Research Articles

Annals of Clinical and Medical Case Reports

Strange And Unpredicted Foreign Body Stories In ENT:

As Peculiarcase Presentations And Review Of Literatures

Khaled Mohamed bofares1* ,Zalfi Adim Haqqar2 and Amna showed amazing and odd history as well as clinical presentation, which
Fathi Ben Sasi3 encouraged and forced us to make this report just to highlight and focus
on certain clinically applicable points regarding these unpredicted and
1professor of otorhinolaryngology, Omar Almoukhtar University, AL- forgotten issue.
Beyda city, Libya,
2Senior registrar, Al-Beyda medical center, AL-Beyda city, Libya. Keywords:
3SHO, Al-Beyda medical center, AL-Beyda city, Libya. strange foreign bodies, unpredicted foreign bodies, neglected foreign
bodies, missed foreign bodies, accidental foreign bodies.
Corresponding author:
Khaled Mohamed bofares, 2. Introduction
professor of otorhinolaryngology, Omar Almoukhtar University, AL-
Beyda city, Libya, The foreign bodies accidents are considered as one of urgencies and
emergencies in the medicine as general and in the ENT specialty
Roles of contribution particular. This condition is considered as important issue because of its
threatening effect on the victims’ life particularly those of child-hood age
KMB: He is the first author, who was the professor and senior consultant group. The increase of the incidence of this condition in the community
that performed the procedures as well as completely wrote the manuscript. constitutes a worried indicator, which reflects the serious concerns as one
ZAH &AFB: they were the residents, who received the referred patients of significant causes of sudden deaths among children. In addition, it can
at the department, preparing them including history taking, complete be used as a reliable indicator for the lack of proper child’s careat the
clinical evaluation, requesting for required investigations, informed level of the family particular, and at the level of the population as general.
consent preparation, consultant on charge as well as operative theater The family negligence can be contributed by many factors as maternal
team notification, postoperative care and follow up sessions conductance. education and literacy, family size, environmental sanitation, housing
hygiene, and socio-economic status of the family [1], [2], [3], [4], and [5].
Received Date: 12 Sep 2024 The foreign bodies’ accidents outcomes range from minor morbidities,
Accepted Date: 01 Oct 2024 to sever morbidities, to life threatening circumstances and increasing the
Published Date: 07 Oct 2024 rate of mortalities. This is depending up on many factors as the site of the
foreign body accident, the type of the foreign body and duration of foreign
Citation: body staying. In accordance, the foreign bodies of the ear and nose usually
Khaled Mohamed bofares. Strange And Unpredicted Foreign Body are creating less morbidity as compared to foreign bodies of respiratory as
Stories In ENT: As Peculiarcase Presentations And Review Of well as alimentary tracts, which may lead to serious and fatal situations.
Literatures. Annals of Clinical and Medical Case Reports 2024. On the other hand, the sharp foreign bodies and the corrosives bearing
foreign bodies as the button batteries (disc batteries) may lead to more
1. Abstract severe complications as compared to other types of foreign bodies. In
addition, the duration of staying of the foreign body is considered as very
Although the foreign body cases are considered as one of common significant determinant for its outcomes. However, this can correlated
urgencies and emergencies at ENT departments all over the world. These with the type of the foreign body i.e. for certain types of foreign bodies
cases can be ranged from the life-threatening situations as in case of foreign as corrosive chemicals bearing foreign bodies, the time factor has very
body aspiration, to neglected foreign bodies as in cases of foreign bodies important prognostic effect. The worseness of the prognosis is directly
of nose and external auditory canal. It is commonly that the foreign body proportional to the prolongation of foreign body staying duration [3], [4],
cases are presented among the extreme younger child-hood age group, and [5].
and usually there will be a definitive history given by parents or guardians
that indicating the diagnosis. However, sometimes the circumstance There are well-established and customary facts regarding foreign
will become strange and surprising when the foreign body is discovered bodies accidents, the foreign bodies accidents are commonly presented
accidently during the investigation for unpredicted complain, or when among extreme childhood age groups and mentally retardant adults, it
the patient is presented as adult age group with completely developed is of lesser incidence rate among the normal adults. Although, there are
mental status. This was the scenario among our three case stories, those certain varieties of foreign bodies accidents, which could be specifically

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common at certain adult clusters as scarf pins among young women, the as a case of throat infection, treated the baby by oral antibiotic with
dentures among old ages, and esophageal food impaction among dentiless synergistic oral decongestant and instead of his improvement, he became
adults [6], [7], and [8]. The foreign bodies of the ear and the nose are progressively worse. Thus, at the fifth day, the parents consulted the
usually easier to be diagnosed as compared to the respiratory as well as pediatrician, who asked for neck and chest conventional X-ray, where
alimentary tracts foreign bodies. Moreover, the accidental discovering of the tragedy was discovered. There was impacted large sized disc battery
the neglected aural as well as nasal foreign bodies is more predictable and (button battery) at the level of crico-pharyngeal sphincter (Figure-1). In
reachable as compared to the missed aspirated and ingested foreign bodies accordance, by the returning back to the parents with this positive X-ray
[9]. There are well-established basics for the suggestion and diagnosis of finding, as the mother is known case of diabetes mellitus, she remembered
foreign bodies aspiration and ingestion accidents. The history constitutes that, few days back she lost the disc battery of her glucometer machine.
the most significant aspect for the diagnosis of foreign body aspiration
as well as ingestion accidents. However, the clinical and the radiological Figure-1: Conventional X-ray demonstration of the impacted foreign
findings are considered as complementary and secondary elements body at the level of crico-pharynx.
in favor of the diagnosis of these cases. In accordance, the clinical
manifestations and the radiological findings may become of higher rate
of significance if the foreign body was missed and the time of its staying
was prolonged. The secondary effects of the missed foreign bodies can
reason these clinical and/ or radiological findings.Moreover, among the
patients with the missed respiratory tract foreign bodies, the presentation
could be in form of persistent incurable pneumonia, bronchiectasis, and
lung abscess, while in cases of missed alimentary tract foreign bodies, the
manifestations might be in a clinical picture of unexplained dysphagia as
well as odynophagia [21] and [22].

In the same context, it was noted that the missed foreign bodies usually
discovered among extreme age groups, children at age below six years and
elderly above sixty years. In addition, the discovering of missed foreign
bodies among the mentally retarded people is very predictable. It is scarcity
and unforeseen to discover a missed foreign body among intelligent and
mature child or adult patient with well mental status [21], [22], and [23].
Thus, through this case series, we tried to postulate for the presentation of
three situation of peculiar foreign bodies accidents with unpredicted and Therefore, the baby was decided for urgent rigid esophagoscopy, which
unique pattern of events, which cannot be suspectedas they were presented was done under general anesthesia with endotracheal intubation and
with unusual scenarios. For this reason, we considered these three cases as sufficient muscular relaxation. The rigid esophagoscope of size 8x12x25
important case series report for further new recommendations those can was passed and the intraoperative findings were:A) There was foreign
be obtained from this distinctive experience. body in form of large sized disc battery recognized impacted at the level
of crico-pharyngeal sphincter. B) The chemical material of the battery
3. Cases presentations was found leaky out the battery to contaminate the wall and the lumen
of the esophagus. C) The wall of the esophagus showed extensive and
3.1. Case-1: circumferential deep damage of the mucosa, extending up to the level
Fifteen months old male Palestinian baby has been received by our of the muscular layer with brownish-black necrotic tissue ( according to
resident SHO at our ENT department- Al-Beyda medical center, Al- Zargar’s classification of local esophageal damage by corrosive agents,
Beyda city- Libya, as a referred case from pediatric department at the it was graded as grade-IIIb). In the same context, our intervention was
same center. The baby was accompanied with his parents, who presented including: A) Recognition of the foreign body, grasped using the crocodile
the history. The main complaint was absolute dysphagia with drooling forceps and extracted (Figure-2). B) Theresiduals of the escaped chemical
of saliva one day before the time of the reference. The mother noted material were sucked out.C) The proper irrigation with sterile normal
the dysphagia five days before, as mild dysphagia that elucidated by saline solution was done, associated with repetitive suction and clearance
the prolongation of the duration of the bottle-feeding more than usual. of the affected segment. D) After we made sure that the all-corrosive
This was progressing along these five days to become severe at the material was properly cleaned, the reassessment of the area was done to
fifth day with bothersome odynophagia and drooling of the saliva. The confirm the Zargar grade of the wall chemical injury. E) By the end, the
mother recognized the odynophagia by the crying of the baby during the nasogastric tube (NGT) was inserted under controlled as well as visualized
swallowing process. During the first four days, the general practitioner field, and further proper fixation was done for it.

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Figure-2: The extracted foreign body (disc battery), with escaped

corrosive chemical material and sloughed necrotic soft tissue.

3.2. Case-2:
Seventeen years old Libyan girl presented with her parents as referred
The postoperative care was according to the specific therapeutic protocol emergency case from casualty department to our ENT department- Al-
for three weeks, in form of: A) The patient kept as inpatient under closed Beyda medical center, Al-Beyda city- Libya with history of foreign
observation that including body temperature, pulse rate, respiratory rate, body ingestion few hours before the time of her presentation. This was
systemic blood pressure, irritability, restlessness, andany pain onset. associated with sudden, abrupt history of absolute dysphagia bother some
B) The patient kept on complete NGT feeding accompanied with daily with severe odynophagia that interfere even with the swallowing of the
IV fluids body requirements. C) The patient coveredby combination saliva. In addition, there was history of repetitive attacks of vomiting of
oftriple parenteralbroad-spectrum antibiotics, which were amoxicillin bloody stained secretions. The strange part of the story of this patient that
with clavulanic acid, ceftriaxone, and metronidazole, 300mg/8 hourly, the event was happened when the family members were sitting together
250mg/12 hourly, and 125mg/8 hourly consecutively .D) In addition to during the dinner. There was one glass-cup broken and some of glass
the antibiotics, the baby kept on hydrogen- pump blocker (omeprazole) pieces dropped and mixed with food, and accidentally the patient during
by IV route in a dose of 10mg once a day. In accordance, the mother was the eating she felt sharp object escaped from the oral cavity to her pharynx
advised to encourage her baby to suck the antacid gel packages of fruity during the swallowing of the food. There was no other significant history
flavours every 6 hours frequency. E) Moreover, the baby was covered by apart of some element of psychological disturbance as noted by the parents
antifungal oral suspension (Nystatin), three times a day. On the other hand, in favor of depression psychopathy, but the patient had not been diagnosed
during the first week, the blood was extracted every 48 hours for leukocyte or received any treatment before.
count, erythrocytes sedimentation rate (ESR), and C- reactive protein, in
addition to the requesting for X-ray neck as well as chest. In same context, On examination, according to visual analogue scale (VAS) the patient
at the last two weeks, the previously mentioned investigations were done was in severe pain with evidence of neck rigidity. There was excessive
once per week. At the end of third week, the NGT was removed after drooling of the saliva with absolute dysphagia. No evidences of
frequent trials of oral fluids followed by semisoft diets. The baby was subcutaneous emphysema, or tenderness at any part of the neck. The
assessed clinically and radiologically to confirm the complete healing X-ray neck revealed evidences of neck spasm that indicated by the loss
of the esophageal wall before the remove of NGT. After three months, of normal cervical lordosis. In addition, there was clear evidences of
the barium swallowing study was done to evaluate for any consequence significant dilation of the upper part of the esophagus with illustrated air
esophageal segmental stricture or tracheo- esophageal fistula, which was bubbles at the dilated segment.Therefore, accordingly the patient decided
free with complete normal flow of the barium (Figure-3). Last follow up for esophagoscopy procedure under general anesthesia, which done
session was after one year via which complete assessment of the child was as emergency intervention by passing the rigid esophagoscope of size
done that showed a satisfied thrive status with normal feeding process, and 12x16x35. The intraoperative findings and procedures were: A) There was
no any significant complain from the parents. evidences of pooling of the saliva. B) there was small mucosa abrasion at
the posterior pharyngeal wall, which constitutes the source of the bleeding
Figure 3: The barium swallowing study, three months after the procedure, as complained by the patient.C) The foreign body was recognized at the
which illustrated a caomplete normal barium flow. level of aortic sphincter (around 25cm from the incisor teeth), it was piece
of transparent glass. D) The foreign body grasped gently with peanut

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forceps (the crocodile forceps may crush the foreign body) and extracted she was playing with it at her mouth during the writing of her homework
out under the protection of the esophagoscope itself (Figure-4). E) The alone at her room from three months ago, which is the same time of the
esophagoscope of the same size was re-passed again just to assess for any beginning of her illness. However, the patient ignored this event at that
injuries, there was no evidences of any injuries due to maneuvering of the time, and did not tell her parents about this history. In accordance, up to
foreign body. that moment, the diagnostic bronchoscopy became absolutely indicated,
which was decided as emergency procedure under general anesthesia. The
Figure-4: The extracted foreign body (piece of glass). patient was intubated by rigid bronchoscope of size 5mm and it was a
surprise, the foreign body was seen. It was the plastic pen- head, of blue
color, impacted at right main bronchus. The foreign body was removed
using crocodile forceps (figure-5). The rinsing of accumulated muco-
purulent secretions was done. The child was recovered in complete good
status; she did not need additional intensive care. Moreover, the child was
kept postoperatively at the word just for control of her chest infection by
parenteral administration of ceftriaxone in a dose of 500mg/ 12hourly; in
addition to orally administered bronchodilator as wellas mucolytic syrups.
The patient stayed in the hospital for two days, and after that she was
discharged in good conditions to continue her treatment as out patient.

Figure-5: The extracted foreign body (plastic pen-head).

On the other hand, the patient was kept in the word under postoperative
care protocol that including: A) Early oral feeding just after full recovery.
B) Oral administration of amoxicillin with clavulanic as broad-spectrum
antibiotic in a dose of 1000mg 12 hourly. C) Complete restriction of
analgesics as well as antipyretics administration. D) The patient kept in
the word for 24 hours for close observation, and after post-procedure
evaluating neck and chest X-ray, she was discharged in satisfied best
conditions and completely normal swallowing function.

3.3. Case-3:
Eleven years old female Libyan child had been presented as a referred
case from the pediatrician with history of persistent productive cough as
bothersome manifestation of recalcitrantright lung broncho-pneumonia
that not responding to the treatment. There was history of attacks of 4. Discussion
fever and wheezy chest associated with exertional dyspnea, from three
months ago. On the examination of the chest, the auscultation findings Although, the foreign body accidents are considered as one of the common
revealed harsh bronchial breathing sound at the right side of the chest emergency conditions at the world as general and at our society particular.
associated with rhonchi and crepitations scattered all over the right side However, these three cases can be described as unique and peculiar cases
of the chest. In addition, the intensity of the breathing sound is decreased as compared to the other usual cases of foreign body accidents. Regarding
at the affected side as compared to the other side. On the other hand, the the first case, it is surprisingly that the large sized disc battery stayed in
radiological evaluation by conventional chest X-ray revealed a picture of the esophagus for five days with escaped its corrosive material and did not
broncho-pneumonia with scattered radio-opaque patchy illustration. cause the perforation of the esophageal wall. Scientifically speaking, this
could be explained by one fact only that the battery’s material is already
Therefore, the clinical as well as the radiological presentation gave to us expired. This fact can be confirmed and correlated with the history, which
the high suggestion of the missed foreign body aspiration. Thus, we return was given by the mother that the swallowed disc battery was missed after
to the parents and child herself to ask them directly about any history she removed it from her glucometer to be changed by new one. On the
of foreign body aspiration or chocking, unfortunately the answer was other hand, it is surprisingly that how this case was missed for all this
negative.Surprisingly, after few minutes, the child suddenly shouted to period and no body suggest the possibility of foreign body ingestion,
confirm a positive history of chocking with the plastic pen-head, when especially when this baby presented with absolute dysphagia with

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completely normal throat. addition to the gustatory perception as well as salivation secretion, which
should be maintained. This may need to advice the mother to encourage
The disc battery (button battery) is considered as one of most dangerous her kid for daily frequent sessions of suckings. In accordance, as I noted
foreign bodies. This is because of its extensive destructive effect due to from my experience, the best choice is the administration of antacids oral
the electrical as well as the corrosive chemical action. Therefore, the disc gels with different fruits flavors. This will give us the chance to achieve
battery foreign bodies once diagnosed anywhere; they should be extracted two goals, the first is the obtaining of the antacid effect to neutralize the
as soon as possible. It was found that the severity of the destructive effect refluxed gastric acid, and the second to maintain all those mentioned
of this kind of foreign bodies is directly proportional to the duration of its physiological reflexes[10], [11], [12], [13], [14], [15], and [16]. On the
negligence. In same context, it was established that the safety zone of the other hand, by three to six months after corrosive agents’ esophageal
staying duration of this type of foreign bodies should not exceed two hours traumas, the patients should be evaluated by barium swallowing study to
[10], [11], [12], [13], [14], [15], and [16]. In accordance, the diagnosis of rule out any evidence of local healing with strictures. In the same context,
the disc battery ingestion can be illustrated by the conventional X-ray, if there are clinical manifestations suggestive esophageal strictures the
which will show characteristic appearance of radiolucent rim surrounding diagnostic fibro-optic esophagescopy may be indicated[10], [11], [12],
the disc of the battery (figure-6) [14], [15], [16], and [17]. On the other [13], [14], [15], and [16].
hand, after the remove of this variety of the foreign bodies from the
esophagus, the proper cleaning and rinsing of the area should be done by Although, many literatures stated that the most important aspect for the
repetitive normal saline irrigation and suction [16], [17], [18] and [19]. diagnosis of the foreign body aspiration accidents is the presence of the
This should be followed by proper assessment of the esophageal wall definitive history. In contrary, as we can elucidate from our experience that
and grading of the injury according Zargar’s grading system [20]. The the history of definitive foreign body aspiration is not always considered
insertion of NGT should be taken as rule in our management protocol for the diagnosis, sometimes the history is ignored or hidden. The part of
whenever there evidences of esophageal wall injury (from grade-I to the history, which may remain significant at this circumstance, is of the
grade-IV) [16], [17], [18], [19] and [20]. The NGT insertion is important persistence of the respiratory symptoms that resist to the treatment[21],
to achieve these three aims: 1) The complementary feeding process to the [22], [23], [24], [25], [26], and [27]. Therefore, we may consider the
parenteral nutrition. 2) The drainage of the gastric juice for the purpose of diagnostic bronchoscopy as a part of the patient evaluation, who presented
the prevention of its reflux that may increase the severity of the injury and with refractoryrespiratory manifestations despite of sufficient medical
interfere with the proper healing process. 3) The NGT is used as stent for treatment [24], [25], [26], [27], [28], [29], and [30]. In accordance, the
the esophageal lumen to allow the healing without strictures formation. same recommendation can be applied for those patients, who manifested
with persistent symptomology after extraction of the foreign bodies of
The NGT will be kept for 14-21 days; this is the recommended duration for the respiratory tract just to exclude the missed residual foreign bodies. In
NGT in the cases of corrosive esophageal traumas, which was found to be accordance, the missed foreign bodies bronchimight be misdiagnosed as
sufficient for satisfied outcomes[10], [11], [12], [13], [14], [15], [16],[17], asthma, due to the chronicity of the manifestations as well as the resembling
[18], [19] and [20]. In addition, as a part of the management of these cases, of the clinical data to those among asthmatic patients[27], [28], [29], and
the patients should be kept on certain post-procedure medications, which [30]. On the other hand, the neglected foreign bodies bronchi may become
include: 1) Broad-spectrum antibiotics, these are important to control any difficult to be extracted under the endoscopic control techniques, because
possible local superadded infection at the site of the injury, which may of their deep impaction. At this moment, the extensive surgical techniques
make the condition more badly.In addition, the broad-spectrum antibiotics via opened thoracotomy approaches will be only the choice[22], [23], and
are prophylactic against mediastinum infection spreaders. 2) Antacids, [24].
which are important to neutralize the secreted gastric acid that may
refluxed to the esophagus and propagate the severity of the destructive Moreover, for the young patients, who presented with sharp foreign bodies
effect of the corrosive injury. 3) H- pump blocker, it has the same role ingestion accidents, we should exclude the suicidal attempt conditions [31],
of antacids by blocking of the production of gastric acid and therefore it [34], [35], [36], [38], [39], [40] and [41]. Thus, the socio-psychological
reduces the risk of the esophageal reflux.4) Local antifungal agents, these assessment for those varieties of patients should be considered as a part
are important to provide a sufficient prophylaxis against possible fungal of their management [32] and [33]. In addition, from technical point of
flaring-up as the adverse effect of the long-term administration of broad- view, for the patients, who presented with sharp foreign bodies ingestion
spectrum antibiotics.5) Certain vitamins supplement, namely vitamin A, accidents, the esophagoscopic procedure can be performed as rigid or
E, in addition to iron, which found to be very helpful for enhancement of flexible types. However, as we concluded from our long-term experience
healing process[17], [18], [19] and [20]. that the rigid esophagoscopic technique will be preferred as compared to
the flexible esophagoscopic technique. This is reasoned by the providing
For extreme young ages (< 3 years), and as the patient kept for three weeks of a sufficient wide access for a safe extraction of the sharp foreign bodies
on NGT feeding, thus, there are certain physiological reflexes namely by its entrapment in the lumen of the rigid esophagoscope itself to protect
sucking reflex, gag reflex, chewable reflex and swallowing reflex, in the esophageal walls.Therefore, the size of the used rigid esophagoscope

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should the maximum suitable size. e27892.doi: 10.7759/cureus.27892. PMCID: PMC9464042. PMID:
36110438
5. Ethical approval 10. Richard K. Newman; Bjorn Dijkstra; Joshua Gibson. Disc battery
ingestion. National library of medicine. 2023 Aug 14. In: StatPearls
The endorsement and statistical department at AMC- AL-Beyda city- [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan.
Libya ethically approved the publication of this case. PMID: 29262219
11. Cohen WG, Mchugh M, Giordano T, Jacobs IN.Anatomic
6. Acknowledgement Considerations of esophageal button battery ingestion for outcomes
and imaging.Int J Pediatr Otorhinolaryngol. 2024 Jan;176:111803.
We would like extremely thanks the parents/ guardians of those presented doi: 10.1016/j.ijporl.2023.111803. Epub 2023 Nov 24.PMID:
children, who gave use the agreement to publish these unique cases. 38043185
12. Kiefer A, Duppel U, Schützenmeier A, Lang T, Kittel J, Kabesch
Ethical aspects M, Kerzel S.Button Battery Ingestions cause the Majority of Severe
Complications.Klin Padiatr. 2023 Mar;235(2):90-97. doi: 10.1055/a-
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