Beyond the usual: a case series of rare foreign bodies in ENT practice

INTRODUCTION

Foreign bodies (FBs) in the ear, nose, and throat (ENT) areas constitute a major category of otorhinolaryngological emergencies, representing about 11% of cases seen in ENT emergency services globally.¹ These events are especially common in children, with those under 6 years old forming the most frequently affected group. This high incidence in young children stems from their natural curiosity and exploratory behaviour, habit of placing objects in orifices, underdeveloped swallowing reflexes, and absence of molars needed for effective chewing.² Although less common in adults, foreign bodies in this group more often involve the aero digestive tract and are frequently linked to underlying anatomical issues, dental problems, or deliberate ingestion.³ The external auditory canal (EAC) stands out as the most frequent site overall, particularly in paediatric cases, accounting for 44% of incidents, followed by nasal (25%), pharyngeal (23%), oesophageal (5%), and laryngo-bronchial (2%) sites.⁴ Prompt recognition and proper removal are critical to minimizing morbidity and mortality. Complications are more frequent in cases of delayed presentation, unsuccessful prior attempts by non-specialists, or certain types of foreign bodies.⁵ Here we are reporting rare cases of foreign body as management depends on the site and type of foreign body. We are reporting 5 cases of unique foreign bodies.

CASE SERIES

This Cross-sectional study was conducted in 150 patients presenting with foreign body lodgement in ear, nose and throat to Otorhinolaryngology Department of a tertiary care teaching hospital of western Gujarat. Institutional ethical approval and informed consent were obtained. Patients were asked to undergo a predesigned questionnaire.

Patient with FB in ear were evaluated by otoscopic examination. Patient with nose foreign body lodgement underwent X-ray PNS and anterior rhinos copy with zero-degree endoscope. Patient with throat foreign body lodgement underwent X-ray neck, chest and abdomen Anteroposterior/lateral view and indirect laryngoscopy with 70-degree endoscope and CT neck and thorax. FB removal was done by appropriate manner and patient were evaluated for any complications following FB removal. However here we are only reporting 5 unique foreign bodies encountered during the course of study.

Case 1

Case 1 was a 38 years old patient farmer by profession who came to ENT OPD with thorn ingestion while farming. CT neck was done followed by direct laryngoscopy and removal from right pyriform fossa (Figure 1).

Case 2

Case 2 was a 5-year-old male patient who came with ball point stuck on hard palate. FB was seen over hard palate and removed using micro forceps (Figure 2).

Case 3

Case 3 was 3-year-old female patient who came with insertion of shell in left nostril while playing. Shell was removed with the help of eustachian tube catheter (Figure 3).

Case 4

Case 4 was 44-year-old female patient who had dental implant done 1 year ago and came to OPD with suspected ingestion of tooth causing difficulty in swallowing and FB sensation. CT neck was done and FB was visualised at level of C7. Esophagoscopy was done and foreign body was retrieved (Figure 4).

Case 5

Case 5 was 44-year-old male patient who came with history of difficulty in swallowing and pooling of saliva with alcohol ingestion 24 hours ago. Following X-ray FB was suspected. Diagnostic esophagoscopy was done and toothbrush removed from cricopharynx level (Figure 5).

DISCUSSION

Foreign bodies in the ear, nose, and throat constitute a frequent emergency in otorhinolaryngology, particularly in children; however, unusual and diverse foreign bodies may be encountered across all age groups, often posing diagnostic and therapeutic challenges. The present series highlights five rare and unique foreign bodies involving different sub sites of the upper aero digestive tract, emphasizing the need for a high index of suspicion and individualized management. The thorn in the right pyriform fossa represents an uncommon organic foreign body. They carry a high risk of mucosal injury, oedema, and potential perforation. Early endoscopic removal is crucial to prevent complications such as deep neck space infection. The ballpoint pen lodged in the hard palate is an unusual presentation, likely resulting from trauma or accidental impalement.

The sea shell in the nasal cavity, particularly in the left nostril, reflects a typical paediatric habit of inserting objects into the nose. Prompt removal is necessary to avoid complications such as rhinolith formation. The golden tooth impacted in the cervical oesophagus is a rare inorganic foreign body. Dental prostheses are known to be accidentally ingested, especially in elderly patients or during dental procedures. Rigid esophagoscopy remains the gold standard for removal.

The toothbrush in the oesophagus is an exceptionally rare and potentially life-threatening foreign body due to its size and shape. Immediate endoscopic or surgical intervention is warranted. In case study by Shirali et al toothbrush was found as an unusual foreign body in ENT.⁶

An atypical case was described by S. Sheikh et al of a foreign body (a metallic paper clip) in the hypopharynx of an 18-month-old child presenting with recurrent respiratory tract infections.⁷ Another atypical case described by Robert E Wineski et al of a 2-year-old male who presented to the emergency department with atypical symptoms resulting from ingestion and aspiration of a large, flat sticker removed by rigid bronchoscopy.⁸

Overall, this series underscores that foreign bodies in ENT practice can vary widely in nature, size, and location. Successful management depends on early diagnosis, appropriate imaging, and timely intervention. Preventive strategies, including public awareness, parental supervision, and caution during dental procedures, are equally important in reducing the incidence of such unusual presentations. To the best of our knowledge and literature, toothbrush as a foreign body has been reported once by Shirali GN et al, in 1988 and long-standing denture in oesophagus was reported by Subhash Bhatta et al, in 2021.^6-9

CONCLUSION

Foreign body insertion in the ear, nose and throat represents a frequent and significant emergency encountered in otorhinolaryngology practice, particularly among the paediatric population. The above study of unique foreign bodies encountered in Ent department was shown along with the management done to enforce quick action that has to be taken when such situations occur. Foreign body in ENT is largely a preventable and manageable condition when addressed promptly. Strengthening parental awareness, promoting early healthcare seeking behaviour, and ensuring skilled otorhinolaryngological intervention are essential to reducing morbidity. This study reinforces the importance of prompt diagnosis, calm and systematic management, and preventive education as integral components of comprehensive patient care in foreign body emergencies.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Chiun KC, Tang IP, Tan TY, Jong DE. Review of ear, nose and throat foreign bodies in Sarawak General Hospital. A five-year experience. Med J Malaysia. 2012;67(1):17-20.
2. 2. Endican S, Garap JP, Dubey SP. Ear, nose and throat foreign bodies in Melanesian children: an analysis of 1037 cases. Int J Pediatr Otorhinolaryngol. 2006;70(9):1539-45.
3. 3. Oyama LC. Foreign Bodies of the Ear, Nose and Throat. Emerg Med Clin North Am. 2019;37(1):121-30.
4. 4. Parajuli R. Foreign bodies in the ear, nose and throat: an experience in a tertiary care hospital in central Nepal. Int Arch Otorhinolaryngol. 2015;19(2):121-3.
5. 5. Heim SW, Maughan KL. Foreign bodies in the ear, nose, and throat. Am Fam Physician. 2007;76(8):1185-9.
6. 6. Shirali GN, Savant RA, Uppal PK, Bhargava KB. Toothbrush: an unusual foreign body in ENT practice. J Laryngol Otol. 1988;102(11):1068-9.
7. 7. Sheikh S, Natarajan B, Johnston A. Foreign body in the hypopharynx--an unusual presentation. J Accid Emerg Med. 1996;13(4):292-3.
8. 8. Wineski RE, Panico EC, Bailey LN, Cardenas AM, Grayson JW, Wiatrak BJ. Flat sticker as a mobile airway foreign body: A case report and review of the literature. Radiol Case Rep. 2020;15(11):2391-5.
9. 9. Bhatta S, Shifaz A, Sharma D, Nooh H, Seena F, Jameel FR, et al. Foreign Body Denture in the Esophagus for 2 months: A Case Report. Indian J Otolaryngol Head Neck Surg. 2022;74(3):5515-7.