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Foreign Bodies in the Head, Neck, Airways, and Extremities: Curious Findings
Lars Grimm, MD, MHS | September 24, 2021
| Contributor Information
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Foreign Bodies in the Head, Neck, Airways, and Extremities: Curious Findings
Lars Grimm, MD, MHS | September 24, 2021 | Contributor Information
Foreign bodies to the head and neck, airways, and extremities are often the result of trauma or accidental injury, especially in children. The presentation of foreign bodies can be highly variable, depending on their composition and location. Physical examination, clinical symptoms, and imaging (via radiography, ultrasonography [US], and magnetic resonance imaging [MRI]) all play roles in guiding proper diagnosis and treatment. Prompt diagnosis is essential for ensuring appropriate treatment and subspecialty referral as needed.
The image shown demonstrates attempted removal of a corneal foreign body under direct visualization.
Image courtesy of Medscape | Robert Mittendorff, MD, MBA.
Foreign Bodies in the Head, Neck, Airways, and Extremities: Curious Findings
Lars Grimm, MD, MHS | September 24, 2021 | Contributor Information
Extremity Foreign Bodies
Foreign bodies in the extremities are extremely common. Although the presence of a foreign body is usually not in question, radiographs can be valuable to assess for fragmentation of the foreign body (shown) and to evaluate for any associated fractures. This is particularly true for metallic foreign bodies and, sometimes, for larger wooden or glass ones. Smaller nonmetallic foreign bodies may be visible on US.
Appropriate prophylaxis (eg, tetanus vaccination) should be administered per protocol. Use of analgesia, anxiolytics, and even sedation can facilitate removal. Wound irrigation with saline is recommended after foreign body removal, but antiseptic solutions may delay healing and should therefore be avoided.[1]
Image courtesy of Lars Grimm, MD, MHS.
Foreign Bodies in the Head, Neck, Airways, and Extremities: Curious Findings
Lars Grimm, MD, MHS | September 24, 2021 | Contributor Information
Although MRI is not a first-line modality for imaging foreign bodies, its excellent ability to identify soft-tissue structures may be helpful in challenging cases. The images shown demonstrate a linear foreign body on the palmar aspect of the index finger with an associated fluid collection. The use of MRI can also facilitate surgical planning by helping to delineate the relationship between the foreign body and adjacent soft-tissue structures (eg, nerves and blood vessels).
Image courtesy of Lars Grimm, MD, MHS.
Foreign Bodies in the Head, Neck, Airways, and Extremities: Curious Findings
Lars Grimm, MD, MHS | September 24, 2021 | Contributor Information
Aural Foreign Bodies
The computed tomography (CT) scan shows a metallic foreign body in the right external auditory canal.
Aural foreign bodies are a relatively frequent pediatric presentation in the emergency department (ED). In children, anything small enough to fit within the ear canal is a possible finding; however, the most common items are food, toys, beads, stones, insects, and seeds. Sometimes, young patients cannot indicate that they have an object in the ear, in which case the finding of ear pain or discharge, hearing loss, a sense of ear fullness, or some combination thereof may lead to the diagnosis. In adults, the most common aural foreign bodies are hearing aid components and insects.
Foreign bodies typically lodge within the ear canal itself, but if the tympanic membrane is perforated, the item may lie within the middle ear or, rarely, penetrate as far as the inner ear. Physical examination findings depend on the object and the length of time it has been in the ear. Inanimate objects lodged for a short time typically reveal no abnormal finding other than the object itself. Bleeding or erythema may be found if the object has damaged the ear. If the item has been in place for some time, erythema, swelling, and foul-smelling discharge may be present. Insects may injure the canal or the tympanic membrane by scratching or stinging.
Image courtesy of Medscape/Prince Cheriyan Modayil, MRCS, MS, MBBS, DO-HNS.
Foreign Bodies in the Head, Neck, Airways, and Extremities: Curious Findings
Lars Grimm, MD, MHS | September 24, 2021 | Contributor Information
Visualization with an otoscope can typically identify the foreign body, though in some cases, a microscopic otoscope will be needed (shown).
Methods for removing an aural foreign body include mechanical extraction, irrigation, and suction. The characteristics of the object may dictate which removal options are most appropriate. Irrigation under low pressure is the simplest method but should be avoided with organic matter, which may absorb the irrigation fluid and enlarge within the ear canal. Mechanical extraction with forceps may be undertaken with direct otoscopic visualization. Suction removal with low wall suction and direct visualization is best for friable objects that will break if grasped.
Consultation with an otolaryngologist is advised if the object cannot be removed or if perforation of the tympanic membrane is suspected.
Image courtesy of Radiopaedia.org/Dr Frank Gaillard.
Foreign Bodies in the Head, Neck, Airways, and Extremities: Curious Findings
Lars Grimm, MD, MHS | September 24, 2021 | Contributor Information
Nasal Foreign Bodies
The radiograph shows a radiopaque linear foreign body within the nasal cavity (arrow) that appears to reach the sphenoid sinus.
Nasal foreign bodies are often encountered in EDs, particularly with children, in whom synthetic beads and vegetables are the objects most commonly seen.[2]
The most frequent locations for nasal foreign bodies are just anterior to the middle turbinate and below the inferior turbinate (shown). Unilateral foreign bodies affect the right side twice as often as the left, probably because right-handed people can reach the right naris more easily. Unilateral discharge is the most common presentation in patients with objects lodged in the nose, but such patients may also exhibit nasal irritation, epistaxis, sneezing, snoring, sinusitis, stridor, wheezing, fever, and halitosis. In addition, nasal foreign bodies carry the risk of becoming dislodged and dropping into the lower airway.
Image from Thabet MH, Basha WM, Askar S. Biomed Res Int. 2013;2013:846091. [Open access.] PMID: 23936851, PMCID: PMC3725977.
Foreign Bodies in the Head, Neck, Airways, and Extremities: Curious Findings
Lars Grimm, MD, MHS | September 24, 2021 | Contributor Information
The image shows an intraoperative endoscopic view of a button battery in the right nasal cavity. Metallic button batteries are of special concern because they can cause destruction through low-voltage electrical currents, electrolysis-induced release of sodium hydroxide and chlorine gas, and even liquefaction necrosis if their alkaline contents leak into the surrounding tissue.[3]
Visualization with a headlamp and a nasal speculum can help identify the foreign body.
Several different removal techniques are available. For easily visualized nonspherical and nonfriable objects, direct mechanical removal with forceps or hooked probes is preferred. Balloon catheter removal is the next most common method: A Foley or Fogarty catheter is passed beyond the item, inflated, and then retracted. The positive-pressure technique involves occlusion of the unaffected naris and then the administration of pressure via a bag-valve-mask, a parent's mouth, or a specialized device. Removal with suction or glue is recommended for objects with smooth surfaces that are easily visualized.
In most cases, removal of nasal foreign bodies can be performed by nonspecialists, though referral to an otolaryngologist is recommended if attempts at removal fail or if there is significant damage to adjacent structures.
Image courtesy of Lars Grimm, MD, MHS.
Foreign Bodies in the Head, Neck, Airways, and Extremities: Curious Findings
Lars Grimm, MD, MHS | September 24, 2021 | Contributor Information
Ocular Foreign Bodies
The image is a scout radiograph from a CT scan that demonstrates a bungee cord lodged in the globe.
Ocular foreign bodies may be protean in presentation, outcome, and prognosis, depending on the circumstances of the injury. Scoring systems are available to help standardize the degree of injury and the need for intervention.[4] The most common etiology is accidental trauma from using a hammer or power tools.
The final resting place of an ocular foreign body and the damage it causes depend on its size, shape, and momentum at the time of impact, as well as on the site of penetration. Corneal foreign bodies are superficially adherent to or embedded in the cornea of the eye, whereas intraocular foreign bodies penetrate the anterior chamber of the eye or the globe itself.
Evaluation of an ocular foreign body typically begins with a slit-lamp examination. CT is the imaging study of choice for the localization of ocular foreign bodies because it can easily detect radiopaque foreign objects. There is a limited role for US in localizing foreign bodies, even in patients with a ruptured globe.
Image courtesy of Lars Grimm, MD, MHS.
Foreign Bodies in the Head, Neck, Airways, and Extremities: Curious Findings
Lars Grimm, MD, MHS | September 24, 2021 | Contributor Information
Corneal lesions can typically be removed under direct visualization with a cotton-tipped applicator or a needle in the ED. Removal of intraocular foreign bodies usually requires surgical intervention by an experienced ophthalmologist in the form of paracentesis or vitrectomy. The greatest limiting factor in the prognosis is often the amount of damage that occurs during the initial injury. Overall, however, the majority of patients recover most of their eyesight.
Ocular foreign bodies are not always removed. However, screening for an ocular foreign body is extremely important if the patient is to undergo an MRI evaluation. The CT scan in the slide is from a patient with a metallic foreign body in the anterior chamber of the left globe that was present for at least 4 years. If this patient were to undergo MRI, movement of the foreign body induced by the strong magnetic fields could result in extensive damage to the eye and regional structures. Screening is often via ocular radiography, but CT may also be performed.
Image courtesy of Lars Grimm, MD, MHS.
Foreign Bodies in the Head, Neck, Airways, and Extremities: Curious Findings
Lars Grimm, MD, MHS | September 24, 2021 | Contributor Information
The reconstructed CT scan in the slide is from a patient who had a ballpoint pen driven through his orbit, with the tip terminating in the middle cerebellar peduncle.
Emergency CT can be performed to achieve better definition of the extent of a penetrating foreign body. CT angiography can also help delineate injuries to the vasculature, thereby facilitating treatment planning.
Image courtesy of Lars Grimm, MD, MHS.
Foreign Bodies in the Head, Neck, Airways, and Extremities: Curious Findings
Lars Grimm, MD, MHS | September 24, 2021 | Contributor Information
Airway Foreign Bodies
Foreign body aspiration may rapidly produce life-threatening complications. Individuals at risk for aspiration include young children, elderly patients with neurologic disorders or decreased gag reflexes, and patients undergoing procedures involving sedation.
Airway foreign bodies most commonly lodge in the right mainstem bronchus and the lower pulmonary lobe. Children most frequently aspirate peanuts and other organic matter, and adults most often aspirate vegetables, meat, and bones. Aspiration of teeth after accidental or iatrogenic trauma can also occur.
Typically, the history is sufficient to make the diagnosis. Patients will often report a sudden choking sensation, shortness of breath, wheezing, or coughing. On physical examination, respiratory distress, wheeze, stridor, rhonchi, or some combination thereof may be present. Chest radiography can be used to identify radiopaque objects, such as a tooth in the left mainstem bronchus (shown).
Image courtesy of Lars Grimm, MD, MHS.
Foreign Bodies in the Head, Neck, Airways, and Extremities: Curious Findings
Lars Grimm, MD, MHS | September 24, 2021 | Contributor Information
In some circumstances, bronchoscopy may be needed to confirm the suspected diagnosis of an aspirated foreign body. If the patient presents with signs or symptoms of severe airway compromise, administer immediate chest compressions, back blows, or abdominal thrusts, depending on the age of the patient. In rare circumstances, if bronchoscopy is unsuccessful, surgical intervention may be required. Overall, the prognosis is very poor for those with obstructive foreign bodies but excellent for those with nonocclusive ones.
Removal of a nonobstructive foreign body in the airway is not always required. Accordingly, it is necessary to evaluate the risk-to-benefit ratio of removal against that of surveillance. The coronal CT image in the slide shows a metallic radiopaque foreign body in a distal left-lower-lobe bronchus. The patient was clinically fine and had no evidence of postobstructive pneumonia after 1 year of follow-up. This patient was aged 89 years, and the risk of surgical removal was thought to outweigh the benefits.
Image courtesy of Lars Grimm, MD, MHS.
Foreign Bodies in the Head, Neck, Airways, and Extremities: Curious Findings
Lars Grimm, MD, MHS | September 24, 2021 | Contributor Information
Nonradiopaque Foreign Bodies
The radiograph in the slide is from a 12-year-old boy with a puncture wound to the upper calf and shows air in the soft tissues (arrows). US was subsequently performed, revealing multiple echogenic foreign bodies. Intraoperative US was employed to facilitate surgical removal of multiple leaves and twigs.
US is a valuable imaging modality for the evaluation of nonradiopaque foreign bodies, particularly if the object is in the superficial soft tissue and is palpable. Real-time scanning and clinician palpation can ensure that the affected area is accurately investigated, as shown by a 2015 meta-analysis/systematic review that demonstrated 72% sensitivity and 92% specificity.[5] If desired, US can also be used to facilitate removal of any foreign bodies, with a success rate approaching 100%.[6] Foreign bodies typically demonstrate posterior acoustic shadowing or reverberation artifact.[6]
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Contributor Information
Author
Lars Grimm, MD, MHS
Associate Professor
Department of Diagnostic Radiology
Duke University Medical Center
Durham, NC
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
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References
Rupert J, Honeycutt JD, Odom MR. Foreign bodies in the skin: evaluation and management. Am Fam Physician. 2020 Jun 15;101(12):740-7. PMID: 32538598
Abou-Elfadl M, Horra A, Abada RL, Mahtar M, Roubal M, Kadiri F. Nasal foreign bodies: results of a study of 260 cases. Eur Ann Otorhinolaryngol Head Neck Dis. 2015 Dec;132(6):343-6. PMID: 26364542
Thabet MH, Basha WM, Askar S. Button battery foreign bodies in children: hazards, management, and recommendations. Biomed Res Int. 2013;2013:846091. PMID: 23936851
Bourges JL, Boutron I, Monnet D, Brezin AP. Consensus on severity for ocular emergency: the BAsic SEverity Score for Common OculaR Emergencies [BaSe SCOrE]. J Ophthalmol. 2015;2015:576983. PMID: 26294965
Davis J, Czerniski B, Au A, Adhikari S, Farrell I, Fields JM. Diagnostic accuracy of ultrasonography in retained soft tissue foreign bodies: a systematic review and meta-analysis. Acad Emerg Med. 2015 Jul;22(7):777-87. PMID: 26111545
Del Cura JL, Aza I, Zabala RM, Sarabia M, Korta I. US-guided localization and removal of soft-tissue foreign bodies. Radiographics. 2020 May 29;200001. PMID: 32469630
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