ORIGINAL ARTICLE

A Review Of Ear, Nose And Throat Foreign Bodies In

Sarawak General Hospital. A Five Year Experience
Chiun Kian Chai, MD, Ing Ping Tang, MS, Tee Yong Tan, MS, Doris Evelyn Yah Hui Jong, MS

Hospital Umum Sarawak, Jalan Tun Ahmad Zaidi Adruce,93586 Kuching, Sarawak

SUMMARY emergency department 1. The other study was conducted in

Objective: Ear, nose and throat foreign bodies are common in Malaysia by Hon SK assessing the time delay for removal of
ENT clinical practice. This study was designed to establish foreign bodies under general anaesthesia 2. Our study was
the local data of otorhinolaryngeal foreign bodies in term of designed to analyze the prevalence of otorhinolaryngeal
prevalence among paediatric and adult groups, the clinical foreign bodies in different age groups, which included both
features, types of foreign body at different sites, and the children and adult, the associated clinical presentation
laterality of foreign bodies. and the common types of foreign body.

Method: This study was carried out at ENT department,

Sarawak General Hospital, Malaysia, from 1st January 2005 METHODS
to 31st December 2009. A total of 1084 cases were included This was a retrospective study of all the otorhinolaryngeal
and statistically analyzed. foreign bodies presented to ENT department of Sarawak
General Hospital from 1st January 2005 to 31st December
Result: Ear foreign bodies showed the highest incidence 2009. Sarawak General Hospital was the tertiary referral
which was consisted of 480 (44.3%) cases, followed by nose center in Sarawak. The sources of referral included casualty in
in 270 (24.9%) cases, pharynx in 251(23.2%) cases, esophagus Sarawak General Hospital, district hospitals, private hospitals
in 57 (5.3%) cases and laryngo-tracheobronchial tree in 26 and general practitioners. Data were collected from ENT
(2.4%) cases. Otorhinolaryngeal foreign bodies occurred clinic registration books and ward admission records.
more frequently in 0-10 year old age group which Parameters used in this study included demographic data
constituted 651 (60.1%) cases. The descending order of such as age, gender and race. The clinical features, types of
frequency for foreign body sites in adult was pharynx foreign body and laterality of foreign body lodgement were
(17.2%), ear (12.8%), esophagus (3.1%), nose (1.7%) and emphasized in this study as well.
laryngo-tracheobronchial tree (1.1%). The type of foreign
bodies varies with age group and site of foreign body
lodgement. In general, common foreign bodies in both adult RESULTS
and children were food related, with the additional of small A total of 1084 cases were analysed, comprised of 825
objects such as plastic toy in paediatric group. outpatients and 259 inpatients. Among all the foreign
bodies, ear foreign bodies were the most frequently
Conclusion: Otorhinolaryngeal foreign bodies were found encountered which consisted of 480 (44.3%) cases, followed
more frequently in children. The types of foreign body were by nose 270 (24.9%) cases, pharynx 251 (23.2%) cases,
different from age group and sites of foreign body esophagus 57 (5.3%) cases and laryngo-tracheobronchial tree
lodgement. The local food constituted the highest incidence 26 (2.4%) cases. The highest incidence of foreign bodies
of ear, nose, and throat foreign bodies with additional of occurred between 0-5 years and 6-10 years of age which
plastic toys in paediatric group. consisted of 492 (45.4%) and 159 (14.7%) cases respectively.
A total of 628 (57.9%) cases were male while the remaining
KEY WORDS: 456 (42.1%) were female. Among these, 508 (46.9%) patients
Ear, nose, throat foreign bodies, otorhinolaryngeal foreign bodies were Malay, followed by Chinese 206 (19.0%), Iban 176
(16.2%), Bidayuh 161 (14.9%) and other races in the
remaining 33 (3.0%) cases.
INTRODUCTION
Otorhinolaryngeal foreign bodies are common across the Ear Foreign Bodies
ages, it happens in both the children and adult. There were Age distribution
numerous of studies conducted looking into the prevalence, A total of 480 of cases were presented with ear foreign bodies
diagnosis, treatment and complication of ear, nose, and during the study period. The highest incidence of ear foreign
throat foreign bodies. In our region, there were few studies bodies occurred in 0-5 years of age which was consisted of 232
on foreign bodies conducted in the past few years. One was (48.3%) cases. This was followed by children between 6-10
conducted in Singapore by Ngo A looking into the removal of years which numbered 82 (17.1%) cases. There were 27
otorhinolaryngeal foreign bodies in children presented to (5.6%) cases between 11-15 years age group and 19 (4.0%)

This article was accepted: 2 November 2011

Corresponding Author: Chiun Kian Chai, Hospital Umum Sarawak, Jalan Tun Ahmad Zaidi Adruce,93586 Kuching, Sarawak
Email: chiun_kian@yahoo.com.sg

Med J Malaysia Vol 67 No 1 February 2012 17

Original Article

Table I: ENT foreign bodies by site and age groups

AGE Total
0-5 6-10 11-15 16-20 21-30 31-40 41-50 51-60 61-70 >71
Ear 232 82 27 19 30 26 28 26 8 2
48.3% 17.1% 5.6% 4.0% 6.3% 5.4% 5.8% 5.4% 1.7% 0.4% 480
Nose 201 50 1 1 3 5 2 4 2 1
74.4% 18.5% 0.4% 0.4% 1.1 1.9% 0.7% 1.5% 0.7% 0.4% 270
Pharynx 35 15 15 11 34 40 46 31 11 13
13.4% 6.0% 6.0% 4.4% 13.5% 15.9% 18.3% 12.2% 4.4% 5.2% 251
esophagus 18 4 1 2 3 5 16 3 3 2
31.6% 7.0% 1.8% 3.5% 5.3% 8.8% 28.1% 5.3% 5.3% 3.5% 57
LTB tree 6 8 0 2 2 4 1 1 1 1
21.3% 30.8% 7.7% 7.7% 15.4% 3.8% 3.8% 3.8% 3.8% 26
Total 492 159 44 35 72 80 93 65 25 19 1084

Table II: Types of foreign body by site

Type of FBs Total
Seed/ Plastic Metal/ Insects/ Paper/ Fish Chicken Coin dentures Others/
nuts toys/beads stone maggots cotton bone bone unknown
Ear 226 167 38 20 29
47.1% 34.8% 7.9% 4.2% 6.0% 480
Nose 99 95 22 27 27
36.7% 35.2% 8.1% 10.0% 10.0% 270
Pharynx 233 5 13
92.8% 2.0% 5.2% 251
esophagus 17 22 10 5 3
29.8% 38.6% 17.5% 8.8% 5.3% 57
LTB tree 18 1 3 4
69.2% 3.8% 11.5% 15.4% 26
Total 343 263 63 20 27 250 27 10 5 76 1084

cases between 16-20 years age group. Subsequent age groups significantly from age 11 years old onwards which ranged 1-
from 21-60 years old the incidence of foreign bodies ranged 5 cases in each of the subsequence age groups.
from 20-30 cases in each 10 years time frame. There were 8
(1.7%) cases occurred in 61-70 years age group whereas only Clinical features
2 cases (0.4%) found in more than 71 years age group. Two hundred and two (74.8%) patients presented with
history of guardians who saw the foreign bodies in the nose,
Clinical features 63 (23.3%) presented with offensive nasal discharge, 1 (0.4%)
There were 460 patients (95.8%) presented with history of presented with nose bleed and remaining 4 (1.5%) presented
alleged foreign bodies in the ear, 10 (2.1%) presented with with other complaint such as nasal obstruction, growth in the
otalgia, 5 (1.0%) with otorrhoea, 2 (0,4%) with blocked ear nose or trauma to the nose.
and 3 (0.6%) were incidental findings.
Types of foreign body
Types of foreign body The commonest nasal foreign bodies were seeds or nuts,
Seeds or nuts were the commonest ear foreign bodies which was consisted of 99 (36.7%) cases. This was followed by
encountered which consisted of 226 (47.1%) cases. This was plastic toys or beads in 95 (35.2%) cases, papers or cotton in
followed by plastic toys or beads in 167 (34.8%) cases, stones 27 (10.0%) cases, stone or metal in 22 (8.1%) cases and others
or metals in 38 (7.9%) cases, insects or maggots in 20 (4.2%) in 27 (10.0%) cases.
cases, and others which included cotton bud, paper and
unknown material in 29 (6.0%) cases . Site of lodgement
There were 196 (72.6%) cases presented with right nostril
Site of lodgement foreign bodies, 73 (27.0%) cases in left nostril and 1 (0.4%)
Two hundred and ninety six (61.7%) cases presented with case in both nostrils.
foreign bodies in the right ear, 177 (36.9%) cases in the left
ear and 7 (1.5%) cases in both ears. Pharyngeal Foreign Bodies
Age distribution
Nasal Foreign Bodies A total of 251 cases were presented with pharyngeal foreign
Age distribution bodies. Pharyngeal foreign bodies were common throughout
A total of 270 cases were presented with nasal foreign bodies. all the age groups. The highest incidence occurred between
There were 201 (74.4%) and 50 (18.5%) cases presented with 0-5 years of age which was 35 cases or 13.4%. There were 30-
nasal foreign bodies in 0-5 and 6-10 years age group 50 cases encountered in each subsequent age group by 10
respectively. Incidence of nasal foreign bodies dropped years time frame. The incidence dropped after 60 years old.

18 Med J Malaysia Vol 67 No 1 February 2012

 A Review Of Ear, Nose And Throat Foreign Bodies In Sarawak General Hospital. A Five Year Experience

followed by ear and nose 1. This difference happened because

Types of foreign body we recruited all the inpatients and outpatients whereas Hon
The commonest pharyngeal foreign bodies were fish bones, SK only included inpatients in his study.
which was consisted of 233 (92.8%) cases. This was followed
by chicken bone in 5 (2.0%) cases and others in 13 (5.2%) The highest incidence of foreign bodies happened in 0-10 age
cases. group which constituted of 60.1%. This was the age group
when the children started to explore their surrounding world
Esophageal Foreign Bodies with their five senses. They showed high tendency to touch,
Age distribution smell and taste objects accessible by their reach. In contrast,
A total of 57 cases presented with esophageal foreign bodies. the incidence of foreign bodies in adult was more consistent
The incidence showed bimodal distribution. The first peak which did not show any peak in a specific age group. In our
occurred between 0-5 years of age which was consisted of 18 study, the incidence of foreign bodies dropped dramatically
(31.6%) cases. The second peak occurred in 41-50 years age after 10 years old.
group which numbered 16 (28.1%) cases. Others age groups
showed incidence of less than 5 cases each. Many studies conducted showed that high suspicious index
was crucial in diagnosing paediatric foreign bodies 3. This was
Clinical features true for our study as well, as majority of the foreign bodies
Fifty four (94.7%) patients presented with history of alleged occurred in younger age group. This group of patients
swallowed foreign bodies. showed difficulty in expressing their symptoms appropriately.
Interestingly, in our study, many cases presented with history
Types of foreign body of alleged foreign body lodgement informed either by
The commonest esophageal foreign body was chicken bone, patients or guardians. This was constituted of 96.0% in ear
which numbered 22 cases or 38.6%. This was followed by fish foreign bodies, 75.0% in nose, and 94.7% in esophagus. Most
bone in 17 (29.8%) cases, coins in 10 (17.5%) cases, dentures of the times foreign bodies were found thus such history was
in 5 (8.8%) and others in 3 (5.3%) cases. important and should never be overlook. Other clinical
features which should raise the suspicion of foreign bodies
Laryngo-tracheobronchial Tree Foreign Bodies were otalgia (2%), otorrhoea(1%) and blocked ear (0.4%) in
Age of distribution ear foreign bodies, while persistent unilateral nasal discharge
A total of 26 cases were presented with laryngo- (23.2%) and epistaxis (0.4%) in nasal foreign bodies. In
tracheobronchial tree foreign bodies. The highest incidence contrast, the presentation of laryngo-tracheobronchial tree
occurred between 0-10 years of age. There were 6 (23.1%) foreign bodies was more drastic. Stridor was the main
cases encountered in 0-5 years age group and 8 (30.8%) cases symptom (69.2%), followed by wheezing (19.2%) and other
in 6-10 years age group. (11.6%).

Clinical presentation The types of foreign body vary with the age groups and the
There were 18 (69.2%) patients presented with stridor, 5 sites where the foreign bodies were lodged. Foreign bodies in
(19.2%) with wheezing and 3 (11.6%) with other symptoms. adult were mainly food related whereas in paediatric group
mainly consisted of food and small objects like plastic toys.
Types of foreign body The study conducted by Higo also showed similar findings
Eighteen (69.2%) cases were due to seed or nut, followed by where the types of foreign bodies were closely related to the
metal in 3 (11.5%) cases, plastic in 1 (3.8%) case and others sites of foreign body lodgement 4.
in 4 (15.4%) cases.
In paediatic population, seeds or nuts represented the
Site of lodgement commonest foreign bodies in ear (47%) and nose (37%),
A total of 9 (34.6%) cases had foreign bodies located at the closely followed by plastic toys. These were the objects
right main bronchus whereas 3 (11.5%) cases at the left main readily available and reachable by the children in most of the
bronchus. houses. The finding was comparable to the study conducted
by Higo et al which reported plastic toy as the commonest
nasal foreign bodies. Most of the foreign bodies were
DISCUSSION relatively safe except for disc-type battery in the nose which
In our study, we found that ear foreign bodies showed the should be treated as emergency case 4. Unfortunately, there
highest incidence (44.3%) followed by nose (24.9%), pharynx were cases complicated with septal perforation secondary to
(23.2%), esophagus (5.3%) and laryngo-tracheobronchial tree battery in our study. For adult group, the types of ear and
(2.4%). This result was comparable with the study conducted nasal foreign bodies were different. In our study, insects
by Endican et al in Melanesians 3. The order of foreign body (4.2%) and cotton buds were found to be the commonest
frequency above was applicable to the paediatric group, foreign bodies in the ear. Incidence of ear insects was as high
which was defined as 0-15 years old in our study. For adult as 14% in a study conducted by Patrick J. Antonella 5. In our
group, which was defined as 16 years old and above, the order study, the incidence of nasal foreign bodies in adult were
of frequency differed. The highest incidence was found in surprisingly high, which constituted 7.0% of all the nasal
pharynx (17.2%), followed by ear (12.8%), esophagus (3.1%), foreign bodies. These foreign bodies mainly consisted of
nose (1.7%) and laryngo-tracheobronchial tree (1.1%). In glass, wood or stone due to trauma, or happened in those
contrast, the study conducted by Hon SK showed that with psychiatric illness or mentally challenge group.
aerodigestive foreign bodies constituted the highest incidence

Med J Malaysia Vol 67 No 1 February 2012 19

Original Article

Pharyngeal and esophageal foreign bodies were common in Most of the foreign bodies were successfully removed in clinic
both the adult and paediatric groups. Both groups shared the setting which was consisted of 76.1%. Difficult cases would
same common foreign bodies which were fish bone and be posted for removal under general anaesthesia. The study
chicken bone. Fish bones represented the commonest conducted by Hon SK showed that early referral and prompt
pharyngeal foreign bodies which constituted 92.8%, followed removal of foreign bodies could minimize this complication1.
by chicken bone (2.0%) and others (5.2%). For esophageal This should be practiced for all the otorhinolaryngeal foreign
foreign bodies, chicken bones comprised of 38.6%, followed bodies.
by fish bone (29.8%), coins (17.5%), dentures (8.8%) and
others (5.3%). In our study, coins were found exclusively in
paediatric group. The incident happened either due to child’s CONCLUSION
curiosity or accidentally swallowed. The studies conducted Our study showed that ear, nose and throat foreign bodies
by Edican, and Hugo showed coins as the commonest were commoner in children less than 10 years old. History of
esophageal foreign bodies in children which contributed foreign body lodgement was important and should never be
100% and 35.7% respectively 3,4. In contrast, pharyngeal and taken lightly. The types of foreign bodies differed from
esophageal foreign bodies in adult were mainly related to different age groups and sites. The local food constituted the
daily food ingested. The culprit chicken and fish were 2 highest incidence of otorhinolaryngeal foreign bodies with
favourite local food prepared in most of the households in additional of plastic toys in paediatric group.
our study population.

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20 Med J Malaysia Vol 67 No 1 February 2012