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THE EAR
Like noses, the is a favourite place for foreign bodies. Again children will only allow one attempt at removal and this is best performed by expert hands with the aid of a microscope. There is never any urgency for these to be removed. In the event of suspected trauma or a perforation of the tympanic membrane then a hearing test should be performed once the foreign body has been removed and the inflammation has settled. Antibiotic drops can be given to prevent otitis eternal and is useful in reducing the oedema of the external auditory canal making it easier for the foreign body to be removed.

THE NOSE
Infants enjoy putting things in their noses and ears. Sometimes these can go unnoticed and present with a unilateral foul smelling discharge. In a child this symptoms is almost always due to a foreign body. Children with suspected foreign bodies in their nose must be carefully assessed. If a foreign body is seen, there is only one good chance that the child will give for it to be removed. Several attempts by different doctors with nasty looking instruments will only serve to confirm to the child their worst suspicions that hospitals and doctors are horrible and best avoided (not unreasonable in the circumstances). Removal should therefore be attempted only with adequate illumination and ??? specialist. The best instrument to use is a blunt wax hook which is passed beyond the foreign body and then withdrawn. Forceps are pointless as they are usually too large and only push the foreign body further back.

If no foreign body is seen but the history is convincing, an examination under anaesthesia is necessary. Although the risk of inhalation is low, this must always be borne in mind and the child should be kept under observation until the examination can be performed.

THE THROAT
These are either bones, usually fish, or large pieces of food (food bolus) which have not been adequately chewed.

Trapped sharp foreign body
Presentation:
Patients with a trapped sharp foreign body complain of pain on swallowing (odynophagia) which they are able to localise. If they are able to point with one finger where the pain is, this usually suggests that there is a foreign body. With a pharyngeal laceration, patients are often unable to specifically localise the site and the pain does not persist.
Examination findings:
Fish bones are most often found trapped in the tonsils or base of tongue. Careful examination of the oropharynx with use of a mirror should allow these to be identified.
Investigations:
A lateral soft tissue X-ray of the neck is helpful in locating the foreign body if it cannot be seen on direct examination.
Management:
Removal either in the outpatient setting or under anaesthesia.

An impacted food bolus
Presentation:
Painful swallowing and dysphagia.
Typically the sit of impaction is at the level of cricopharyngeus. It is important to ascertain if there is any bone within the bolus as this can cause complications such as pharyngeal tears and mediastinitis.
Examination:
Pooling of salvia in pyriform fossae.
Special investigations:
A lateral neck view and chest X-ray.
Management:
If there is a sharp foreign body within the bolus this needs to be removed as soon as possible by endoscopy. Rigid endoscopy is preferred by ENT surgeons.
A soft food ‘bolus’ may be left to see if they pass spontaneously and a variety of treatments can be given to encourage this. These include simple measures such as drinking fizzy drinks, diazepam to try and relax muscle tone, buscopan to reverse muscle spasm and nifedipine which has some smooth muscle relaxant properties. If these fail to work the food bolus is removed under general anaesthesia with rigid pharyngooesophagoscopy.

THE AIRWAY
A foreign body in the airway is a potentially life threatening event.
Symptoms: severity will depend on site.
- Laryngeal / trachea (more serious): stridor, cough, respiratory distress and dysphonia
- Bronchus (usually less serious): cough, dyspnoea, wheeze
(Note: an improvement in symptoms can be deceptive, as it is likely that the foreign body has passed distally to lodge in one of the bronchi.)
Examination findings:
- Larynx and trachea: signs of respiratory distress with stridor, tracheal tug, intercostals recession
- Bronchus: reduced expansion on affected side, wheeze
Investigations:
- Not recommended or necessary if there is acute airway distress
- If the patient is stable a lateral soft tissue X-ray of the neck and chest X-ray is helpful. This may demonstrate the foreign body and will also show check signs such as lobal collapse or hyperinflation due to the ball valve effect created by the foreign body.
Management:
In the acute episode Heimlichs’ manoeuvre may be attempted to displace the foreign body.
- Laryngotracheal foreign bodies:
With a suspected high level foreign body, urgent endoscopy is required. Patients with lower airway foreign bodies are not usually so distressed and there is time for further evaluation. Bronchoscopy is mandatory in all patients with a suspected history of foreign body inhalation even if the signs and symptoms are minimal. Usually the foreign body is found in the right main bronchus. The is because it is more vertical and shorter than the left main bronchus.