Note: The American Broncho-Esophagological Association (ABEA) awards an annual Presidential Citation for Excellence in Foreign Body Removal. If you have a particularly informative and interesting anecdote, submit it to Dr. Dana Thompson at Dana.Thompson@cchmc.org.
World’s Tallest Man Saves China Dolphins
BEIJING-The long arms of the world’s tallest man reached in and saved two dolphins by pulling out plastic from their stomachs, state media and an aquarium official said. The dolphins got sick after nibbling on plastic from the edge of their pool at an aquarium in Liaoning province. Attempts to use surgical instruments to remove the plastic failed because the dolphins’ stomachs contracted in response to the instruments. Veterinarians then decided to ask for help from Bao Xishun, a 7-foot-9 Mongolian herdsman with 41.7-inch arms. Chen Lujun, manager of Royal Jidi Ocean World, said Mr Bao was successful and the dolphins were recovering nicely…
Although a dolphin is unlikely to show up in an otolaryngologist’s examination room, foreign bodies are often found in patients’ (usually children’s) orifices. Objects commonly include toys including doll accessories, beads (in New Orleans, Mardi Gras beads are common), batteries, erasers, crayons, stones, and folded paper, as well as biologic materials such as insects or seeds. ENToday asked a number of seasoned otolaryngologists to tell us their stories of the most unusual or interesting things they had removed from patients’ noses, ears, or throats. Although most experienced practitioners will be well familiar with what to keep in mind in these situations, we also include a few reminders (see sidebar).
Hook, Line, and Sinker? For Real
Bob Miller [ENToday editorial board chair] and I were residents together at UCLA. We were called down to the emergency room to see an adolescent who had been on a fishing trip. He had a piece of nylon monofilament line coming out of his mouth. I asked him, What’s going on?
He said that when they were done fishing they had to get back in the car to leave. When they were driving in the car, he wanted to take apart his fishing tackle and cut the line. Because he didn’t have a scissors or knife, he put the lead sinker in his mouth and used his teeth to try to cut it off the fishing line. The car hit a bump and jolted him and he swallowed. When we saw the X-ray it showed the fish hook in his piriform sinus, the sinker was in his proximal esophagus, and the line was coming out of his mouth. In the emergency room, someone had tried to pull the line out of his mouth and it hurt him because it had already got stuck in there. There he was, holding this line, because if he swallowed any further, the line would have disappeared down his esophagus.
The patient was sheepish and the mother was very chagrined. We took him to the operating room and intubated him carefully. Under direct vision we grabbed the fish hook and gently removed it out of the mucosa, to which there had only been slight damage.
When I began to write my consult, I realized I was about to write the phrase that he had swallowed a hook, line, and sinker, and that was probably the must amusing part to me. In the years since, I’ve lectured on this case.
Steven D. Handler, MD
Professor of Otolaryngology-Head and Neck Surgery, University of Pennsylvania School of Medicine and The Children’s Hospital of Philadelphia
Christmas in July
The most incredible thing I ever found in a patient’s nose occurred when I was at Yale in 1978. In July, a father brought his 5-year-old son in to see me and he was vexed because the boy had had pus coming from his nose for the past 6 months. He had been to three or four doctors who had treated him with antibiotics, without success. I was the first to look into his nose using a head mirror and a nasal speculum. To my surprise, there was something green in his nostril. I placed a forceps in his nose and pulled out a frond from a Christmas tree! It had been there since the previous holiday season. When the boy had put the piece of fir in his nostril, it had lodged itself in like an umbrella. When his father came into the room, he just shoved it in far enough to be hidden. He never revealed to his dad what he had done until I pulled it out.
Harold (Rick) Pillsbury III, MD
Thomas J. Dark Distinguished Professor of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill Medical Center, and President-elect of the Triological Society
My favorite story is about encountering a live spider in a patient’s ear. I could see the eyes looking at me under the microscope. I instilled mineral oil into the canal, expecting to kill it. The spider, however, had other ideas and quickly left its lair. When viewed under the microscope as it crawled out it looked enormous-and far too close. I pushed back so violently I fell backward off the stool. The patient brushed it to the floor and squashed it with his foot as I watched, speechless.
David Eibling, MD
Professor of Otolaryngology-Head and Neck Surgery, and Vice Chair for Education, University of Pittsburgh Medical Center
A six-year-old boy was camping with his family and awoke suddenly from sleep with a scratching sound in his ear. The family brought him to the emergency room when a live cockroach was seen in his ear. It was successfully removed without damage to the eardrum.
Richard A. Chole, MD, PhD
Lindburg Professor and Chairman, Department of Otolaryngology, Washington University School of Medicine, St. Louis
The patient’s mother thought she was putting ear drops in her three-year-old’s ear. It turned out to be Krazy Glue. The bottles were similar and she mixed them up. Krazy Glue elevates the first layer of skin, so we decided to leave it for two or three days and see if it acted in the ear the way it does on the surface of hands; that is, peeling off. Sure enough, it did, and then we were able to take the patient to the operating room and gently pry this material loose from the skin of the ear canal. Fortunately, it had not attached to the eardrum. The ear canal grew new skin.
An older child, about 17 years old, had had discharge coming from both sides of his nose for about six or seven years. He had been treated for sinus problems as well as other suspected conditions. It turned out he had had nasal surgery seven years before that and the physician had never removed the splints from his nose. Apparently the doctor had forgotten. He had these retained nasal splints in his nose for seven years. We cleaned out his nose and suctioned the discharge. We could see these shiny objects that were sewn to the septum. We made sure to let the prior physician know about it.
We often see gum in the ear and nose. In one patient there was a mass in his nose. Because it was red and hard, the referring physician thought it was a nasal tumor. It turned out it was bubble gum that had been in there for about a year.
Gerald Healy, MD
Chief of Otolaryngology at Children’s Hospital Boston, from a list of unusual cases supplied from his department
I took a toy baby out of a child’s throat. It was about two or three inches long, like a full kewpie doll, but smaller. I remember thinking, Gee, I liked OB rotation, but…
I took out a whistle from a patient’s bronchus. When the patient expired air, it whistled.
A child who had been in a car accident was hospitalized for multiple facial and extremity fractures and had been intubated for a period of time. He then was extubated and about 6 weeks later he came to my office. He had loud noisy breathing that sounded as if he had a mass in his trachea. I scoped him and saw a mass below the vocal cords and I thought, This must be a reaction from the intubation. I took him to the OR and when I took out the mass it appeared pink and fleshy. When I poked around in the flesh I found a piece of his nasal bone. During the car accident it had smashed his nasal bone and he had aspirated it, and a reaction occurred around the bone.
Three Coins in an Esophagus
Coins are frequent-but I’ve taken out three coins at a time.
Monster in My Nose
When I was a resident, a five-year-old patient came in and said he had a monster living in his nose. The mother had heard him say this repeatedly and did not pay much attention to it. But eventually the odor being emitted from the child’s nose was so bad that the regular babysitter refused to stay with the child. The case fit the typical history of unilateral foul-smelling drainage. I examined the nose and suctioned out the foul mucus, and I thought I saw a sort of a pinkish mass. I extracted something that appeared to be soft and spongy, and it was bleeding. I was afraid I had biopsied a tumor connected to his brain. I ran, literally, carrying the tissue, to the pathology lab. That soft, spongy mass turned out to be-a sponge.
Ellen M. Friedman, MD
Professor and Chief, Otolaryngology-Head and Neck Surgery Service, Texas Children’s Hospital, Baylor College of Medicine, Houston
Tips for Foreign Body Diagnosis and Treatment
All of us who have been in otolaryngology practice for a number of years have seen unusual things. If a patient has unilateral purulent nasal discharge, always consider one of two diagnoses: (1) that there is a foreign body present, regardless of the patient’s age; and (2) choanal atresia. In a toddler, it is almost always going to be a foreign body as opposed to choanal atresia. If it is an acute onset of purulent nasal discharge, it may be a button (disc) battery, which can lead to erosion of the nasal septum, nasal collapse, and chronic anatomic structural problems. If there is any chance of it being a button battery, whether it is in the nose, ear, or esophagus, that is an emergent event. If you cannot remove the foreign body with the patient awake, then you need to give the child general anesthesia. If the patient has a foreign body in one orifice, remember to examine every other orifice. Just because a child may say that they put a bead in the right ear, you still may find something in the left ear, and one of the nostrils as well.
Charles M. Myer III, MD
Vice Chair, Department of Otolaryngology-Head and Neck Surgery at the University of Cincinnati College of Medicine, and Director, Residency Program
©2007 The Triological Society