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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 23  |  Issue : 2  |  Page : 75-77

Nasopharynx harboring ingested foreign bodies: Two case reports


1 Department of ENT, PGIMS, Rohtak, Haryana, India
2 Department of ENT, All India Institute of Medical Sciences, Bathinda, Punjab, India

Date of Submission08-Jun-2020
Date of Decision19-Aug-2020
Date of Acceptance25-Sep-2020
Date of Web Publication02-Jun-2021

Correspondence Address:
Dr. Vikasdeep Gupta
Department of ENT, All India Institute of Medical Sciences, Bathinda, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SJOH.SJOH_27_20

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  Abstract 


Foreign bodies are not uncommon in the aerodigestive tract, especially in children. However, the nasopharynx is an infrequent and unusual site for the impaction of an ingested foreign body as the direction of motion is antigravity. The nasopharynx is a potential site for foreign body impaction, which is often overlooked by otolaryngologists. We report two cases of unusual foreign bodies in the nasopharynx. Our cases explain the need for a high degree of suspicion from the beginning and the importance of radiological imaging before any intervention.

Keywords: Foreign body, ingestion, nasopharynx


How to cite this article:
Gupta G, Gupta V, Singla A, Kaur G, Raheja V, Verma N. Nasopharynx harboring ingested foreign bodies: Two case reports. Saudi J Otorhinolaryngol Head Neck Surg 2021;23:75-7

How to cite this URL:
Gupta G, Gupta V, Singla A, Kaur G, Raheja V, Verma N. Nasopharynx harboring ingested foreign bodies: Two case reports. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2021 [cited 2021 Jul 23];23:75-7. Available from: https://www.sjohns.org/text.asp?2021/23/2/75/317438




  Introduction Top


Foreign bodies are not uncommon in the aerodigestive tract, especially in children.[1] However, the nasopharynx is an infrequent and unusual site for the impaction of an ingested foreign body as the direction of motion is antigravity.[2] This usually occurs if there is vomiting after ingestion, and it goes into the nasopharynx. Sometimes parents put the child upside down, and the foreign body goes into the nasopharynx. We report two cases of unusual foreign bodies in the nasopharynx.


  Case Reports Top


Case report 1

A 16-month-old child was brought to the emergency department with a complaint of foreign body ingestion 6 h back. Since then, the child was uncomfortable, had three episodes of vomiting, and refused to eat. Clinical examination did not reveal any signs of respiratory distress. The oral cavity and throat were found to be normal. Computerized tomography from the base of the skull to a clavicle was done to confirm the position of the plastic foreign body. The foreign body was found to be lodged in the nasopharynx [Figure 1]. The case was posted under general anesthesia, and nasal endoscopy was performed. The plastic nut was found to be anchored in hypertrophied adenoid tissue due to the serrated margins of the foreign body [Figure 2]. Due to its peculiar shape and large size, it was not feasible to retrieve the nut through the nose [Figure 2]. Therefore, an alternative plan was made to deliver the foreign body by pushing it into the throat. However, it was so firmly embedded in the adenoid tissue that this plan also failed. Finally, Boyle's Davis mouth gag was introduced. An infant feeding tube was passed through the nose and taken out from the oral cavity to retract the soft palate; the foreign body was dislodged from adenoid tissue and retrieved per orally with the help of Luc's forceps under peroral endoscopic guidance. Check nasal endoscopy was done to rule out any active bleed or residual foreign body. The nasopharynx was found to be normal. After recovery from anesthesia, the patient was shifted to the postoperative room. The recovery was uneventful. The patient was discharged the next day on just normal saline nasal drops. The follow-up was done after 7 days and the patient was asymptomatic.
Figure 1: Computerized tomography scan showing foreign body in the nasopharynx

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Figure 2: Plastic nut removed from the nasopharynx

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Case report 2

An 8-month-old baby presented in the emergency room with the mother having witnessed the ingestion of the metallic bottle cap 2 h before. She had made several naive attempts to remove the foreign body with her finger. The baby was asymptomatic at the time of arrival. Clinical examination was found to be unremarkable. X-ray soft-tissue neck and chest were done to look for the site of foreign body impaction. The X-ray showed that the foreign body was lodged in the nasopharynx [Figure 3]. The case was shifted to operation theatre with a precaution to keep the independent head position to avoid foreign body dislodgement into the larynx. Following endotracheal intubation, the baby was placed in Rose's position, and Boyle's Davis mouth gag was introduced. The foreign body was visualized after retracting soft palate with a tonsillar pillar retractor. It was held with angled forceps and removed gently, avoiding any trauma to surrounding structures [Figure 4]. The postoperative period was uneventful and the child was discharged the next day. The patient was followed up on the 7th day, had no complaints.
Figure 3: X-ray shows a foreign body in the nasopharynx (metallic bottle cap)

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Figure 4: Metallic bottle cap removed from the nasopharynx

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  Discussion Top


A nasopharyngeal foreign body is a rare entity. Most of the time, such foreign bodies are inhaled and reach the nasopharynx through the nasal cavity.[3] In contrast, ingested foreign bodies getting lodged in the nasopharynx is a much rarer entity, the nasopharynx. Unlike our cases, usually, the patient with a nasopharyngeal foreign body has symptoms of nasal obstruction, bleeding, or nasal discharge.[4] An early presentation can with only a few cases reported to date.[2] This may be the result of manual attempts to remove the foreign body or regurgitation of the foreign body by forceful coughing and vomiting.[5] In our first case also, there was a history of three episodes of vomiting, which explains the lodgement of plastic nut in the nasopharynx. Similarly, in case 2, the mother had made several blind attempts to retrieve the foreign body which might have pushed the foreign body into be one of the reasons for the lack of such symptoms in our cases.

The signs and symptoms that are mostly nonspecific in case of foreign body aspiration, and cases of unobserved aspiration, the diagnosis can be delayed, which increases morbidity and the likelihood of chronicity.[6] Nasopharyngeal foreign body lodgment can occur in many cases, such as dislocation of a foreign body from the nasal cavity during extraction attempts, upward migration from the pharynx, or esophagus after forceful pressure due to vomiting or coughing, traumatic penetration, or iatrogenic causes.[7]

The nasopharynx is a potential site for foreign-body impaction, which is often overlooked by otolaryngologists. Our cases explain the need for a high degree of suspicion from the beginning and the importance of radiological imaging before any intervention. In both cases, a positive history of foreign-body ingestion was there but was not suggestive of the site of lodgement and clinical examination was normal, so radiological examination was done initially.

We suggest that whenever we requisite X-ray neck and chest (anteroposterior and lateral), this should include the nasopharynx. In case 1, the foreign body was radiolucent, and therefore computerized tomography was done, which guided us for nasopharyngoscopy instead of esophagoscopy or bronchoscopy, however, in the second case history of metallic foreign body was there, X-ray was done. The objective is to localize the site of the lodged foreign body before any invasive procedure was undertaken.

If ingested foreign bodies could not be localized through history and clinical examination, the nasopharynx should be examined.[8] A supportive nasopharyngoscopy should be done as the suspected nasopharyngeal foreign body may not be radiopaque. The foreign body may get lodged in the bronchi leading to pneumonia, atelectasis, and bronchiectasis, leading to complications.[9]


  Conclusion Top


From the above discussion, we conclude that the nasopharynx is a potential site for an ingested foreign body's impaction so should be kept in the differential diagnosis of an ingested foreign whose site could not be confirmed on clinical examination. Radiological confirmation of a foreign body is necessary before any intervention.

Ethical approval

The study was approved by the Regional Ethics Review Board and informed consent was taken from study subjects.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the parents have given their consent for images and other clinical information to be reported in the journal. The parents understand that names and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Uyemura MC. Foreign body ingestion in children. Am Fam Physician 2005;72:287-91.  Back to cited text no. 1
    
2.
Jagdish Kumar Athmaram Gupta Sunkum. Nasopharyngeal foreign body in an young child. Indian J Otolaryngol Head Neck Surg 2011;63:285-6.  Back to cited text no. 2
    
3.
Kiger J, Brenkert T, Losek J. Nasal foreign body removal in children. Pediatr Emerg Care 2008;24:784-92.  Back to cited text no. 3
    
4.
Gupta M. Endoscopic removal of unusual foreign body from the nasopharynx. Research 2014;1:871.  Back to cited text no. 4
    
5.
Majumder PK, Sinha AK, Mookherje PB, Ganguly SN. An unusual foreign body in nasopharynx. Indian J Otolaryngol Head Neck Surg. 1999 ;52:93. doi: 10.1007/BF02996448. PMID: 23119636; PMCID: PMC3451211.  Back to cited text no. 5
    
6.
Karakoç F, Karadağ B, Akbenlioğlu C, Ersu R, Yildizeli B, Yüksel M, Dağli E. Foreign body aspiration: what is the outcome? Pediatr Pulmonol. 2002 ;34:30-6. doi: 10.1002/ppul.10094. PMID: 12112794.  Back to cited text no. 6
    
7.
Briggs RD, Pou AM, Friedman NR. An unusual catch in the nasopharynx. Am J Otolaryngol 2001;22:354-7.  Back to cited text no. 7
    
8.
Kumar S, Singh DB, Singh AB. An unusual nasopharyngeal foreign body with unusual presentation as nasal regurgitation and change in voice. BMJ Case Rep. 2013 Jul 24;2013:bcr2013010005. doi: 10.1136/bcr-2013-010005. PMID: 23884977; PMCID: PMC3736250.  Back to cited text no. 8
    
9.
Oysu C, Yilmaz HB, Sahin AA, Külekçi M. Marble impaction in the nasopharynx following oral ingestion. Eur Arch Otorhinolaryngol 2003;2013:522-3.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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