Friday, 3 February 2012

Who swallows foreign objects and stuffs them up their noses?

Foreign bodies in human bodies are relatively uncommon, but they are important and interesting. Sometimes, they may even provide a great deal of lowbrow amusement. Foreign bodies may be ingested, inserted into a body cavity, or deposited into the body by a traumatic or iatrogenic injury. Most ingested foreign bodies pass through the gastrointestinal tract without a problem. Most foreign bodies inserted into a body cavity cause only minor mucosal injury. However, ingested or inserted foreign bodies may cause bowel obstruction or perforation; lead to severe hemorrhage, abscess formation, or septicemia; or undergo distant embolization.

Motor vehicle accidents and bullet wounds are common causes of traumatic foreign bodies. Metallic objects, except aluminum, are opaque, and most animal bones and all glass foreign bodies are opaque on radiographs. Most plastic and wooden foreign bodies (cactus thorns, splinters) and most fish bones are not opaque on radiographs. All patients should be thoroughly screened for foreign bodies before undergoing a magnetic resonance imaging study.

Dr. Steven Moss has pretty much seen it all—lodged in people’s digestive tracts. As a gastroenterologist at Rhode Island Hospital, he has helped remove batteries, blades and even bed springs from people’s esophagi and stomachs. But these patients weren’t children. They were adults who had swallowed dangerous objects on purpose.
“Intentional, rather than accidental, swallowing is a poorly recognized and underappreciated problem,” Moss said. Small, smooth objects can generally pass through the body safely, but official guidelines for gastroenterologists recommend removing anything larger than six to 10 centimeters within 24 hours and sharp objects and batteries as soon as possible.

In an analysis of patients at his hospital, Moss and his colleagues found that just 33 people made up the total 305 adult cases where intentionally swallowed objects had to be removed. One habitual swallower was seen 67 times in the course of the eight-year study.

“The reasons for foreign body ingestion vary," Colin Harrington, a psychiatrist at Rhode Island Hospital and co-author on the new study, said in a statement. “It is one of many forms of self-injurious behavior.” Some 79 percent of patients had been diagnosed with at least one psychiatric disorder (outside of their swallowing behavior).

Despite having swallowed some seriously sharp objects, however, none of the patients suffered major complications, and surgery was avoided in all but two cases (by removing the intruding article endoscopically).

Nonetheless, safely retrieving these objects isn’t easy—or cheap. With medical, administrative and personnel costs (guards were often required to watch patients to make sure they didn’t swallow anything else), the price of these 305 procedures topped $2 million (an average of more than $45,400 per individual patient). Most of the costs (79 percent) were paid out by Medicare or Medicaid, the analysis found.
"Foreign body ingestion is poorly understood, difficult to treat, and consumes considerable physician time and hospital resources," Moss said. "Attention should be focused on investigating how to avoid these preventable and costly episodes."

Foreign body ingestions or insertions are seen in four broad categories of patients: (a) children, (b) mentally handicapped or mentally retarded persons, (c) adults with unusual sexual behavior, and (d) “normal” adults or children with predisposing factors or injurious situational problems. This latter group includes individuals who may abuse drugs or alcohol, engage in criminal activities, engage in extreme sporting activities, or may be subject to child or spousal abuse. Mentally handicapped or mentally retarded individuals are often repeat offenders and will present multiple times for unusual injuries and foreign body insertions and ingestions.

Foreign body ingestions are common in children and mentally handicapped adults. Typical examples include children swallowing coins and mentally handicapped adults swallowing razor blades and silverware. Fortunately, the vast majority of all swallowed objects pass through the gastrointestinal tract without a problem.

When I was five years old, I swallowed the metal base of a metal soldier that had broken off. My mother took me to the hospital and they were going to cut me open thinking that the metal base may have been made of lead. My mother went home to bring back the metal soldier to the hospital. They concluded that the base was also made of metal and not made of lead. When I was six, I accidentally swallowed two pennies. When my youngest daughter was seven, she swallowed a ring. The hospital took an X-ray and concluded that it would eventually work its way out of her body—which it did just as the pennies and the metal base I swallowed worked their way out of my body.

Elongated or sharp objects, such as needles, eating utensils, bobby pins, or razor blades, are more likely to lodge at areas of narrowing (from bowel adhesions or strictures) or to impinge at regions of anatomic acute angulation The duodenal loop, duodenojejunal junction, appendix, and ileocecal valve region seem to be more predisposed to impaction from these types of objects.

Although it isn’t common, young children sometimes inhale certain foods (such as nuts, seeds, and popcorn) and small objects (such as buttons and beads). Such objects may cause either partial or total airway blockage. Coins, small toys, marbles, pins, screws, rocks, and anything else small enough for infants or toddlers to put in their mouths can be swallowed. If the object passes through the esophagus and into the stomach without getting stuck, it will probably pass through the entire GI tract.

Any child who may have inhaled an object should be seen by a doctor. Children with obvious breathing trouble may have a total airway blockage that requires emergency medical attention.

If choking or coughing goes away, and the child does not have any other symptoms, he or she should be watched for signs and symptoms of infection or irritation. X-rays may be needed.

Bronchoscopy may be necessary to make a definitive diagnosis and to remove the object. Antibiotics and respiratory therapy techniques may be used if infection develops.

Any child who is believed to have swallowed a foreign object should be watched for pain, fever, vomiting, or local tenderness. Stools (bowel movements) should be checked to see if the object exited the body. This may sometimes cause rectal or anal bleeding.

Even sharp objects (such as pins and screws) usually pass through the GI tract without complications. X-rays are sometimes needed, especially if the child has pain or the object does not pass within 4 to 5 days.

Only the imagination limits the objects and circumstances that result in things getting stuck inside of the nose. Common objects found in noses include food material, tissue paper, beads, toys, and rocks. My brother when he was very small pushed a mothball up his nose.

Most cases of foreign bodies in the nose and nasal cavity are not serious and occur in toddlers and children from 1-8 years of age. Children develop the ability to pick up objects at about the age of 9 months, so foreign objects in the nose are much less common in children 9 months of age or less.

An object that is simply stuck in the nose and not causing other symptoms can usually wait until morning or the following day for removal. The object does, however, have to be completely removed quickly and without discomfort and danger.

In addition, an object stuck in the nose has the potential to dislodge and travel into the mouth where there is the danger of swallowing it, or even worse, inhaling it into the lungs, which may block airflow.

The subject of this article is foreign objects in the nose and it is not intended to cover toxic chemical inhalants such as hydrocarbons, organophosphates, cocaine, or other toxins.

The vast majority of foreign bodies are placed in the nose voluntarily for an endless variety of reasons. When questioning children about this possibility, it is important to approach them in a nonjudgmental manner. Otherwise, the adult runs an increased risk that the child will deny having put something in their nose to avoid punishment. This could easily result in a delay of its discovery and increase the risk of complications.

Trauma is another common cause for items to get shoved inside the nose. When a person falls or gets struck in the face, it is important to consider the possibility that an object may be stuck in the nose and is completely out of view.

Fortunately, most people who are old enough can and will tell their doctor about an object's presence in their nose.

Typically, foreign items in the nose result in complaints of pain or difficulty breathing through that side of the nose.

Nasal bleeding is also a common symptom of a foreign body in the nose because the tissues of the nose can be easily scratched. Much of this blood can drip down the back of the throat and be swallowed. Because blood is quite nauseating, the person may vomit, which can appear black or bloody, depending on how long the blood remains in the stomach.

The nasal space connects to the back of the mouth, so it is also possible for an object to be pushed back into the throat. Individuals may swallow the object or choke on it. Complaints of choking, wheezing, difficulty breathing, or inability to talk should prompt an evaluation of the entire nose and throat in addition to the lungs so that foreign bodies will not be overlooked. Gathering information in regard to what kind of foreign object it may have been will assist the health care practitioner to determine if an X-ray will show the object, especially if the object is metal.

Some individuals, especially children, who are motivated to place something in their nose might also think it is fun to put something in the other side of their nose as well as in one or both ears. A doctor will check all the likely places if there is a suspicion of additional foreign bodies. Moreover, children have been known to place objects in their younger siblings nose, ears, and other places.

Infection is another common symptom of a foreign object in the nose. Lost or forgotten tissue paper is a common source of such a problem. This scenario is not uncommon in adults and children. People will typically complain of continuing nasal discharge from one side of the nose. Many of these people have been treated with one or more antibiotics. Unfortunately, antibiotics alone will not cure this condition until the offending object is removed. In addition, the sinuses are all connected to the nasal passages. Because a foreign body in the nose will frequently become infected and block the drainage sites of the sinuses, sinusitis should also raise the question of a foreign object inside the nose.

Although a person can usually sense the presence of something out of the ordinary in their nose, it may be confused with nasal congestion, so small objects or torn tissue paper can easily go undetected.

A foul odor can be a sign of a foreign body that has been in the nose for a period of time. The object can manifest itself by producing bad breath or a foul odor from the nose, possibly linked to a nasal discharge associated with the foreign object.

The skin under the nose may become raw from the continuous discharge or from frequent wiping. Impetigo is an infection of the skin that is commonly associated with this problem. Impetigo typically appears as a raw rash with faint yellow, crusty material over it. Impetigo just in this area must prompt a thorough evaluation of the nose to ensure that the nose is clear.

I for one would prefer to put sweets in my mouth and smell nice perfume. As to swallowing foreign objects or stuffing them up one’s nose, I will leave that to the crazy people or children who don’t know any better.

No comments: