Lupine Publishers | Evaluation of Ear, Nose and Throat Foreign Bodies in the Department of ENT-Head and Neck Surgery in a Teaching Hospital

Lupine Publishers | Journal of Otolaryngology

Abstract

Objective: FB (foreign bodies) in ear, nose and throat are often encountered by otolaryngologists in their daily practice and is commonly seen in both children and adults. Depending upon the type and location of FB, it may have serious impact on individual’s health if instant appropriate action is not taken. That’s why, there’s frequent visits to ED (emergency department) on having FB in ear and aerodigestive tracts. The objective of this study was to evaluate the nature, common sites, modes of presentation, modes of management of FB, age and gender distribution.
Materials and Methods: A retrospective hospital-based study was done in Universal College of Medical Sciences, Bhairahawa, Rupandehi, Nepal from March 2014 to September 2017. The information was obtained from hospital record books.
Results: Out of 483 total patients, 287 (59.42%) were male and 196 (40.57%) were female. Most of them were less than 10 years old. Of the 483 patients, 202 (41.82%) had FB in the ear, 132 (27.32%) in the nose and 149 (30.84%) in the throat. Living FB were found in 54 (26.73%) patients out of 202 in the ear, 10 (7.57%) patients out of 132 in the nose and none in the throat. Of the total patients, 97 (20.08%) required general anesthesia (GA) to remove FBs and the rest 427 (88.4%) patients were dealt with or without local anesthesia. Most of the FBs were removed promptly on presentation otherwise within 24 hours of presentation in the hospital.
Conclusion: FB in ENT were found more commonly in the children and the commonest site was ear. Timely presentation, prompt diagnosis and needful management in a center with otolaryngology practice reduces the morbidity and mortality. Most of the FB in ENT can be removed in outpatient department (OPD) or emergency room (ER) with or without local anesthesia (LA).
Keywords: Ear; Nose; Throat; Foreign Bodies; Local Anesthesia

Introduction

A foreign body (FB) is any object or substance that is not derived from the individual’s own body part and can cause harm by its mere presence if prompt medical care is not provided [1,2]. They may be found in Ear, Nose and Throat. They are very common in otorhinolaryngological clinical practice. It can be introduced spontaneously or accidentally by both children and adults. However, children are common victims as they have habit of inserting nearby objects in their nose, ear or mouth, imitation and also other contributing factors are like boredom, playing, mental retardation, insanity, and attention deficit hyperactivity disorder, along with availability of the objects and absence of watchful caregivers. Consequently, it may cause minor irritation to life threatening problem. A proper technique, good light, appropriate instrument, a co-operative or fully restrained patient and a gentle approach by the related doctor or health worker are required for the removal of FB. One should have a clear diagnosis before making attempts to remove the FB so as to lessen the morbidity [3,4]. FB may be classified as animate (living) and inanimate (nonliving). The inanimate FB can again be classified as vegetative (organic) and non-vegetative (inorganic) FB, and hygroscopic (hydrophilic) and non-hygroscopic (hydrophobic) [1,2]. The objective of this study was to evaluate the nature, common sites, modes of presentation, modes of management of FB, age and gender distribution.

Materials and Methods

A retrospective study was conducted in the Department of ENT – Head and Neck Surgery, Universal College of Medical Sciences, from March 2014 to September 2017. The data were obtained from the hospital record books. Otoscopy and anterior rhinoscopy were performed to diagnose FB of the ear and nose respectively. Instruments such as Jobson Horne probe, FB hook, Tilley’s forceps, and crocodile forceps were used in FB removal from the nose and ear. Syringing and suctioning were also done for FB ear removal. Plain X-ray of the neck was done in patients with a history of FB ingestion. Flexible nasopharyngo laryngoscopy (NPL) and flexible upper gastrointestinal (UGI) endoscopy were done in cases where the FB was not visible in X-ray to rule out presence of a FB or to determine its site of impaction and in selected cases UGI endoscopy was used for FB removal too. It was followed by removal of the FB from the oropharynx/hypopharynx and esophagus with direct laryngoscopy or rigid esophagoscopy, respectively under general anesthesia (GA). FB struck in the oropharynx or parts of hypopharynx were confirmed with the help of Lack’s tongue depressor and head light or indirect laryngoscopy and removed with the Tilley’s forceps under local anesthesia (LA) in the OPD with patient co-operation.

Results

There were 483 patients recorded, out of which 287 (59.42%) were male and 196 (40.57%) were female with male to female ratio 1.46:1. The number of FB (Table 1 & Figure 1) in ear was 202 (41.82%), 132 (27.32%) in nose and 149 (30.82%) in the throat. Out of 202 FB in ear, 54 (26.73%) was animate and 148 (73.26%) inanimate. Out of 132 nasal FB, 10 (7.57%) was animate and 122 (92.42%) was inanimate. The FB encountered in throat was entirely of inanimate nature.

Figure 1. Few examples of ENT foreign bodies. A) FB toy battery in esophagus and removed with rigid esophagoscope, B) FB coin in esophagus, C) FB button battery in esophagus, D) FB bead removed from ear, E) FB denture, F) FB bead removed from nose, G) FB metal hook in esophagus, H) FB insect in ear and I) FB chicken bone with meat bolus in esophagus.

FB in Ear

Total of 202 patients were recorded with FBs in the ear. The most common type of FB in the ear was grain seed 25.74% (52) followed by FB bead 19.8% (40). Fifty-four (26.73%) patients had animate (living) FBs. These were mostly insects in the form of maggots, cockroach, grasshopper, butterfly, housefly and ticks. Hundred and forty-eight (73.26%) patients had inanimate (nonliving) FBs. Out of 148 patients, fifty-two (35.13%) had hygroscopic FBs in the form grain seed in the form of bean, pea, wheat, paddy and gram as shown in Table 1. The rest ninety-six (64.86%) patients had non-hygroscopic FBs in the form of bead, cotton pledget, pebble, eraser, paper, button batteries, plastic ball and vegetable twig or thorn. Majority of cases were seen in 0-10 years age group i.e. 72% (147). The most common site of FB lodgement was found to be the external auditory canal. Most of these FBs were removed in the OPD or in the ER with or without local anesthesia (LA). In 4 children, the FB were found impacted in the deeper part of EAC (3 button batteries and 1 plastic ball) and had to remove under GA via post-aural approach.

FB in the Nose

Hundred and thirty-two (27.32%) had FB lodgement in the nose. The most common was grain seed 40 (Out of it, only 10 (7.57%) patients had living FBs i.e., 9 had maggots and 1 had leech. The rest 122 (92.42%) patients had nonliving FBs as shown in Table 1. Forty FB (30.3%) were of hygroscopic nature in the form of grain seed and the rest sixty nine percent being non-hygroscopic as in Table 1. Of the total number of 132 patients 122 patients (92.42%) were children and the rest 10 (7.57%) patients were adults with animate type of FBs. Hundred and five (86.06%) of the children presented with history of FB insertion nose by their caretakers, while in 17 (12.87%) children neither the patients nor the caretakers were certain of FB insertion. Unknowingly, they were treated as a case of sinusitis due to complaints of nasal blockage, headache and unilateral fetid discharge by the pediatricians and primary care physicians, which was later, referred to our center and revealed to be forgotten FB. Sometimes, even one has to depend on imaging like x-rays /CT scans to rule out the FBs where the patients are unable to recall the events. Otherwise, most of the times the typical history provides clue for clinching the diagnosis. Most of the FB were removed in the ER and OPD with or without LA and only 3 cases (2.27%) required removal under GA i.e. 2 cases of beads and 1 case of grain seed which on manipulation went posteriorly and also patient being uncooperative.

Foreign Bodies in the Throat

A total of 149 patients presented with the complaint of ingestion of FB.  The most common type of FB was coin of one rupee, 2, 5 and 10 rupees and the common site of the impaction was cricopharyngeal junction in all the 50 patients (33.55%). The sites of other types of FB impaction were oral cavity, oropharynx, hypopharynx, thoracic esophagus and lower gastro-esophageal sphincter region. All the ingested FB were inanimate, with 84 (56.37%) being organic and 65 (43.62%) being inorganic. Organic FBs were meat bolus and bone (fish, chicken, mutton, and buffalo meat) and one of plum seed. The inorganic FBs included button battery, thorn, denture, coin, and metallic objects as shown in Table 1. Age less than 10 years old were the most common group with FB coin. FBs fish bone and vegetable twig/thorn lodged in oral cavity and oropharynx were removed under LA. Out of 40 FB coin, 10 were dislodged spontaneously via gastrointestinal route, 5 FB meat bolus and 7 FB chicken bone were removed by flexible endoscopy and the rest of the FBs were removed under GA without  postoperative complications.

Table 1. Different types of Foreign bodies (FB) in ENT.

Discussion

In our study, we’ve found higher incidence of FB in children less than 10 years old in 66.04% (319) patients. This is consistent with study by Iseh and Yahya [5], Ogunleye AOA and Sogebi R [6], Ahmad M, et al. [7]. This may be consequent of children’s exploring habit and lodging objects into the natural orifices of body, accidentally or intentionally. We found 59.42% of patients to be male and 40.5% to be female with male: female ratio 1.46:1. The male: female ratio was shown to be 1:1.05 by Gregogri et al. [8] whereas it was 1:1.26 in the study of Ogunleye AO et al. [9] and 1.35:1 by Agrawal S, Ranjit A study [10]. This suggests male are more susceptible than female to foreign body insertion in the orifices. In this study we observed ears were the most common site of lodgement of foreign bodies (41.82%) followed by throat (27.32%) and nose (27.32%). Parajuli R [11] and Shrestha I, et al. [4] also found in their study ears as the most common site for impaction of foreign bodies followed by throat and nose.  The most common foreign body in the ear and nose was the variety of grain seeds like bean, pea, paddy, wheat, gram, maize and foreign body coin was highest in throat. Removal methods, most commonly used for ear, nose and throat FBs were similar to those presented by Parajuli R [11], in order of preference the alligator forceps, Jobson Horne probe, foreign body hook, Tilley’s forceps and ear syringing. No patient required endoscopy or indirect laryngoscopy to remove oropharyngeal FB. The need for general anesthesia to remove FB varies in literature, with percentages varying from 8.6% to 30% [12]. There were no complications reported post FB removal.

Conclusion

FB in ENT are common in both pediatric and adult population. Comparatively the children are seen to be more vulnerable to have ENT FB lodgement.  Significant complications may arise if FB in ENT are not taken care of immediately and skillful removal is must. Thus, proper care and watch must be provided by care takers or the family members in order to prevent the encounter of such objects, especially in pediatric group.

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Lupine Publishers | Color Changes of Pediatric Dental Bridges

Lupine Publishers | Pediatric Dentistry Journal

Abstract

Dental technology that depended on the standardized lost-wax casting technology has been greatly improved with the introduction of dental CAD ⁄ CAM systems. The aim of the present study was to compare between the color changes of CAD/CAM acrylic and manually performed acrylic bridges used for pediatric patients. Forty study casts of children aged 2 - 4 years old of both genders, with prematurely lost one of the maxillary central incisors and the adjacent lateral incisor was carious and considered to be abutment tooth were involved in this study for construction of cantilever bridges. For each cast, two bridges were constructed; 1st one is CAD/CAM acrylic bridge and the other one is manually performed acrylic bridge. After immersing the bridges in saturated chocolate solution for different time intervals, color changes of the bridges were measured using 3Shape scanner system.

Keywords: Color; Changes; CAD/CAM; Bridges; Pediatric; Patient

Introduction

Trauma and/or dental caries is the common causes those result in premature loss of teeth in children. Cosmetic/aesthetic restoration of such condition considers to be challenging in the pediatric dental field. In case of premature tooth loss in anterior incisal segment there will result in arch space loss and teeth’s inclination that causing a collapse of the anterior teeth and midline shifting [1], as well as may lead to parafunctional habits [2]. Mahmoud (2009) found that anterior tooth loss had effect on patient’s quality of life and gave negative effects on him/his [3]. Al Rawi (2017) found that placement of cantilever acrylic bridges for restoring the aesthetic dental appearance of preschool children resulted in positive successes both to the child and parents [4]. Extrinsic discoloration of teeth and oral prostheses is stains caused by foods or beverages. In pediatric patients such stain mostly occurred due to colored foods such as beets or chocolate as well as berries and candies [5, 6]. This study considered to be the first step of our series studies deal with determining different physical and mechanical properties of the prostheses used for pediatric patients we planned to carry out (in vitro and in vivo studies). Starting with the present study that aimed to compare between the color changes of CAD/CAM and manually performed acrylic bridges used for pediatric patients. After immersing the bridges in chocolate solution for different time intervals, color changes of the bridges were measured using 3Shape scanner system.

Material and Methods

This study starting with collection of forty study casts of children aged 2-4 years old of both gender, with prematurely lost one of the maxillary central incisors and the adjacent lateral incisor was carious and considered to be abutment tooth were involved in this study for construction of cantilever bridges (Figure 1). For each cast, two bridges were constructed; 1st one is CAD/CAM acrylic bridge and the other one is manually performed acrylic bridge (Figure 2). Construction CAD/CAM bridge: The cast was 3D scanned by special scanner (710 3D) (smart optics Sensortechnik GmbH, Germany). The design of the bridge was carried out using Exocad Program (smart optics Sensortechnik GmbH, Germany). Acrylic block (Poly-methyl methacrylate) of classic shade A1 (Ivoclar vivadent, Switzerland) was used for fabrication of the bridge using CAD/ CAM machine (Charly dental, ZI Fonlabour, France). The bridge was finished and polished very well [4]. Construction of manually acrylic bridge: Wax pattern was fabricated on cast then followed the technique of typical wax loss; the heat-cure acrylic (Ivoclar vivadent, AG, FL-9494 Schaan/Liechtenstein) of classic shade A1 was used for bridge fabrication. Finally, surface finishing and polishing was done [7]. Saturated chocolate solution was prepared using 15g chocolate powder (MacChocolate TM, Malaysia) with 100ml distilled water. Baseline color readings for acrylic bridges were taken then immersed in chocolate solution for different time intervals (one week and two weeks) and maintained in incubator of 37 °C, Fresh chocolate solution was prepared every day. Before color measurements after one week and two weeks’ time intervals, the bridges were rinsed with distilled water for 30 seconds, cleaned with a soft bristle toothbrush and then dried with tissue paper [8]. Color measurement was carried out in the facial surfaces at the center third of the abutment and the center third of the pontic part of each bridge as shown in Figure 3. Color measurements of the bridges were measured using 3Shape scanner system (3 Shape A/S, Holmens Kanal 7.1060 Copenhagen K Denmark) and according to the software program of the system, Classic shade (Ivoclar vivadent, Switzerland) was depended.

Figure 1: One of the study casts involved in this study

Figure 2: One of the study casts involved in this study

Figure 3: Demonstrated the color shade measurement of the abutment and pontic portions of the acrylic bridge.

Results

Table 1 demonstrated the color shade of all samples at the baseline and after one-week and two weeks-time intervals. The results of the present study revealed that for all samples, the color measurement demonstrated that in CAD/CAM group even with using A1 shade acrylic block but at the baseline measurement the abutment revealed A0 shade while the pontic revealed A1 shade. Meanwhile, in manual group the abutment measured to be A1 shade and the pontic gave B1 shade. The results demonstrated that for all samples there were no changes in the color shade of CAD/CAM and manually fabricated acrylic bridges after one-week time interval, meanwhile, there were significantly color changes of all abutment and pontic portions of all samples of both bridge types after two weeks-time interval immersed in chocolate solution (Figure 4 & 5).

Figure 4: color shade measurement of CAD/CAM acrylic bridge after two weeks.

Figure 5: Color shade measurement of manual acrylic bridge after two weeks.

Table 1: Demonstrated the color shade of all samples at the baseline and after one-week and two weeks-time intervals.

Discussion

Restorations in the oral cavity are exposed to several factors that make them vulnerable to color changes, such as temperature, humidity, food and beverages. In the oral environment, restorative materials are also subjected to numerous other liquids, to temperature and load stress, and to tooth brushing. The success of restorations depends not only on mechanical and physical properties, but also on the esthetic appearance [9]. The color measurement in this study demonstrated that in CAD/CAM group even with using A1 shade acrylic block but at the baseline measurement the abutment revealed A0 shade while the pontic revealed A1 shade. These occurred because the thickness of the abutment was only about 0.5mm lead to that the color measured of the abutment was lighter than the pontic portion. Meanwhile, in manual group the abutment measured to be A1 shade and the pontic gave B1 shade. These results agreed with other studies those found the thickness of the material significantly affected the color shade of the prostheses [10,11].

The results demonstrated that the color changes demonstrated only after two weeks-time intervals immersed in chocolate solution. Even the color shades recorded in the CAD/CAM group considered to be lighter than in manual fabricated group, the discoloration from chocolate solution was probably due to adsorption of color colorant of chocolate solution at the surface of the prostheses.

The CAD/CAM bridges fabricated from blocks of pre-polymerized acrylic resin those had a hydrophobic surface that repels water [12]. As well as, perfect polishing surfaces of the bridges involved in this study revealed the limited discoloration that occurred agreed with other research [13]. As the duration of immersion increased, the color change values of both types of prostheses were recorded by 3Shape scanner system. Thus, the time is considered to be important factor in the staining of the dental prostheses and these results agreed with others [14,15]. Fabrication of dental prostheses with the help of CAD/ CAM technology is related to the advantages of high-density polymers based on highly cross linked polymethylmethacrylate [16]. Those advantages include; good esthetic, low water solubility and absorption, sufficient strength, low toxicity, easy repair with simple fabrication technique [17]. The using of hot cure acrylic for fabrication of dental prostheses even of some advantages but the main disadvantages include porosity with the presence of residual monomer which is a potential allergen, increased finishing time, brittle and uneven thickness [18]. A limitation of this study is that it was an in vitro study and need to be collected with in vivo study to measure the degree of color changes of the prostheses with presenting the effect of saliva and oral hygiene measures. Further clinical and in vitro studies are necessary to evaluate the susceptibility of CAD/CAM and manually acrylic bridges to discoloration by other beverages and nutrients.

Conclusion

Color considered as the most important factors for aesthetic appearance of dental restorations. In addition to the optimal chemo mechanical properties of acrylic resins, their availability in different color-shades has increased their application in fixed and removable prostheses. Acrylic resins can have acquired discoloration over time because of the process of adsorption and liquid molecules adhere to resin materials which was decreased their effect with using of CAD/CAM technology over conventional methods of acrylic resin prostheses fabrication.

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