Foreign objects

Definition

Foreign bodies can enter the human body by swallowing, insertion, or traumatic force, either accidentally or on purpose. The word "foreign" in this context means "originating elsewhere" or simply "outside the body."

Description

Children and adolescents may experience health problems caused by foreign objects getting stuck in their bodies. Young children in particular are naturally curious and may intentionally put such shiny objects as coins or button batteries into their mouths. They also like to stick small items in their ears and up their noses. Older children and teenagers may accidentally swallow a nonfood object or ingest a foreign body that gets stuck in the throat, like a fish bone or toothpick. Airborne particles can lodge in the eyes of people at any age. In addition, foreign bodies may be driven into the face or other parts of the body by the force of a collision or explosion.

Foreign bodies may be found in hollow organs (like swallowed batteries in the stomach) or in tissues (like bullets). They can be inert or irritating. If they irritate the surrounding tissue, they cause inflammation and scarring. Foreign objects can bring infection with them or acquire it and protect it from the body's immune defenses. They can obstruct passageways in the body either by their size or by the scarring they cause. Some foreign objects, particularly lead shot or other small objects containing lead, are toxic.

Demographics

Swallowing of foreign bodies is a fairly common pediatric emergency; about 80,000 cases involving persons 19 years old or younger are reported each year to the 67 poison control centers in the United States. In a recent survey of the parents of 1,500 children, 4 percent reported that their children had swallowed a foreign object of some kind. The highest incidence of swallowed foreign bodies is in children between the ages of six months and four years.

The type of object most frequently swallowed varies somewhat across different historical periods and cultures. A recent study comparing the Jackson collection of foreign bodies removed from children between 1920 and 1932 with data collected from North American children's hospitals between 1988 and 2000 found that coins have replaced safety pins as the objects most commonly swallowed by American children. In Asia, on the other hand, fish bones are a frequent offender because fish is a dietary staple in most countries of the Far East.

In younger children, boys are at slightly greater risk than girls (53% to 47%) of swallowing foreign objects. Among teenagers, however, males are at a much higher risk than females of swallowing foreign bodies or inserting them into the rectum.

Younger children usually swallow or insert foreign objects into their bodies accidentally, usually as a result of play or exploring their environment. Adolescents, however, are more likely to swallow or insert foreign bodies intentionally as a risk-taking behavior, a bid for attention, or under the influence of drugs or alcohol. Adolescent girls with eating disorders have been reported to swallow toothbrushes. A small minority of teenagers who harm themselves by swallowing or inserting foreign bodies suffer from schizophrenia or another psychotic disorder.

Causes and symptoms

Causes

The causes of foreign body ingestion or insertion range from traumatic accidents or casual exploration and play to intentional risk-taking, desire for sexual stimulation, an eating or personality disorder, or psychotic behavior. Cases of repeated swallowing of foreign objects by small children may indicate neglect or a dysfunctional home environment.

Symptoms

The symptoms of foreign body ingestion or insertion depend in part on the organ or part of the body affected.

eyes Dust, dirt, sand, or other airborne material can lodge in the eyes as a result of high wind or an explosion, causing minor irritation and redness. More serious damage can be caused by hard or sharp objects that penetrate the surface of the eye and become embedded in the cornea or conjunctivae (the mucous membranes lining the inner surface of the eyelids). Swelling, redness, bleeding from the surface blood vessels, sensitivity to light, and sudden vision problems are all symptoms of foreign matter in the eyes.

ears and nose Toddlers sometimes put small objects into their noses, ears, and other openings. Beans, dried peas, popcorn kernels, hearing-aid batteries, raisins, and beads are just a few of the many items that have been found in these bodily cavities. On occasion, insects may also fly into a child's ears or nose. Pain , hearing loss, and a feeling of fullness in the ear are symptoms of foreign bodies in the ears. A smelly or bloody discharge from one nostril is a symptom of foreign bodies in the nose.

airways and stomach At a certain age children will eat almost anything. A very partial list of items recovered from young stomachs includes the following: coins, chicken bones, fish bones, beads, pebbles, plastic toys , pins, keys, buckshot, round stones, marbles, nails, rings, batteries, ball bearings, screws, staples, washers, a heart pendant, a clothespin spring, and a toy soldier. Some of these items will pass right on through the digestive tract and leave the body through the feces. The progress of metal objects has been successfully followed with a metal detector or x rays . Other objects, like needles, broken poultry bones, or razor blades, can get stuck at various points in the digestive tract and cause trouble.

Most complications of swallowed foreign bodies occur in the esophagus at one of three points: the thoracic inlet at collarbone level (70%); the mid-esophagus (15%); and the sphincter at the lower end of the esophagus where the esophagus joins the stomach (15%). If a swallowed object passes into the stomach, it is unlikely to cause complications unless it is either sharp and pointed in shape or made of a toxic material.

Some foreign objects lodge in the airway. Although children eat small objects and stick things into their bodily openings of their own volition, they inhale them unwittingly while choking . Probably the most commonly inhaled item is a peanut. Items as unusual as crayons and cockroaches have also been found in children's windpipes. These items always cause symptoms (difficulty swallowing and spitting up saliva, for instance) and may elude detection for some time while the child is being treated for asthma or recurring pneumonia .

rectum Sometimes a foreign object will successfully pass through the throat and stomach only to get stuck at the juncture between the rectum and the anal canal. Items may also be self-introduced to enhance sexual stimulation and then get stuck in the rectum. Sudden sharp pain during elimination may signify that an object is lodged in the rectum. Other symptoms vary depending upon the size of the object, its location, how long it has been in place, and whether or not infection has set in.

When to call the doctor

The specific symptoms of foreign body ingestion vary somewhat depending on the item and its location in the body. Parents or caregivers may observe the child swallowing the object, or the child may report doing so. In general, parents should take the child to the doctor or emergency room in any of the following situations occurs:

• foreign bodies in the eyes or skin that are the result of an automobile accident, explosion, gunshot injury, or similar trauma
• foreign body appears to have caused an infection in the surrounding tissue
• foreign body is made of lead or contains corrosive chemicals (most commonly batteries)
• foreign body is pointed or has sharp edges (needles, pins, broken glass, toothpicks, razor blades, pop-off tabs from soda cans, etc.)
• child complains of pain on swallowing, pain in the chest, abdominal pain, or severe pain on defecation
• child drools heavily
• child coughs up, vomits, or defecates blood
• child loses consciousness or becomes delirious as a result of esophageal or airway blockage
• child is known to have Crohn's disease, Meckel's diverticulum, or other chronic disorder of the digestive tract (These disorders increase the risk of complications from swallowed foreign bodies.)

Diagnosis

In most cases the doctor needs only a brief history to determine what type of foreign object is involved and where it may be lodged in the child's body. Objects in the ear, nose, or eye can usually be seen on visual examination. In the case of swallowed objects, the doctor examine the inside of the child's mouth and throat to look for signs of tissue damage and bleeding. The doctor may perform a digital examination to locate objects lodged in the rectum.

In general, the doctor may use an endoscope to look for a foreign object in the body as well as to remove it. He or she may order an x ray of the neck, chest, and/or abdomen to locate a foreign body in the esophagus, airway, or lower digestive tract. Most foreign bodies swallowed by small children are radiopaque, which means that they show up on a standard x ray. Metal detectors can successfully identify the location of soda can tops and other aluminum objects that will not show up on an x ray.

Blood tests are not usually necessary unless the doctor suspects that the foreign body has caused an infection or bleeding.

Treatment

Eyes

Small particles like sand may be removable without medical help, but if the object is not visible or cannot be retrieved, prompt emergency treatment is necessary. Trauma to the eyes can lead to loss of vision and should never be ignored. Before an adult attempts any treatment, he or she should move the child to a well-lighted area where the object can be more easily spotted. Hands should be washed and only clean, preferably sterile, materials should make contact with the eyes. If the particle is small, it can be dislodged by blinking or pulling the upper lid over the lower lid and flushing out the speck. A clean cloth can also be used to pick out the offending particle. Afterwards, the eye should be rinsed with clean, lukewarm water or an ophthalmic wash.

If the foreign object cannot be removed at home, the eye should be lightly covered with sterile gauze to discourage rubbing. A physician will use a strong light and possibly special eye drops to locate the object. Surgical tweezers can effectively remove many objects. An antibiotic sterile ointment and a patch may be prescribed. If the foreign body has penetrated the deeper layers of the eye, an eye surgeon will be consulted for emergency treatment.

Ears and nose

A number of ingenious extraction methods have been devised for removing foreign objects from the nose and ears. A bead in a nostril, for example, can be popped out by blowing into the mouth while holding the other nostril closed. Skilled practitioners have removed peas from children's ears by tiny improvised corkscrews and marbles by cotton-tipped applicators with super glue. Tweezers often work well, too. Insects can be floated out of the ear by pouring warm (not hot) mineral oil, olive oil, or baby oil into the ear canal. Metal objects can be removed from the nose or ears with the help of a magnet. Items that are lodged deep in the ear canal are more difficult to remove because of the possibility of damaging the eardrum. These require emergency treatment from a qualified physician.

Airways and stomach

Mechanical obstruction of the airways, which commonly occurs when food gets lodged in the throat, can be treated by applying the Heimlich maneuver . If the object is lodged lower in the airway, a bronchoscope (a special instrument to view the airway and remove obstructions) can be inserted. On other occasions, as when the object is blocking the entrance to the stomach, a fiberoptic endoscope (an illuminated instrument that views the interior of a body cavity) may be used. The physician typically administers a sedative and anesthetizes the child's throat. The foreign object then is either pulled out or pushed into the stomach, depending on whether the physician thinks it will pass through the digestive tract on its own. Objects in the digestive tract that are not irritating, sharp, or large may be followed as they continue on through. Sterile objects that are causing no symptoms may be left in place. Surgical removal of the offending object is necessary, however, if it contains a toxic substance; is likely to penetrate the stomach wall; or is longer than 2.36 inches (6 cm) or wider than 0.8 inches (2 cm).

Rectum

A rectal retractor can remove objects that a physician can feel during a digital examination of the rectum. In most cases the doctor will inject a local anesthetic before extracting the object. Surgery under general anesthesia may be required for objects deeply lodged within the body, as in the case of a 14-year-old Dutch adolescent who had inserted a soda can into his rectum.

Treatment of any health problem related to a foreign body may include a psychiatric consultation if the doctor suspects that the swallowing or insertion of the foreign body is related to autism or mental retardation (in small children) or an eating or personality disorder (in adolescents).

Prognosis

The prognosis of foreign body ingestion or insertion varies according to the nature of the object and its location in the body but is quite good in most cases. With regard to foreign bodies in the digestive tract, between 80 percent and 90 percent pass through without incident; 10–20 percent can be removed with an endoscope; and fewer than 1 percent require surgical removal.

KEY TERMS

Bronchoscope —A lighted instrument that is inserted into the windpipe to view the bronchi and bronchioles, to remove obstructions, or to withdraw specimens for testing.

Conjunctiva —Plural, conjunctivae. The mucous membrane that covers the white part of the eyes (sclera) and lines the eyelids.

Cornea —The clear, dome-shaped outer covering of the eye that lies in front of the iris and pupil. The cornea lets light into the eye.

Crohn's disease —A chronic, inflammatory disease, primarily involving the small and large intestine, but which can affect other parts of the digestive system as well.

Endoscopy —Visual examination of an organ or body cavity using an endoscope, a thin, tubular instrument containing a camera and light source. Many endoscopes also allow the retrieval of a small sample (biopsy) of the area being examined, in order to more closely view the tissue under a microscope.

Heimlich maneuver —An emergency procedure for removing a foreign object lodged in the airway that is preventing the person from breathing. To perform the Heimlich maneuver on a conscious adult, the rescuer stands behind the victim and encircles his waist. The rescuer makes a fist with one hand and places the other hand on top, positioned below the rib cage and above the waist. The rescuer then applies pressure by a series of upward and inward thrusts to force the foreign object back up the victim's trachea.

Meckel's diverticulum —A congenital abnormality of the digestive tract consisting of a small pouch off the wall of the small bowel that was not reabsorbed before birth. A Meckel's diverticulum increases the risk that a foreign object in the digestive tract will get trapped or stuck in the small intestine and cause problems.

Radiopaque —Not penetrable by x rays. A radiopaque object will look white or light when the x-ray film is developed. Most objects that children swallow can be detected by an x-ray study because they are radiopaque.

Sphincter —A circular band of muscle that surrounds and encloses an opening to the body or to one of its hollow organs. These muscles can open or close the opening by relaxing or contracting.

Prevention

Using common sense and following safety precautions are the best ways to prevent foreign objects from entering the body. For instance, parents and grandparents should toddler-proof their homes, storing batteries in a locked cabinet and properly disposing of used batteries, so they are not in a location where curious preschoolers can retrieve them from a wastebasket. Sewing kits, razor blades, and other potentially dangerous items should also be stored in childproof locations. To minimize the chance of youngsters inhaling food, parents should not allow children to eat while walking or playing. Fish should be carefully boned before it is served to younger children. Many eye injuries can be prevented by wearing safety glasses while using tools or participating in certain sports .

Parental concerns

Parental concerns in younger children should be directed toward the prevention of accidental swallowing or ingestion of foreign bodies. In most cases, these accidents can be successfully treated when they do occur, and they are unlikely to cause long-term damage to the child's health. In addition, small children are not likely to repeat behaviors that result in a trip to the doctor's office or hospital emergency room.

Ingestion or insertion of foreign bodies in older children and adolescents is a matter of greater concern to parents, however, because it is much more likely to be intentional, to reflect the presence of an eating disorder or other psychiatric problem, to be a repeated behavior, and to result in serious bodily harm.

See also Heavy metal poisoning; Lead poisoning.

Resources

BOOKS

"Foreign Bodies." Section 3, Chapter 24 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck Research Laboratories, 2002.

"Foreign Bodies in the Rectum." Section 3, Chapter 35 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck Research Laboratories, 2002.

PERIODICALS

Cakir, B., et al. "Localization and Removal of Ferromagnetic Foreign Bodies by Magnet." Annals of Plastic Surgery 49 (November 2002): 541–44.

Clifton, J. C., et al. "Acute Pediatric Lead Poisoning: Combined Whole Bowel Irrigation, Succimer Therapy, and Endoscopic Removal of Ingested Lead Pellets." Pediatric Emergency Care 18 (June 2002): 200–02.

Douglas, S. A., et al. "Magnetic Removal of a Nasal Foreign Body." International Journal of Pediatric Otorhinolaryngology 62 (February 1, 2002): 165–67.

McKinney, P. E. "Acute Elevation of Blood Lead Levels Within Hours of Ingestion of Large Quantities of Lead Shot." Journal of Toxicology: Clinical Toxicology 38 (2000): 435–40.

Muensterer, O. J., and I. Joppich. "Identification and Topographic Localization of Metallic Foreign Bodies by Metal Detector." Journal of Pediatric Surgery 39 (August 2004): 1245–48.

Reilly, B. K., et al. "Foreign Body Injury in Children in the Twentieth Century: A Modern Comparison to the Jackson Collection." International Journal of Pediatric Otorhinolaryngology 67, Supplement 1 (December 2003): S171–S174.

Steenvoorde, P., et al. "Retained Foreign Body in a 14-Year-Old Boy." Journal of Pediatric Surgery 38 (October 2003): 1554–56.

ORGANIZATIONS

American Academy of Emergency Medicine (AAEM). 555 East Wells Street, Suite 1100, Milwaukee, WI 53202. Web site: <www.aaem.org>.

American Academy of Family Physicians (AAFP). 11400 Tomahawk Creek Parkway, Leawood, KS 66211–2672. Web site: <www.aafp.org>.

American Academy of Otolaryngology, Head and Neck Surgery Inc. One Prince St., Alexandria, VA 22314–3357. Web site: <www.entnet.org>.

WEB SITES

Conners, Gregory P. "Pediatrics, Foreign Body Ingestion." eMedicine, July 26, 2004. Available online at <www.emedicine.com/emerg/topic379.htm> (accessed November 18, 2004).

J. Ricker Polsdorfer, MD

Foreign Objects

Definition

"Foreign" means "originating elsewhere" or simply "outside the body." Foreign bodies typically become lodged in the eyes, ears, nose, airways, and rectum of human beings.

Description

Both children and adults experience problems caused by foreign objects getting stuck in their bodies. Young children, in particular, are naturally curious and may intentionally put shiny objects, such as coins or button batteries, into their mouths. They also like to stick things in their ears and up their noses. Adults may accidentally swallow a non-food object or inhale a foreign body that gets stuck in the throat. Even if an object like a toothpick successfully passes through the esophagus and into the stomach, it can get stuck inside the rectum. Airborne particles can lodge in the eyes of people at any age.

Foreign bodies can be in hollow organs (like swallowed batteries) or in tissues (like bullets). They can be inert or irritating. If they irritate they will cause inflammation and scarring. They can bring infection with them or acquire it and protect it from the body's immune defenses. They can obstruct passageways either by their size or by the scarring they cause. Some can be toxic.

Causes and symptoms

Eyes

Dust, dirt, sand, or other airborne material can lodge in the eyes, causing minor irritation and redness. More serious damage can be caused by hard or sharp objects that penetrate the surface and become embedded in the cornea or conjunctiva (the mucous membranes around the inner surface of the eyelids). Swelling, redness, bleeding from the surface blood vessels, sensitivity to light, and sudden vision problems are all symptoms of foreign matter in the eyes.

Ears and nose

Children will sometimes put things into their noses, ears, and other openings. Beans, popcorn kernels, raisins, and beads are just a few of the many items that have been found in these bodily cavities. On occasion, insects may also fly into the ears and nose. Pain, hearing loss, and a sense of something stuck in the ear are symptoms of foreign bodies in the ears. A smelly, bloody discharge from one nostril is a symptom of foreign bodies in the nose.

Airways and stomach

At a certain age children will eat anything. A very partial list of items recovered from young stomachs includes the following: Coins, chicken bones, fish bones, beads, rocks, plastic toys, pins, keys, round stones, marbles, nails, rings, batteries, ball bearings, screws, staples, washers, a heart pendant, a clothespin spring, and a toy soldier. Some of these items will pass right on through and come out the other end. The progress of metal objects has been successfully followed with a metal detector. Others, like sharp bones, can get stuck and cause trouble. Batteries are corrosive and must be removed immediately.

Children eat things and stick things into their bodily openings of their own volition. But they inhale them unwittingly. The most commonly inhaled item is probably a peanut. A crayon and a cockroach have been found in a child's windpipes. These items always cause symptoms (difficulty swallowing and spitting up saliva, for instance) and may elude detection for some time while the child is being treated for asthma or recurring pneumonia.

Adults are not exempt from unorthodox inedibles. Dental devices are commonly swallowed. Adults with mental illness or subversive motives may swallow inappropriate objects, such as toothbrushes.

Rectum

Sometimes a foreign object will successfully pass throught the throat and stomach only to get stuck at the juncture between the rectum and the anal canal. Items may also be self-introduced to enhance sexual stimulation and then get stuck. Sudden sharp pain during elimination may signify that an object is lodged in the rectum. Other symptoms vary depending upon the size of the object, its location, how long it has been in place, and whether or not infection has set in.

Diagnosis

The symptoms are as diverse as the objects and their locations. The most common manifestation of a foreign object anywhere in the body is infection. Even if the object started out sterile, germs still seem to find it and are able to hide from the body's defenses there. Blockage of passageways—breathing, digestive or excretory—is another result. Pain is common.

Treatment

Eyes

Small particles like sand may be removable without medical help, but if the object is not visible or cannot be retrieved, prompt emergency treatment is necessary. Trauma to the eyes can lead to loss of vision and should never be ignored. Before attempting any treatment, the person should move to a well-lighted area where the object can be more easily spotted. Hands should be washed and only clean, preferably sterile, materials should make contact with the eyes. If the particle is small, it can be dislodged by blinking or pulling the upper lid over the lower lid and flushing out the speck. A clean cloth can also be used to pick out the offending particle. Afterwards, the eye should be rinsed with clean, lukewarm water or an opthalmic wash.

If the foreign object cannot be removed at home, the eye should be lightly covered with sterile gauze to discourage rubbing. A physician will use a strong light and possibly special eyedrops to locate the object. Surgical tweezers can effectively remove many objects. An antibiotic sterile ointment and a patch may be prescribed. If the foreign body has penetrated the deeper layers of the eye, an opthalmic surgeon will be consulted for emergency treatment.

Ears and nose

A number of ingenious extraction methods have been devised for removing foreign objects from the nose and ears. A bead in a nostril, for example, can be popped out by blowing into the mouth while holding the other nostril closed. Skilled practitioners have removed peas from the ears by tiny improvised corkscrews; marbles by q-tips with super glue. Tweezers often work well, too. Insects can be floated out of the ear by pouring warm (not hot) mineral oil, olive oil, or baby oil into the ear canal. Items that are lodged deep in the ear canal are more difficult to remove because of the possibility of damaging the ear drum. These require emergency treatment from a qualified physician.

Airways and stomach

Mechanical obstruction of the airways, which commonly occurs when food gets lodged in the throat, can be treated by applying the Heimlich maneuver. If the object is lodged lower in the airway, a bronchoscope (a special instrument to view the airway and remove obstructions) can be inserted. On other occasions, as when the object is blocking the entrance to the stomach, a fiberoptic endoscope (an illuminated instrument that views the interior of a body cavity) may be used. The physician typically administers a sedative and anesthetizes the throat. The foreign object will then either be pulled out or pushed into the stomach, depending on whether or not the physician thinks it will pass through the digestive tract on its own. Objects in the digestive tract that are neither irritating, sharp nor large may be followed as they continue on through. Sterile objects that are causing no symptoms may be left in place. Surgical removal of the offending object is necessary if it is causing symptoms.

Rectum

A rectal retractor can remove objects that a physician can feel during physical examination. Surgery may be required for objects deeply lodged within the recturm.

Prevention

Using common sense and following safety precautions are the best ways to prevent foreign objects from entering the body. For instance, parents and grandparents should toddler-proof their homes, storing batteries in a locked cabinet and properly disposing of used batteries, so they are not in a location where curious preschoolers can fish them out of a wastebasket. To minimize the chance of youngsters inhaling food, parents should not allow children to eat while walking or playing. Adults should chew food thoroughly and not talk while chewing. Many eye injuries can be prevented by wearing safety glasses while using tools

Resources

PERIODICALS

Gilchrist, B. F., et al. "Pearls and Perils in the Management of Prolonged, Peculiar, Penetrating Esophageal Foreign Bodies in Children." Journal of Pediatric Surgery 32, no. 10 (October 1997): 1429-31.

KEY TERMS

Bronchoscope— An illuminated instrument that is inserted into the airway to inspect and retrieve objects from the bronchial tubes.

Conjunctiva— Mucous membranes around the inner surface of the eyelid.

Cornea— The rounded, transparent portion of the eye that covers the pupil and iris and lets light into the interior

Endoscopy— The surgical use of long, thin instruments that have both viewing and operating capabilities.

Heimlich maneuver— An emergency procedure for removing a foreign object lodged in the airway that is preventing the person from breathing. To perform the Heimlich maneuver on a conscious adult, the rescuer stands behind the victim and encircles his waist. The rescuer makes a fist with one hand and places the other hand on top, positioned below the rib cage and above the waist. The rescuer then applies pressure by a series of upward and inward thrusts to force the foreign object back up the victim's trachea.