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Foreign bodies typically become lodged in the eyes, ears, nose, airways, and rectum which are the main orifices of human beings. Foreign bodies can be in hollow organs (like swallowed batteries) or in tissues (like bullets). They can be inert or irritating. If they irritate they will cause inflammation and scarring. They can bring infection into the body or acquire infectious agents and protect them from the body's immune defenses. They can obstruct passageways either by their size or by the scarring they cause. Some can be toxic.
Both children and adults experience problems caused by foreign objects getting stuck in their bodies. Young children, in particular, are naturally curious and may intentionally put shiny objects, such as coins or button batteries, into their mouths. They also like to stick things in their ears and up their noses. Adults may accidentally swallow a non-food object or inhale a foreign body that gets stuck in the throat. Airborne particles can lodge in the eyes of people at any age. These foreign bodies often result in allergies which are either temporary or even turn into a chronic allergy. This is especially evident in the case of dust particles.
Most objects that are swallowed will, if they have passed the pharynx, pass all the way through the gastrointestinal tract. Rarely an object becomes arrested (usually in the terminal ileum or the rectum) or a sharp object penetrates the bowel wall. If the person who swallowed the foreign body is doing well, usually an x-ray image will be taken which will show any metal objects, and this will be repeated a few days later to confirm that the object has passed all the way through the digestive system. Also it needs to be confirmed that the object is not stuck in the airways, in the bronchial tree. If the foreign body causes problems like pain, vomiting or bleeding it must be removed. Also swallowed mercury batteries should be removed as soon as possible as they are very dangerous especially to small children. Many different object may enter body tissue and cavities under a variety of circumstances.
The main methods of entry are:
PERCUTANEOUS FOREIGN BODY
These are commonly metal, glass or splinters of wood associated with industrial, road or domestic accidents and self-harm injuries. Generally, two projections at the right angles to each other are required, without movement of the patient between exposures, particularly when examining the limbs. The projections will normally be antero-posterior as postero-anterior and a lateral of the area in question, as described in the appropriate chapters.
A radio-opaque marker should be placed adjacent to the site of entry of the foreign body. The skin surface and a large area surrounding the site entry should be included on the images, since foreign body may migrate, e.g. along muscle sheaths, and high-velocity foreign bodies may penetrate some distance through the tissues.
Compression must not be applied to the area under examination. Oblique projections may be required to demonstrate the relationship of the foreign body to adjacent bone. A tangential (pro-file) projection may be required to demonstrate the depth of the foreign body and is particularly useful in examination of the skull, face, thoracic abdominal walls. Sometimes a single tangential projection may be all that is required to show a superficial foreign body in the scalp or soft tissues in the face.
The exposure techniques should demonstrate both bone and soft tissue to facilitate identification of partially opaque foreign bodies and to demonstrate any gas in the tissues associated with the entry of the foreign body.
The most usual exposure technique for conventional radiography are:
kVp sufficiently high to demonstrate bone and soft tissue on a single exposure
Use of two film/screen combinations of different speeds or a film/screen combinations and non-screen film to demonstrate bony detail on one film and soft tissue on the other film with one exposure.
The used of digital image acquisition offers significant advantages in the localization of foreign bodies. CR and DR both allow soft tissue and bone to be visualized from one exposure using post-processing. The use features such as edge enhancement and windowing enable much better demonstration of foreign bodies that have radio-opacity similar to that of the surrounding tissue.
INGESTED FOREIGN BODIES
A variety of objects, such as coins, beads, needles, dentures and fish bones, may be swallowed accidentally, or occasionally intentionally, particularly by young children. A technique used to smuggle drugs through customs involves packing the substance into condoms, which are subsequently swallowed.
The patient should be asked to undress completely and wear a hospital gown for the examination. The approximate time of swallowing the object and the site of any localized discomfort should be ascertained and noted on the request card, along with the time of the examination. However, any discomfort may be due to abrasion caused the passage of the foreign body. It is important to gain the patientââ‚¬â„¢s cooperation, especially in young children, since a partially opaque object may be missed if there is any movement during the exposure. The patient should be practice arresting respirations before commencement of the examination.
If the patient is a young child, then the examination is usually restricted to a single antero-posterior projection to include the chest, neck, and mid-to upper abdomen. The lower abdomen usually excluded, to reduce the dose to the gonads as the examination is usually preformed to confirm the presence of foreign bodies lodged in the stomach unable to pass through the pylorus.
Care must be taken to ensure that the exposure selected is sufficient to adequately penetrate the abdomen as well as to visualize the chest.
The examination of the older children and adults may require a lateral projection of the neck to demonstrate the pharynx and the upper esophagus, right anterior oblique projection of the thorax to demonstrate the esophagus, and an antero-posterior abdomen projection to demonstrate the remainder of the alimentary tract, exposed in that order. Each image should, preferably, be inspected before the next is exposed, and the examination terminated upon discovery of the foreign body, to avoid unnecessary irradiation of the patient. The cassette used should be large enough to ensure overlapping areas on adjacent images.
Non-opaque foreign body may be outlined with a small amount of barium sulphate. A few cases require a barium-swallow examination. If no foreign body is demonstrate within the alimentary tract, and particularly if there is doubt as to whether the foreign body has been ingested or inhaled, then a postero-anterior projection of the chest will be required to exclude an opaque foreign body in the respiratory tract or segmental collapse of the lung, which may indicate the presence of non-opaque foreign body in the appropriate segmental bronchus. All projections should preferably be exposed in the erect position. A fast film/screen combination and short exposure time should be employed.
INHALED FOREIGN BODY
Foreign bodies may be inhaled. Infants and young children habitually put object into their mouth, and these may be inhaled. Teeth may be inhaled after blow to the mouth or during dental surgery. Such foreign bodies may lodge in the larynx trachea or bronchi.
The adult patient should be asked to undress completely to the waist and to wear a hospital gown for the examination. A postero-anterior projection of the chest projection will be required initially. Alternatively, an antero-posterior chest image is acquired when examining children. A lateral projection of the neck, including the nasopharynx, may also be required.
In the case of a non-opaque inhaled foreign body, postero-anterior projections of the chest in both inspiration and expiration will be required to demonstrate air trapping due to airway obstruction. This may manifest itself as reduced lung attenuation on expiration and /or mediastinal shift.
The kVp must be sufficiently high to demonstrate a foreign body that might otherwise be obscured by the mediastinum. A fast imaging system (film/screen combination) and short exposure time should be employed.
Cross-sectional imaging such as CT and MRI are additional technique that may provide useful information. MRI is contraindicated in cases of suspected ferrous material, since the examination may result in movement of the foreign body.
Bronchoscopy may be used to demonstrate the position of a foreign body may be removed during this procedure.
INSERTED FOREIGN BODY
Foreign body are sometimes inserted into any of the body orifices. Infant and young children, for example, may insert object into the nasal passage or an external auditory meatus. In these cases, radiography is required only occasionally, since most of these objects can be located and removed without recourse to radiography.
When radiography is requested, two projection of the area concerned at the right-angles to each other will be required. Swabs may be left in the body following surgery. Such as swabs contain a radio-opaque filament consisting of polyvinylchloride (PVC) impregnated with barium sulphate for radiographic localization.
Ultrasound should be the initial modality selected for the detection of an intrauterine contraceptive device. It is also very effective in the detection of soft tissue foreign bodies with the advantage of incurring no radiation burden where it is available. There have been incidents where object such as vibrators have become lodged into the rectum. In these cases, a single antero-posterior projection of the pelvis may be required. Patient who are prone to self-harm may inserted a variety of objects into their body cavities and under the skin.
TRANSOCULAR FOREIGN BODIES
Foreign body that enter the orbital cavity are commonly small fragments of metal, brick, stone or glass associated with industrial, road or domestic accidents.
Plain film is the first modality for investigation of a suspected radio-opaque foreign body in the orbit. For further investigation, or assessment of a non-opaque foreign body, CT scanning can be very useful. Ct will give information about damage to the bones of the medial and superior orbital margins, and evidence of any damage suffered by the brain if the orbital roof has been breached. Ultrasound is useful for detecting superficial foreign bodies and soft tissue damage but is less to ocular ultrasound expertise is less likely to be immediately available, and there is extra hazards of introducing coupling gel into a possibly deep wound. Radiographic localization may be carried out in two stages:
To confirm the presence of an intra-orbital radio-opaque foreign body.
To determine whether the foreign body is intra- or extra-ocular.
Images showing fine detail are essential. A small focal spot (e.g. 0.32 mmÂÂ²), immobilization with a head band and a high definition film/screen combinations is recommended. Metal fragments down to 0.1 x 0.1 x 0.1 mm in size may be detected by conventional radiography. Intensifying screen must be scrupulously clean and free of any blemishes producing artifact that could be confused with foreign bodies. A cassette with perfectly clean screens may be set aside especially for these examinations
CONFIRMATION OF A RADIO-OPAQUE FOREIGN BODY
A modified occipito-mental projection with the orbital-meatal base line (OMBL) at 30 degrees to the cassette is undertaken, with the patient either prone or erect. Ideally, a dedicated skull unit is selected as this will provide the maximum degree of resolution required for the visualization of a small foreign body.
The chin is raised so the OBML is at 30 degrees to either the vertical or horizontal beam. This position projects with the walls of the orbit lying parallel to the cassette. Using a vertical or horizontal beam, the central ray is directed to the interpupillary line. The beam is either collimated to include both orbits or just the orbit ender examination, depending on the departmental protocol.
LOCALIZATION OF INTRA-ORBITAL FOREIGN BODY
The method described the position of the foreign bodies relative to the centre of the eye and whether it is intra- or extra-ocular. It should be ascertained that the patient is able to maintain ocular fixation, i.e. keep the eyes fixed on some given mark, since the exposure are required with the patient looking in different directions. The examination is preferably carried out a skull unit. The following projections are required:
Occipito-mental (modified) with the centering adjusted to the middle of the interpupillary line. Two exposures are made, one with the eyes level and looking forwards and the other with the eye under examination adducted (turned towards the nose)
Lateral, with centering adjusted to the outer canthus of the eye. Three exposure are made, one with the eyes level looking forward, one with the eyes is raised and one with the eyes looking lowered.
In each case, the patient should look steadily at some predetermined mark or small object during the exposure. A tracing is made from the lateral projections showing three shadows of the foreign bodies. Straight lines are drawn to joint them. The lines are then bisected at the right angles midway between the shadows. The point of intersection is slightly anterior anterior to the zygomatic border of the orbit. In this case the foreign body is in the eyeball. If the intersection is remote from the zygomatic border it will indicate that the foreign body is in the surrounding tissue or muscles. A second tracing from the occipito-mental projections enables lateral movement of the foreign body to plotted and shows its antero-posterior position relative to the centre of the pupil.
Causes and Symptoms
The causes of foreign body ingestion or insertion range from traumatic accidents or casual exploration and play to intentional risk-taking, desire for sexual stimulation, an eating or personality disorder, or psychotic behavior. Cases of repeated swallowing of foreign objects by small children may indicate neglect or a dysfunctional home environment.
The symptoms of foreign body ingestion or insertion depend in part on the organ or part of the body affected.
EYES. Dust, dirt, sand, or other airborne material can lodge in the eyes as a result of high wind or an explosion, causing minor irritation and redness. More serious damage can be caused by hard or sharp objects that penetrate the surface of the eye and become embedded in the cornea or conjunctivae (the mucous membranes lining the inner surface of the eyelids). Swelling, redness, bleeding from the surface blood vessels, sensitivity to light, and sudden vision problems are all symptoms of foreign matter in the eyes.
EARS AND NOSE. Toddlers sometimes put small objects into their noses, ears, and other openings. Beans, dried peas, popcorn kernels, hearing-aid batteries, raisins, and beads are just a few of the many items that have been found in these bodily cavities. On occasion, insects may also fly into a child's ears or nose. Pain, hearing loss, and a feeling of fullness in the ear are symptoms of foreign bodies in the ears. A smelly or bloody discharge from one nostril is a symptom of foreign bodies in the nose.
AIRWAYS AND STOMACH. At a certain age children will eat almost anything. A very partial list of items recovered from young stomachs includes the following: coins, chicken bones, fish bones, beads, pebbles, plastic toys, pins, keys, buckshot, round stones, marbles, nails, rings, batteries, ball bearings, screws, staples, washers, a heart pendant, a clothespin spring, and a toy soldier. Some of these items will pass right on through the digestive tract and leave the body through the feces. The progress of metal objects has been successfully followed with a metal detector or x rays. Other objects, like needles, broken poultry bones, or razor blades, can get stuck at various points in the digestive tract and cause trouble.
Most complications of swallowed foreign bodies occur in the esophagus at one of three points: the thoracic inlet at collarbone level (70%); the mid-esophagus (15%); and the sphincter at the lower end of the esophagus where the esophagus joins the stomach (15%). If a swallowed object passes into the stomach, it is unlikely to cause complications unless it is either sharp and pointed in shape or made of a toxic material.
Some foreign objects lodge in the airway. Although children eat small objects and stick things into their bodily openings of their own volition, they inhale them unwittingly while choking. Probably the most commonly inhaled item is a peanut. Items as unusual as crayons and cockroaches have also been found in children's windpipes. These items always cause symptoms (difficulty swallowing and spitting up saliva, for instance) and may elude detection for some time while the child is being treated for asthma or recurring pneumonia.
RECTUM. Sometimes a foreign object will successfully pass through the throat and stomach only to get stuck at the juncture between the rectum and the anal canal. Items may also be self-introduced to enhance sexual stimulation and then get stuck in the rectum. Sudden sharp pain during elimination may signify that an object is lodged in the rectum. Other symptoms vary depending upon the size of the object, its location, how long it has been in place, and whether or not infection has set in.
REFER TO THE DOCTOR DURING EMERGENCY
The specific symptoms of foreign body ingestion vary somewhat depending on the item and its location in the body. Parents or caregivers may observe the child swallowing the object, or the child may report doing so. In general, parents should take the child to the doctor or emergency room in any of the following situations occurs:
foreign bodies in the eyes or skin that are the result of an automobile accident, explosion, gunshot injury, or similar trauma
foreign body appears to have caused an infection in the surrounding tissue
foreign body is made of lead or contains corrosive chemicals (most commonly batteries)
foreign body is pointed or has sharp edges (needles, pins, broken glass, toothpicks, razor blades, pop-off tabs from soda cans, etc.)
child complains of pain on swallowing, pain in the chest, abdominal pain, or severe pain on defecation
child drools heavily
child coughs up, vomits, or defecates blood
child loses consciousness or becomes delirious as a result of esophageal or airway blockage
child is known to have Crohn's disease, Meckel's diverticulum, or other chronic disorder of the digestive tract (These disorders increase the risk of complications from swallowed foreign bodies.)
In most cases the doctor needs only a brief history to determine what type of foreign object is involved and where it may be lodged in the child's body. Objects in the ear, nose, or eye can usually be seen on visual examination. In the case of swallowed objects, the doctor examine the inside of the child's mouth and throat to look for signs of tissue damage and bleeding. The doctor may perform a digital examination to locate objects lodged in the rectum.
In general, the doctor may use an endoscope to look for a foreign object in the body as well as to remove it. He or she may order an x ray of the neck, chest, and/or abdomen to locate a foreign body in the esophagus, airway, or lower digestive tract. Most foreign bodies swallowed by small children are radiopaque, which means that they show up on a standard x ray. Metal detectors can successfully identify the location of soda can tops and other aluminum objects that will not show up on an x ray.
Blood tests are not usually necessary unless the doctor suspects that the foreign body has caused an infection or bleeding.
Small particles like sand may be removable without medical help, but if the object is not visible or cannot be retrieved, prompt emergency treatment is necessary. Trauma to the eyes can lead to loss of vision and should never be ignored. Before an adult attempts any treatment, he or she should move the child to a well-lighted area where the object can be more easily spotted. Hands should be washed and only clean, preferably sterile, materials should make contact with the eyes. If the particle is small, it can be dislodged by blinking or pulling the upper lid over the lower lid and flushing out the speck. A clean cloth can also be used to pick out the offending particle. Afterwards, the eye should be rinsed with clean, lukewarm water or an ophthalmic wash.
If the foreign object cannot be removed at home, the eye should be lightly covered with sterile gauze to discourage rubbing. A physician will use a strong light and possibly special eye drops to locate the object. Surgical tweezers can effectively remove many objects. An antibiotic sterile ointment and a patch may be prescribed. If the foreign body has penetrated the deeper layers of the eye, an eye surgeon will be consulted for emergency treatment.
Ears and Nose
A number of ingenious extraction methods have been devised for removing foreign objects from the nose and ears. A bead in a nostril, for example, can be popped out by blowing into the mouth while holding the other nostril closed. Skilled practitioners have removed peas from children's ears by tiny improvised corkscrews and marbles by cotton-tipped applicators with super glue. Tweezers often work well, too. Insects can be floated out of the ear by pouring warm (not hot) mineral oil, olive oil, or baby oil into the ear canal. Metal objects can be removed from the nose or ears with the help of a magnet. Items that are lodged deep in the ear canal are more difficult to remove because of the possibility of damaging the eardrum. These require emergency treatment from a qualified physician.
Airways and Stomach
Mechanical obstruction of the airways, which commonly occurs when food gets lodged in the throat, can be treated by applying the Heimlich maneuver. If the object is lodged lower in the airway, a bronchoscope (a special instrument to view the airway and remove obstructions) can be inserted. On other occasions, as when the object is blocking the entrance to the stomach, a fiberoptic endoscope (an illuminated instrument that views the interior of a body cavity) may be used. The physician typically administers a sedative and anesthetizes the child's throat. The foreign object then is either pulled out or pushed into the stomach, depending on whether the physician thinks it will pass through the digestive tract on its own. Objects in the digestive tract that are not irritating, sharp, or large may be followed as they continue on through. Sterile objects that are causing no symptoms may be left in place. Surgical removal of the offending object is necessary, however, if it contains a toxic substance; is likely to penetrate the stomach wall; or is longer than 2.36 inches (6 cm) or wider than 0.8 inches (2 cm).
A rectal retractor can remove objects that a physician can feel during a digital examination of the rectum. In most cases the doctor will inject a local anesthetic before extracting the object. Surgery under general anesthesia may be required for objects deeply lodged within the body, as in the case of a 14-year-old Dutch adolescent who had inserted a soda can into his rectum.
Treatment of any health problem related to a foreign body may include a psychiatric consultation if the doctor suspects that the swallowing or insertion of the foreign body is related to autism or mental retardation (in small children) or an eating or personality disorder (in adolescents).
The prognosis of foreign body ingestion or insertion varies according to the nature of the object and its location in the body but is quite good in most cases. With regard to foreign bodies in the digestive tract, between 80 percent and 90 percent pass through without incident; 10ââ‚¬"20 percent can be removed with an endoscope; and fewer than 1 percent require surgical removal.
Using common sense and following safety precautions are the best ways to prevent foreign objects from entering the body. For instance, parents and grandparents should toddler-proof their homes, storing batteries in a locked cabinet and properly disposing of used batteries, so they are not in a location where curious preschoolers can retrieve them from a wastebasket. Sewing kits, razor blades, and other potentially dangerous items should also be stored in childproof locations. To minimize the chance of youngsters inhaling food, parents should not allow children to eat while walking or playing. Fish should be carefully boned before it is served to younger children. Many eye injuries can be prevented by wearing safety glasses while using tools or participating in certain sports.
Parental concerns in younger children should be directed toward the prevention of accidental swallowing or ingestion of foreign bodies. In most cases, these accidents can be successfully treated when they do occur, and they are unlikely to cause long-term damage to the child's health. In addition, small children are not likely to repeat behaviors that result in a trip to the doctor's office or hospital emergency room.
Ingestion or insertion of foreign bodies in older children and adolescents is a matter of greater concern to parents, however, because it is much more likely to be intentional, to reflect the presence of an eating disorder or other psychiatric problem, to be a repeated behavior, and to result in serious bodily harm.
Refernce : a) www.e-radiography.com
c) Medical Imaging Techniques, Reflection and Evaluation by
Elizabeth Carver and Barry Carver
d) Radiological Procedures, Stephan Chapman and Richad