Foreign Bodies in the Nose, Paranasal Sinuses, and Throat

Foreign bodies in the nose, paranasal sinuses, and throat are pathological conditions in which external objects enter the human body. These foreign bodies get stuck in or on the surface of tissues, causing discomfort and unpleasant sensations. If left for a prolonged period, they can contribute to the development of chronic infections.

Classification of Foreign Bodies in the Nose and Throat

Foreign bodies in the nose:

• Living foreign bodies;
• Non-living foreign bodies;
• Rhinoliths.

Foreign bodies in the paranasal sinuses:

• Dental filling material;
• Teeth.

Foreign bodies in the throat:

• Foreign body in the palatine tonsil;
• Foreign body in the lateral folds;
• Foreign body in the uvula.

Etiology

Living foreign bodies in the nasal cavity are more common among residents of tropical regions, although isolated cases have been described in residents of central regions of Russia. Among living foreign bodies, one can encounter larvae, leeches, helminths, and arthropods. Flies and botflies lay their larvae in the nasal cavity, arthropods crawl in during sleep outdoors, and leeches enter when swimming in water bodies.

Non-living foreign bodies are more common in adults with mental disorders and in children who insert objects during play or exploration of their environment. However, there are cases of foreign bodies entering during vomiting (food remnants), facial injuries, or forgotten during surgical procedures (often dressing materials).

They are categorized as:

• Organic (seeds, fruit pits, small food particles);
• Inorganic (beads, parts of stationery items, plasticine, buttons, teeth, stones, toy parts);
• Metallic (coins, batteries, screws, nails, hairpins) foreign bodies.

Rhinoliths, or nasal stones, form either by the deposition of salts of various microelements on a foreign body or by the accumulation of these salts in poorly ventilated areas of the nasal cavity where mucus accumulates abundantly (floor of the nasal cavity, inferior nasal meatus).

Foreign bodies in the paranasal sinuses enter from the nasal cavity or the oral cavity when there is a pathological communication (oroantral fistula). The maxillary sinuses are most commonly affected. The presence of dental filling material in the sinuses indicates previous dental procedures during which the integrity of the upper jaw was compromised, perforating the wall into the maxillary sinus. Teeth in the maxillary sinuses are extremely rare and can be a result of embryogenesis disorders (tooth develops inside the nasal sinus instead of the upper jaw), tooth displacement, or tooth fragments during injury or surgical intervention.

The cause of foreign bodies in the throat is most often inattention and haste while eating. Small bones, pieces of meat, glass shards, small pills, and plastic wrappers are more likely to get stuck. Young children left unattended may put small household items, toy parts, buttons, or plant parts in their mouths and accidentally swallow them. In hot countries, living foreign bodies (insects, leeches) can enter with food or water.

Anatomy

The presence of foreign bodies in the nasal cavity promotes a local inflammatory response in the form of infiltration and hyperemia of the mucosa with increased mucoserous discharge. If the foreign body is not removed promptly (within 2-3 days), the discharge becomes purulent, mucosal pressure sores form, and the process becomes chronic, spreading to surrounding structures. Chronic rhinitis, rhinosinusitis, and nasal septum perforation can develop. Small lithium button batteries pose a particular danger, as they can cause severe electrochemical burns within a few hours of being in the nasal cavity, forming ulcers and perforations.

Living foreign bodies, while passing through part of their life cycle in the nasal cavity, can penetrate the soft tissues of the nose, leading to the development of an inflammatory process.

Prolonged presence of inanimate foreign bodies in some patients leads to the formation of rhinoliths, when mineral salts precipitate around the foreign body (nucleus), but the presence of a foreign body is not a prerequisite for the formation of nasal stones. The etiology and triggers are not fully understood. Often, a combination of several factors is necessary: the presence of pathological narrowing in the nasal cavity with impaired ventilation (deviated septum, spurs, hypertrophied turbinates), where a large amount of mucus constantly accumulates, and a focus of chronic infection. All this contributes to the precipitation of mineral salts and the formation of stones, which can be of different sizes, from small and poorly visible to huge ones obstructing several nasal passages, up to the destruction of bone structures, and replicating the nasal cavity in the form of casts.

Foreign bodies of the sinuses are characterized by a local inflammatory response, accompanied by edema and hyperemia of the mucous membrane, abundant mucous or mucopurulent discharge, impaired mucociliary transport in the affected sinus. In the presence of objects that have fallen from the oral cavity (teeth or their parts, filling material), there is a violation of the integrity of the lower bony wall of the sinus with the presence of oroantral union, and in some cases – fistula with purulent discharge, the objects themselves are deposited at the bottom of the sinus. Cases have been described in which small elements can evacuate from the sinus independently through natural openings by the movement of cilia and mucus.

Foreign bodies of the pharynx: on examination, the presence of pathologic contents in the soft tissues, usually partially immersed in the mucosa. Depending on the localization, it can be the palatine tonsils (occurs most often due to their loose structure with the presence of lacunae and protruding position in the oropharynx), also foreign bodies can get into the space between the palatine tonsils and the palatine arch, which causes some difficulties in the diagnostic search.

Less common are foreign bodies of the uvula, palatine arches, and lateral pharyngeal folds. If foreign bodies are not removed in time, with a favorable outcome, they can encapsulate and self-reject after a few days. If a foreign body remains in the tissue for a long time, localized inflammation can develop, accompanied by infiltration and hyperemia, in rare cases – the presence of serous-purulent discharge, and parapharyngitis or more serious complications (parapharyngeal abscess and mediastinitis) can also develop. After removing foreign bodies, abrasions and small hemorrhages may remain.

Signs of foreign bodies in the nasal cavity and pharynx

All foreign bodies in the nose are characterized by difficulty in nasal breathing, sneezing, and abundant mucous discharge from one half of the nose. Sometimes pain and discomfort in the nose may appear, as well as bleeding, which is especially characteristic in the presence of living foreign bodies and lithium batteries.

Rhinoliths can remain in the nasal cavity for a long time without clinical manifestations and be discovered during routine otorhinolaryngological examination or during surgical interventions. An ENT doctor should be alerted to nasal stones by complaints of prolonged pain, nasal discharge, and difficulty breathing, which are unilateral in nature, a history of a foreign body entering that half of the nose, as well as frequent recurrent unilateral rhinosinusitis.

Foreign bodies in the paranasal sinuses can proceed for a long time without clinical symptoms and more often manifest after a long period of time under the guise of chronic sinusitis. Patients complain of headache and a feeling of pressure in the affected sinus, congestion, and mucopurulent discharge. When the maxillary sinus is affected, pain may radiate to the upper jaw, and when the sphenoid sinus is affected, patients note pain in the occipital region. The presence of a pathological communication with the oral cavity may manifest as purulent discharge with an unpleasant odor from the mouth.

In the presence of immunodeficiency or chronic endocrine system pathologies (diabetes mellitus), foreign bodies may manifest only with paraorbital or intracranial complications, which is an extremely unfavorable sign.

In some cases, foreign bodies in the paranasal sinuses can be discovered accidentally during CT/MRI of the facial skull or during endoscopic surgeries to improve nasal breathing.

The main complaint in the presence of foreign bodies in the pharynx is painful sensations and discomfort at the site of their localization, intensifying when swallowing, tickling, and coughing. Complaints may persist for some time even after the removal of foreign objects.

Diagnosis

Diagnosis of foreign bodies in the nasal cavity is based on medical history data and rhinoscopy. In case of difficulty in diagnosis, nasal cavity fibroscopy, X-ray of the paranasal sinuses or lateral projection of the nasopharynx (for radio-opaque objects), CT scan of the facial bones are performed.

For the diagnosis of foreign bodies in the paranasal sinuses, imaging methods such as CT and MRI are used. Subsequently, endoscopy of the nasal cavity and paranasal sinuses is performed, which in this case is a therapeutic and diagnostic method.

Diagnosis of foreign bodies in the pharynx is based on oropharyngoscopy data. In some cases, it is quite difficult to detect a foreign body due to its location – in the thickness of the palatine tonsil, when only a small tip is sticking out, which is hidden behind the palatine arch and the foreign body itself is translucent, for example, a fish bone. The patient’s anxiety and hypersalivation also cause difficulties. In such cases, it is necessary to calm the patient, give them clean drinking water, spray the mucosa with a local anesthetic (for example, 10% lidocaine), if they have no allergic reaction, and try to rotate the palatine tonsil outward from the palatine arches for better examination. In cases where it is not possible to visually determine the location of the foreign body, palpation is used and, if necessary, X-ray (if the foreign body is radio-opaque). In some cases, there is no foreign body at the time of examination, but complaints persist due to residual effects such as abrasions and bruises; such patients are recommended dynamic observation and treatment of the mucosa with antiseptic solutions for rapid healing.

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Treatment

Treatment involves removal of the foreign body from the nose, for which hooks, forceps, clamps, and nasal aspirators are used. The procedure is performed after anemization and, if necessary, local anesthesia of the nasal cavity. In some cases, particularly with especially agitated patients, especially children, intravenous sedation or general anesthesia is used. If foreign bodies are present in the deep parts of the nasal cavity, endoscopy may be required.

Rhinoliths are more often detected and removed during surgical interventions to improve nasal breathing (septoplasty, vasotomy of nasal turbinates), the nasal stone is crushed and evacuated in parts.

Foreign bodies in the paranasal sinuses are removed during surgery under general anesthesia using endoscopic equipment. Sanitation of the paranasal sinuses, restoration of sinus aeration and nasal breathing are performed. If there is an oroantral fistula or sinus, their plastic surgery is performed with the participation of maxillofacial surgeons.

After removal of foreign bodies, it is recommended to rinse the nose with saline solutions, use local decongestants until the edema subsides, and apply local antiseptic or antibacterial medications.

Treatment of a foreign body in the pharynx also involves its removal, for which forceps, tweezers, or mosquito clamps are used. Removal should preferably be performed on an empty stomach after irrigating the site of entry with anesthetic solutions (10% lidocaine solution). If abrasions and hemorrhages are present, local anti-inflammatory therapy and a soft diet are prescribed.