A rare case of polyembolokoilamania of nose in a neuropsychiatry patient

INTRODUCTION

Nasal foreign body are very common in children.¹ In adults, it is common among mentally retarded, drug abuse, psychiatric patients or is iatrogenic.^1,2 The ratio of male to female is 5.8 to 4.2. The incidence of foreign body in ear, nose and throat is 9-15%.² Foreign body in the nose alone is 19.5%.

In children detecting foreign body is difficult due to lack of history in most of the times. It is suspected with symptoms of long standing unilateral foetid nasal discharge, not responding to medications.² Similarly it is difficult to detect foreign body insertion or ingestion in a psychiatry patient due to their mental instability and this goes unnoticed in majority of cases.³ These foreign bodies are retained until it impart emergencies such as difficulty in breathing, aspiration, chronic cough, severe pain or foul smell detected by the care takers.⁴ It can be picked up accidently or during imaging. As a result most of the psychiatric patients present with foreign body with its complications. Henceforth in a neuropsychiatry patient with drug abuse we should be more cautious and do a meticulous examination to prevent the impending complications. Here we present a case of multiple foreign bodies of nose in a neuropsychiatric substance abuse patient.

CASE REPORT

A 25 year old male psychiatric patient was referred to Department of ENT from Psychiatry department with complaints of aural fullness, bleeding and pain in both the ears for three weeks. Patient had history of drug abuse to cannabis, nicotine, alcohol and inhaling fevibond for four years. He had history of disturbed childhood due to the death of his parents at the age of 2 years. He grew up with his younger brother in a remand home. On examination he was alert, shy and responds vaguely to oral commands. Ear examination revealed bilateral tympanic membrane intact with no signs of bleeding. Throat was clinically normal. To our surprise anterior rhinoscopy visualised blackish hard mass with yellowish green mucopurulent discharge in both nasal cavities. On probing a hard metallic object was felt in both nasal cavities. Patient did not cooperate for posterior rhinoscopy. Diagnostic Nasal Endoscopy could not be done due to the hindrance caused by the foreign body. On attempting to remove there were multiple variant nasal foreign bodies such as a part of a metal key, safety pin, part of bottle cap obstructing both the nasal cavity.⁵ After the removal, nasal endoscopy revealed a large septal perforation in anterior aspect of the septum.

Patient was advised nasal decongestant drops, oral antihistamines and analgesics for three days. Follow up after three days was done. Complaints of aural fullness and ear pain reduced.

DISCUSSION

“Polyembolokoilamania” is a scientific term used for insertion of the foreign body into one or more of one’s own bodily orifice.^3,6

Foreign body ingestion or insertions are common among adults with intellectual or mental disabilities, substance abuse, psychiatric disorders or in response to delusional belief or command hallucination.⁴ This could be a part of self-mutilation or attention seeking behaviour.⁷ Often they combine this with inhaling fumes or inhalational agents. In psychosis, it is seen as a part of self-mutilation, for getting erotic pleasure, malingering or factitious illness.^3,6 Most of them may have a disturbed emotions like disgust, anger, embarrassment or fear. In adolescents it is seen as a result of attention seeking, poor judgement while under the influence of drug or alcohol.

Foreign body can be an animate or inanimate, inert, hygrophilic, corrosive or even iatrogenic. Most commonly they are seen in the lower part of the nose or anterior to middle turbinate. Commonest symptoms are unilateral foetid nasal discharge, pain and sneezing which are difficult to elicit from psychiatric patients.^2,4 Most of their complaints will be vague or unrelated. Long standing foreign body case in nose results in inflammatory exudates, granuloma, mucosal edema or rhinolith.⁸ They have a potential risk of dislodgement to areodigestive tract. Foreign body results in complications such as sinusitis, vestibulitis, irritative rhinitis, septal perforation, otitis media and sometimes meningitis or tetanus.^2,8

Investigations such as diagnostic nasal endoscopy, X-ray PNS and lateral skull can be done.^4,8 CT or MR imaging should be done for patients not co-operative for DNE.

Once identified the most challenging part in dealing with psychiatric patients is removal of foreign body. Various instruments such as foreign body hook, foley’s catheter glue, and suction pressure can be used and complications if present can be treated in the same or later sitting.⁵ These patients have higher tendency to insert foreign body in other orifices also.⁶ Hence a thorough exanimation of the other systems should be done mandatorily.

CONCLUSION

In psychiatry patients there is high risk of foreign body insertions. Hence while dealing with such patients it’s a great challenge from clinical point of view in diagnosing as well as in removing the foreign body and in treating the complications if any. Timely detection and prompt treatment will reduce the medical morbidity. In this report we emphasise the importance of meticulous examination and diagnosing the foreign body. This report focuses on creating an awareness among the ENT surgeons to routinely examine foreign body in all the psychiatric patients whom we encounter.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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