Introduction
The standard management for a suspected aerodigestive tract foreign body includes bronchoscopy, laryngoscopy and oesophagoscopy, together with physical examination and Radiological investigation (inspiratory and expiratory chest films). Once a foreign body has been removed, it is common practice to rule out the presence of a second foreign body. Similarly, a vanishing foreign body should prompt investigation of other areas.
Nasal cavity foreign bodies commonly present with unilateral nasal obstruction and purulent discharge or epistaxis. Foreign bodies in the nasopharynx are rare, and may go undetected for many years.Reference Briggs, Pou and Friedman1–Reference Awty7 They are more difficult to diagnose, and carry the risk of dislodgement resulting in aspiration.
In this article, we describe four cases (Table I) of children who presented with signs and symptoms of a lower aerodigestive tract foreign body, who on examination were found to have a nasopharyngeal foreign body.
Table I Demographic data on four paediatric cases of nasopharyngeal foreign body mimicking lower aerodigestive tract foreign body
Pt no = patient number; b'scope = bronchoscopy; o'scope = oesophagoscopy; FB = foreign body; y = years; m = months; R = right; L = left
Case reports
Patient one
A four-year-old boy was found by his mother outside in his backyard ‘choking’ and in respiratory distress, including a cyanotic episode.
In the emergency department, he was found to have decreased air entry into the right lung, and a chest X-ray showed some mild hyperinflation on the left. He was in mild respiratory distress when evaluated by the paediatric otolaryngology service, and a probable diagnosis of an airway foreign body was made.
Anaesthesia was induced without incident; in particular, no coughing was noted. Bronchoscopy and oesophagoscopy were normal. However, nasopharyngoscopy using a Boyle–Davis mouthgag and a mirror revealed a fair-sized twig impacted in the adenoid bed. The twig was removed uneventfully.
Follow-up X-rays were normal, and the patient was discharged home.
Patient two
A three-year-old girl suffered a witnessed choking event while playing with some small toys and other material on her living room floor. She was cyanotic and briefly apnoeic, according to her family. Her condition improved over minutes, with only a persistent cough remaining. She was brought to the emergency department by her family.
On examination, she was found to have decreased air entry to the left lung fields, with a normal chest X-ray.
Due to the strong history, persistent cough and clinical findings, the patient was taken to the operating theatre for endoscopy. At induction, she gave a few brief coughs but was stable. Bronchoscopy and oesophagoscopy were normal. However, a piece of clear, brittle plastic was found in the patient's nasopharynx, using a telescope trans-nasally, and was removed.
After removal, the patient was stable and was discharged home.
Patient three
A three-year-old girl was in her backyard when she abruptly started coughing and became distressed. There was no obvious cyanosis but the child had severe coughing bouts, to the point of vomiting, over a period of almost 30 minutes.
She was brought to the emergency department of a peripheral hospital, and was found to have mild inspiratory stridor and a persistent cough. A chest X-ray was reported as normal, and she was transferred to our institution for review.
On examination in the emergency department, she was found to have mild inspiratory stridor, coarse sounds in both lungs, and occasional desaturations (to percentages in the high 80s).
Based on the clinical history, the patient was taken to the operating theatre. At induction, the anaesthetist had some difficulty in maintaining oxygen saturation, and the bronchoscope was urgently inserted. No abnormality was found in the larynx, trachea or bronchi. The patient's oxygenation stabilised, the bronchoscope was removed and oesophagoscopy was performed. A narrow nasal endoscope was then inserted to examine the nasopharynx. A piece of tree bark was found in the nasopharynx. The patient was then intubated, a Boyle–Davis mouthgag inserted and the foreign body removed without incident.
The patient was discharged, stable, that evening.
Patient four
An 11-month-old girl was found playing on the floor near a cedar twig. She had a coughing and gagging episode which was followed by a 5-second apnoeic spell. Her mother attempted to withdraw the object by inserting her finger into the child's mouth. The mother was noted to have felt a twig in the back of the child's mouth, but was unable to extract it.
On presentation to the emergency department, the child was reported to have vomited four times, and to have been drooling since the initial episode, but no other respiratory symptoms had occurred since the initial episode.
Chest X-ray and lateral neck X-ray were normal.
Based on the clinical history and the suspicion of a foreign body in the oesophagus and possible cedar needles in the airway, it was decided to proceed to surgery. Induction of anaesthesia was unremarkable. Laryngoscopy and bronchoscopy were performed, with no evidence of a foreign body. The patient was intubated and oesophagoscopy was undertaken. There was no evidence of a foreign body in the oesophagus. As examination of the nasopharynx commenced, a cedar twig was noted underneath the soft palate. A Boyle–Davis mouthgag was inserted and the twig was removed. A second twig was also identified abutting the right eustachian tube orifice. The second twig was also removed and the child was discharged home in stable condition later that day.
Discussion
The anatomical boundaries of the nasopharynx extend from the base of the skull to the soft palate. Foreign bodies in the nasopharynx are rare, with only a handful of reported cases.Reference Briggs, Pou and Friedman1–Reference Awty7 Objects that have been reported in the nasopharynx include teeth, coins, rings, leeches and fish.Reference Briggs, Pou and Friedman1, Reference Parker, Bingham and Osbourne3, Reference Mahmood and Lello8–Reference Bilgen, Karci and Uluoz10 While nasopharyngeal foreign bodies are believed to be more common in patients with palatal defects and after penetrating trauma,Reference Awty7, Reference Walby and Kerr11–Reference Espinosa-Reyes, Fonnegra, Cardona-Gonzalez and Rosselli13 they have also been reported in patients presenting with symptoms and signs of lower aerodigestive foreign bodies.Reference Oysu, Yilmaz, Sahin and Kulekci9, Reference Eghtedari14, Reference Berry and Tay15
Our case series highlights the importance of examining the nasopharynx when a child presents with an apparent lower aerodigestive tract foreign body that cannot be found. All four of our cases presented with symptoms or signs of lower aerodigestive tract foreign bodies. Three of our cases mimicked airway foreign bodies and one case mimicked an oesophageal foreign body. On review of the literature, nasopharyngeal foreign bodies present more commonly in a delayed fashion after a reported choking episode, with symptoms of nasopharyngeal obstruction, or as an incidental finding.Reference Oysu, Yilmaz, Sahin and Kulekci9, Reference Eghtedari14, Reference Berry and Tay15 None of our cases involved a delayed presentation, perhaps because all had a convincing history, physical signs and/or radiographic findings suggestive of a lower aerodigestive tract foreign body. A lateral neck X-ray was only performed in one of our reported cases, and was normal.
The mechanism by which foreign bodies are introduced into the nasopharynx is largely unknown. It has been suggested that attempted removal by a concerned parent or bystander may cause the object to become forcefully lodged in the nasopharynx. Coughing or emesis may eject an aerodigestive tract foreign body into the nasopharynx (as highlighted in our second patient); this event may occur during the initial aspiration or later during induction of anaesthesia. Parker et al. reported two cases of swallowed coins that were later found in the nasopharynx following forceful coughing episodes.Reference Parker, Bingham and Osbourne3 One of these children (aged six years) underwent attempted retrieval of the foreign body by digital extraction, by his father.Reference Parker, Bingham and Osbourne3 Both of these children presented without signs or symptoms of aerodigestive foreign body.Reference Parker, Bingham and Osbourne3 A traumatic or iatrogenic event can cause a foreign body to lodge in the nasopharynx.Reference Vlantis and Freedman16, Reference Finkelstein, Talmi, Zohar and Ophir17 Finkelstein et al. reported the case of a sponge left in the nasopharynx following pharyngeal flap surgery.Reference Finkelstein, Talmi, Zohar and Ophir17 Bullets have also been found in the nasopharynx secondary to penetrating trauma.Reference Vlantis and Freedman16 It has been suggested that ingested foreign bodies may be propelled superiorly by the gag reflex, and become lodged in the nasopharynx in children.Reference Oysu, Yilmaz, Sahin and Kulekci9
• Foreign bodies in the nasopharynx are uncommon
• This paper describes four cases of nasopharyngeal foreign body mimicking the signs and symptoms of lower aerodigestive tract foreign body
• A patient with a suspected aerodigestive foreign body should undergo thorough history-taking, physical examination and radiological investigation (including inspiratory and expiratory chest films), as well as flexible nasal endoscopy which usually views the nasopharynx
• A patient with suspected aerodigestive foreign body in whom no foreign body can be found on bronchoscopy, oesophagoscopy or laryngoscopy should undergo nasopharyngeal examination
• Nasopharyngeal foreign bodies can safely be removed, after oral endotracheal intubation, via a transoral approach
Our four patients all had signs or symptoms of a lower aerodigestive tract foreign body. It seems likely therefore that the foreign body was initially in the lower aerodigestive tract and then became lodged in the nasopharynx, either through coughing, induction of anaesthesia or attempted retrieval by a bystander (as in patient four).
Treatment of suspected lower aerodigestive tract foreign body involves bronchoscopy, oesophagoscopy and laryngoscopy. If the foreign body is not found, or is suspected on history-taking or physical examination to be in the nasopharynx, the airway should be secured and removal of the foreign body from the nasopharynx attempted via a transoral approach. The greatest risk of retrieval of a nasopharynx foreign body without securing the airway is aspiration and possible death, which has been reported in one case.Reference Baigel4 To avoid the potential for aspiration, the airway should be secured with an endotracheal tube prior to attempted removal. As highlighted in our cases, a Boyle–Davis mouthgag and a mirror are useful in facilitating removal. A rigid endoscope and forceps can also be used for removal of a nasopharyngeal foreign body once the airway has been secured. We propose an algorithm for the management of paediatric aerodigestive tract foreign bodies (Figure 1), in order to avoid missing a nasopharyngeal foreign body.
Fig. 1 Algorithm for management of paediatric aerodigestive tract foreign body (FB). *Clinicians should always be aware that two FBs may be present. Pt = patient; OT = operating theatre
Retained foreign bodies in the nasopharynx may cause symptoms similar to adenoid hypertrophy and (with at least one reported case) obstructive sleep apnoea.Reference Lieberman, Yagupky and Lavie18 Additionally, long-standing nasopharyngeal foreign bodies can present as otitis media, epistaxis, recurrent rhinosinusitis, halitosis, mouth-breathing and purulent nasal discharge.Reference Briggs, Pou and Friedman1, Reference Eghtedari14 The longest reported duration for a retained nasopharyngeal foreign body is 20 years.Reference Tay19 In such cases, dislodgement and possible aspiration is always a risk, as the foreign body may descend and potentially cause airway obstruction.
