Ear, nose and throat
FOREIGN BODY IN THE EAR
Action
1. Remove insects to relieve pain. Fill the ear with olive oil to asphyxiate it, or kill it with alcohol. Gently remove it by syringing the ear with water at body temperature.
2. Inanimate foreign bodies may yield to gentle syringing, but those that occlude, or nearly occlude, the meatus cannot be removed by syringing so they need to be extracted with an instrument. Commonly inserted small pieces of sponge rubber can be removed using crocodile forceps if they lie close to the external auditory meatus. Unless you are expert, do not attempt to remove solid foreign bodies, since you risk damaging the middle ear, including the ossicular chain. A general anaesthetic may be required.
3. If the child is cooperative, examine the ear in a good light, initially without, then with, an auroscope. When the child is relaxed and quiet, touch the foreign body with a fine probe to confirm its shape and texture. You may not need to insert an aural speculum to do this. Look for a graspable edge; if you can seize it with very fine Hartmann’s crocodile forceps you may be able to remove it.
DIFFICULTY
1. If the object is smooth and rounded, such as a bead, do not apply forceps; they cannot grasp the object, and risk pushing it deeper into the meatus, through the drum, ossicular chain and possibly into the facial nerve and labyrinth.
2. The safest way to remove an occluding foreign body is under general anaesthesia, using an operating microscope. If this is not available, use illuminating loupes and the largest aural speculum the meatus will accept. Insinuate a stapedectomy hook beyond the object anteroinferiorly unless there is an obvious space above it, turn the hook to engage it, and ease it out by rolling or sliding. Alternatively, try the effect of using a small sucker.
REMOVAL OF NASAL FOREIGN BODY
Appraise
1. Suspect a self-inserted foreign body in any young child with unilateral nasal discharge. The discharge is usually foul smelling, causing obstruction and often contains blood.
2. The foreign body is commonly a screwed-up fragment of paper, vegetable matter, a plastic or metal bead, or rubber sponge.
Prepare
1. As with aural foreign bodies, first gain the child’s cooperation. You may succeed if the foreign body is graspable and if you have appropriate instruments, clear visibility, a headlight, and are skilful in using a nasal speculum. If any of these are lacking, it needs to be removed under general anaesthesia by a specialist with oral, not nasal, intubation.
2. Ask the anaesthetist to avoid inflating the lungs with a face-mask, since this could force a nasal foreign body backwards.
Place the patient in the tonsillectomy position, which is supine with the neck extended. Use a Boyle-Davis gag to prevent the foreign body slipping backwards into the nasopharynx, where it will stay because this is the most dependent part.
4. If the object is graspable use fine forceps; otherwise, use a small hook that can be passed above the foreign body, easing it downwards and forwards for delivery.
MANIPULATION OF FRACTURED NOSE
Appraise
1. Realignment of displaced nasal bones is not only a cosmetic operation. Nasal fractures are frequently associated with nasal obstruction and many nasal fractures have an associated fracture of the nasal septum.
2. Nasal fractures may be associated with other facial injuries such as a fractured maxilla or ‘blow-out’ fracture of the orbit. Do not fail to examine the patient for other facial injuries.
3. Try to manipulate nasal fractures within 2 weeks of the injury. The most suitable times to do so are either very early, before there has been much nasal swelling, or at about 7 days when much of the swelling around the fracture site has subsided. If you try to manipulate the nasal bones while there is much swelling, it is difficult to see whether or not the nose is straight.
Action
1. It may be possible to straighten the nose by digital pressure, easing the nasal skeleton back into the midline. You can often manipulate it without anaesthesia within the first hour or two after injury. Alternatively re-align the nasal bones under local anaesthesia. You may feel a click as the fragments move into place.
2. If you cannot reduce the fracture in these ways you need the aid of general anaesthesia.
