like
coin, inert FB, plastic, etc.
– Heightened risk of complications—
Three special types of FB ingestions with a higher risk of
complications are button batteries
(also called ‘disc’ or ‘coin’ batteries), multiple magnets and sharppointed objects.
Ingestion of button batteries
(also called ‘disc’ or ‘coin’ batteries)—If a button battery
becomes impacted in the oesophagus, then an electrical current is
created between the positive and
negative poles. This current can
cause thermal injury and produces hydroxide ions with a
rapid rise in the local pH resulting in a caustic alkaline injury.
Injury begins within 15min and
can lead to a perforation in hours.
Complications can include localized oesophageal mucosal necrosis and chronic stricture
formation. More serious complications involve oesophageal perforation and erosion into adjacent
structures such as the mediastinum, trachea or vascular structures. More than 90% of serious
complications occurred in children 5 years old or younger, with
batteries 20mm in diameter and
greater and impactions for prolonged periods.
Multiple magnets—While a
single, small, smooth magnet
will usually pass without complications, multiple magnets create
complications. Tissue may
become trapped between the
magnets leading to pressure ischaemia, perforation, stula formation, obstruction or volvulus.
Sharp-pointed object—These
types of FB stuck in the oesophagus also have a higher risk of
perforation and need urgent
removal. These foreign bodies
are needles, safety razors, dentures with wires, spring coils
and pieces of glass.
(b) Onset of symptoms
• Sudden onset—Acute onset of pain—
Suggestive of oesophageal laceration/
perforation or high-risk foreign body
(battery, multiple magnets, sharp FB).
• Gradual onset—It usually suggests a
low risk of foreign body (smooth, inert
FB, coin).
(c) Associated other symptoms
• Airway symptoms—If an oesophageal
FB presses on the trachea, it may cause
respiratory symptoms such as wheezing, cough, dyspnoea or stridor.
However, airway foreign bodies would
also need to be considered.
18.4 FB inENT, Head andNeck
501
• Fever—This suggests oesophageal
perforation.
• Throat pain—Throat pain suggests
trauma to the throat or another FB in
the oropharynx or laryngopharynx.
(d) Past H/O underlying oesophageal stric-
ture, neuromuscular disease (myasthenia
gravis), external and mechanical factors,
ankylosing spondylitis, mental retardation, psychiatric illness and use of dentures, DM, hypertension.
2. Examination
(a) General examination—The patient may
appear anxious and uncomfortable with
swallowing. If the patient is unable to
swallow saliva, this indicates a complete
obstruction is needing more urgent treatment. Vital signs, patient’s ability to handle secretions.
(b) Systemic examination—The respiratory
system should be checked for decreased
air entry, abnormal breathing patterns,
wheezing or stridor.
(c) Local examination
• The physical exam should initially
focus on airway patency and look for
signs of complications such as haematemesis, abnormal breath sounds,
tenderness in the neck, chest or abdomen, or subcutaneous emphysema.
• The water-drinking test and positive
laryngeal rub both have high
sensitivity and specicity for oesophageal FBs.
• However, adequate visualization of the
oral cavity, nasal passages, pharynx
and larynx is crucial for ruling out an
FB in the upper aerodigestive tract.
• Tongue depressor, transnasal exible
endoscopy, indirect laryngeal mirror,
Mackintosh laryngoscope and exible
pharynx laryngoscopy may subsequently be utilized.
• Examination is crucial and indeed is
generally reliable for supra-cricoid
FBs. For cricoid and infra-cricoid bodies, however, further careful monitoring is warranted.
18.4.2 Foreign Body inNose
andNasopharynx
FB in the nose—The common items that children put in their noses include small toys, pieces
of eraser, tissue, clay (used for arts and crafts),
food, pebbles, dirt, paired disc magnets, button
batteries, etc. Small button batteries may, within
hours, cause chemical burns, ulceration and liquefaction necrosis, leading to septal perforation.
Button batteries require prompt removal and a
thorough inspection of the nasal cavity for complications. Magnetic NFBs have been shown to
cause pressure necrosis and even perforation of
the nasal septal muco-perichondrium. Therefore,
they require prompt removal. The FB in the nose
presented with various symptoms. The most
common symptom of a foreign body in the nose
is nasal discharge. The discharge appears only on
the side of the nose with the object and often has
a bad odour. In some cases, your child may also
have a bloody nose. Sometimes a whistling sound
can be heard while your child is breathing.
(a) History/chief complaints/symptoms
• What are the chief complaints/symptoms—The FB in the nose may be presented as:
– Nasal discharge—A FB in the nostril
causes nasal drainage. This discharge
may be clear, grey or bloody. Nasal
discharge with a bad odour is a sign of
an infection
– Breathing difculty/nasal obstruc-
tion—It is usually unilateral or
bilateral
– Epistaxis—A sharp FB or long-stand-
ing FB may present with epistaxis
– Nasal pain—A sharp FB or long-
standing FB may present with nasal
pain
– Nasal irritation
– New-onset snoring
– Sneezing
– Wheezing
– Unilateral facial swelling—A vegeta-
tive FB may present with unilateral
facial swelling
502
18 History andExamination ofNon-traumatic Emergency ofENT, Head, Neck andSkull Base
• Duration of symptoms—Short or long
• Site of foreign body—The most common
site is between the septum and inferior
meatus
• Type of foreign body—Non-vegetative
FB, vegetative FB, button batteries, magnets and living foreign bodies
• H/O FB insertion, trauma, removal, rearm injury, assault, RTA
(b) Examination of patient
• Local examination
– External examination of nose—
Swelling, tenderness
– Anterior rhinoscopy
– Site of FB, size of FB, type of FB
– Bleeding in nose—It suggests a pre-
vious attempt has been made to
remove FB.
18.4.3 Foreign Body inEar
FB in ear—Most foreign bodies in the ear lodge
in the ear canal and become stuck. These foreign
objects cannot fall out from the ear on their own
until you remove them or get them removed.
Small, inert foreign bodies, such as beads, can
stay for 1–2 weeks in the ear without causing any
complications. Usually, adults and sometimes
children give a history of FB insertion in their
ear, but small children may not be aware of it. A
foreign object in the ear can cause pain, infection
and hearing loss.
(a) Chief complaints of a foreign body in the
ear
• What are the symptoms
– Sensation of fullness or having some-
thing stuck in the ear
– Ear pain (otalgia)—Depending on
what the insect does to the ear while
inside, such as piercing or biting, the
patient will most likely experience
pain, inammation and irritation
– Decrease in hearing on the affected side
– Tinnitus—If the insect is still alive, the
buzzing sound can be heard by the
patient
– H/O FB insertion present
• Duration of symptoms
– Short duration—Vegetative FB, sharp
FB, live FB
– Long duration—Inert FB can remain
in the ear without many symptoms for
a long duration.
• Mode of onset of symptoms
– Sudden onset—The sharp FB, insect,
vegetative FB
– Insidious onset—Inert FB, smooth FB
– Late-onset—Inert FB, smooth FB
• Associated symptoms can include vomiting and nausea, cough, bleeding from ear,
vertigo, any history of FB removal.
(b) Examination of patients with FB in ear
• Local examination
– Otoscopy—To know type of foreign
body; live FB, inert FB
Damage to EAC or middle ear
Bleeding
Site of lodgment of FB
Status of the tympanic membrane
Tragal tenderness
18.4.4 Foreign Body inThroat
FB in throat—The throat (pharynx) is bound
superiorly by the base of the skull (nasopharynx) and inferiorly by the cricoid cartilage/inferior border of the C6 vertebra. The hypopharynx
contains the larynx and the upper openings of
the trachea and the oesophagus. Sharp FBs like
sh or chicken bones are more frequently
impacted at the tonsils and base of the tongue;
smooth FBs are more frequently found at or
below the cricopharyngeal muscle. All pharyngeal foreign bodies are medical emergencies
that require airway protection. Because complete airway obstruction usually occurs at the
time of aspiration and results in immediate
respiratory distress, emergency intervention is
essential. The most common foreign bodies in
the throat are pieces of plastic, metal pins, seeds,
nuts, bones, coins, dental appliances, coins, button batteries and other radiopaque objects, sh
bones.