A remarkable diversity of foreign bodies can be found in the ears and respiratory tract of children. Indeed, many instances of ear or nose disease of undetermined etiology are due to foreign bodies. More children under five die in the home from accidental foreign body aspiration than from any other cause. A history of foreign body insertion is usually obscure or unobtainable. Nevertheless, the physician should keep this in mind when faced with a diagnostic enigma.

The symptoms produced by a foreign body will vary with its size, composition, location, and length of time it has been present. Inorganic substances rarely stir up as much local reaction as do organic ones. Concomitant moisture facilitates infection with its secondary suppuration; this is one of the cardinal signs of a foreign body.

Any attempt at removal of a foreign body which does not succeed will make a bad situation worse. The child is usually apprehensive and the parents are aggravated. The physician, therefore, should be wary of falling into the trap of trying to do a removal without adequate instruments or good control of the patient. Only infrequently does removal have to be done urgently. Unless the airway is obstructed, there is adequate time to provide sedation or anesthesia and obtain proper instruments. The instruments should be so shaped that they can be inserted behind the mass without their manipulation pushing it further inward. Magnifying loops can be helpful in finding a small crevice on the side through which to pass the instrument. We have seen several instances where a small bead lying in the lateral aspect of the external auditory canal was pushed through the isthmus into the middle ear during attempts at removal. Neither the child nor his parents appreciated this well-meant effort.

The isthmus of the external canal represents the major challenge for the removal of foreign bodies. Edema of the canal wall can so trap an object that a surgical incision becomes necessary for removal. An object smaller than the canal can be grasped with Hartman forceps. Larger objects can be removed by inserting a hook or loop past and behind it, and then withdrawing. Non-vegetable items can occasionally be forced out by a stream of water directed superiorly into the canal. Vegetable matter, such as beans, should not be irrigated with water because these tend to swell and become impacted. A water stream is contraindicated also whenever there is any possibility of a perforation.

Animate objects, such as insects, should be killed first. This is easily done by filling the canal with alcohol or mineral oil. They can then easily be removed by forceps or irrigation. Metallic foreign bodies may be removed by a magnet borrowed from the ophthalmologist.

A special problem exists when a foreign body has become attached to the tympanic membrane, since removal nearly always results in perforation. It is important to first give such a patient systemic antibiotic, and refrain from putting any sort of drops in the canal. After the removal, the membrane will usually heal unless secondary infection should develop. Occasionally, it becomes necessary to graft the membrane later.

A cotton tipped applicator in the ear will often traumatize the canal and drum. This typically occurs when the child decides to copy the parent and accidentally pushes the stick in too far. Such a traumatized ear should first be gently cleaned and inspected. Irrigation should be avoided, since this will force debris into the middle ear cavity if a perforation is present. Give the patient a systemic antibiotic. Many otologic surgeons treat such a perforation as a surgical emergency. They give the child a general anesthetic and debride the torn edges of the perforation, grafting when necessary. Prompt action may prevent more extensive surgery later.

A persistent unilateral nasal discharge in a child should make the physician strongly suspect the presence of a foreign body, especially when the discharge is bloody and accompanied by an offensive odor. An ipsilateral serous otitis media is often present also when the foreign material has been present for any length of time. The absence of a positive history for insertion of the foreign object is or little consequence, for most children will not admit to this act. Nasal x-rays should be obtained because the object may be radiopaque.

Special problems have arisen in recent years because of plastic toys. They cause little odor because of their low reactivity, yet granulation tissue forms around them to give the gross appearance of a tumor.

Procedure. What should the physician do when faced with the possibility of a nasal foreign body? First, explain the situation to the child's parents. Then sedate the child who is anxious and irritable with intramuscular meperidine and a barbiturate. Proceed by spraying a nasal vasoconstrictor into the nostril and cleaning the vestibule with gentle suction. Examine the nose using a nasal speculum on the surgical head of an otoscope. Telescopes may be used for cooperative patients. Soft objects can be grasped with a Hartman or alligator forceps. Harder, larger objects are best removed by passing a hook or loop behind them and then withdrawing.

Pushing the object posteriorly into the nasopharynx should be avoided if at all possible. Few parents appreciate having their child put to sleep time so that the same foreign body can be removed from a bronchus or the esophagus.

The signs and symptoms produced by pharyngeal foreign bodies vary with the region involved. Nasopharyngeal symptoms are similar to those in the nose with the exception that the disease is bilateral. In the oropharynx and hypopharynx, foreign bodies give rise to respiratory symptoms and difficulty in swallowing. This is an especially indicative symptom in young infants who may ingest a remarkable variety of objects. Any infant who refuses to eat or who has trouble handling his buccal secretions should be evaluated for a foreign body.

The pharyngeal foreign body can usually be seen by inspection. Older children may indicate the site to be examined. With small children, a laryngoscopy is usually necessary. Palpation with a finger should be avoided because this may push the object down further and even impact it, with catastrophic results.

Ingested fish bones either pass through without difficulty or lodge in the soft palate or tonsillar areas. Rarely do they stick in the hypopharynx or esophagus. The child will complain of a sticking sensation and point to the area around the greater cornu of the hyoid bone when the tonsil is the site of injury. Fish bones embedded in the tonsil may be removed without anesthesia by means of a tonsil hemostat.

Removal of other pharyngeal foreign bodies requires skillful manipulation and is not difficult if done properly. Proper instruments should be on hand, however, in the event that immediate tracheotomy becomes necessary.

The initial symptoms of a foreign body in this region are typically dramatic, but the drama may be ignored. The aspiration instantly produces a spasm of coughing but unless there is marked respiratory embarrassment the mucosa rapidly adapts to the abnormal situation. One must then wait for secondary symptoms. The wait will be short with organic objects because the child will soon have pneumonia. With plastic or metallic objects, years may pass before symptoms become manifest. "All that wheezes is not asthma."  Wheeze is unilateral, ipsilateral.

Diagnosis can usually be made by either roentgenographic or fluoroscopic examination. The foreign material often acts like a check valve, producing air flow obstruction or expiration. This may produce a demonstrable shift of the mediastinal structures which can easily be seen by x-ray evaluation.

The procedure for removal of a bronchial foreign object is the same as for bronchoscopy in general. The mechanical problems involved with removal of each type of foreign body are beyond the scope of this article. General anesthesia is recommended because absolute control of the patient is essential.

The ingestion of foreign bodies by young children is very common yet it is surprising how few of these result in clinical difficulties. Round and smooth objects usually enter the stomach without difficulty. Patients with objects lodged at the cardioesophageal junction may be safely watched for 24-48 hours before any attempt at removal. This will give adequate time for spontaneous passage to occur, if it is going to. Objects caught high near the cricopharyngeus muscle should be removed as soon as feasible, since these are likely to become dislodged or cause respiratory embarrassment from pressure on the trachea. They also hamper the patent's ability to swallow his secretions.

The diagnosis of esophageal foreign body can be made by radiographic examination with the use of contrast media. Radiolucent objects can be visualized by having the child swallow a cotton ball coated with barium. The child may be given liquids with safety, but solid food should be avoided since these may force a sharp edge through the esophageal wall leading to mediastinitis.

The removal of an esophageal foreign body is hazardous because the wall is thin and may have become further weakened by inflammation.

Enzymes such as papase are occasionally fed in order to digest organic objects. This technique may be hazardous because the enzymes will also digest areas of the esophageal wall which have become damaged by pressure necrosis from the foreign body. Rigid endoscopy under general anesthesia is the safest procedure available.

Removal of a foreign body represents one of the most rewarding aspects of the practice of medicine. It can be a diagnostic challenge as well as a mechanical one. The patient who was distraught such a short time before becomes instantly grateful when the removal is accomplished with facility and safety.