Patterns and Clinical Presentation of Foreign Bodies in ENT among Sudanese Children in Khartoum State Hospitals

Background: Foreign bodies (FBs) in ENT are a common problem in Sudanese children and are associated with life threatening complications. Objectives: To study the patterns and presenting symptoms of children who are presented with foreign bodies Inhalation, Ingestion and insertion in the Nose and Ears. Methodology: This is a prospective hospital based descriptive study, conducted at Khartoum ENT Hospitals fromMarch 2013 to January 2015. Result: 150 patients with foreign bodies were studied in Khartoum ENT Hospitals. The commonest age group between 3–6 years in 64% of patients. Male to Female ratio is1.3:1. F.Bs nose constituted higher percentage in (28%) of cases, F.Bs inhalationswere presented in (24.7%), F.Bs earwere presented in (24.7%) and F.Bs ingestion were presented in (22.7%). Regarding the type of inhalations, peanut was presented in (56.8%) of cases and the commonest presenting symptoms was cough in (94%) of patients. Conclusion: Certain food items especially peanuts if given to children below the age of 2 years have to be given with caution and under close supervision. Bronchoscopy should always be considered in optimum conditions. Public health education is essential in order to prevent these avoidable problems.


Literature Review
Foreign bodies (F.Bs) lodged within the ear, nose, larynx, trachea, pharynx and esophagus may present as a minor irritation or a life-threatening problem [1].
Multiple F.Bs are not uncommon, especially in small children, so all other orifices of the head should be inspected after removal of a foreign body from the external auditory canal [10].
Balbani AP, et al report that F.Bs are inserted into the ears more commonly by school children than by toddlers.In a review of 191 aural foreign bodies, 74 percent were in children aged from 6 to 12 years, small toys being the most common objects [6,7].
Nasal F.Bs tend to be located on the floor of the nasal passage, just below the inferior turbinate, or in the upper nasal fossa anterior to the middle turbinate [13].
All pharyngeal F.Bs are medical emergencies that require airway protection, because complete airway obstruction may occurs at the time of aspiration and results in immediate respiratory distress and so emergency intervention is essential.Common obstructing F.Bs in children include balloons, pieces of soft deformable plastic, and food boluses [15].
The most common F.Bs in the throat are pieces of plastic, metal pins, seeds, nuts, bones, coins, and dental appliances [1,2].
Radiography can be helpful in localizing coins, button batteries, and other radiopaque objects, but most pharyngeal F.Bs , including fish bones, are radiolucent [12,14].
Foreign Body aspiration by children in Sudan is not uncommon; especially those below the age of 5 years.Children are at risk because of their curious nature, strong oral tendency and lack of molar teeth.It usually affects the larynx and trachea and rarely the lungs [8,16].
Sharfi AO reported that a total of 150 bronchoscopies were performed: 89 cases (56%) were below 2 years of age; 45 cases (30%) were between 2-5 years; and 18 cases (14%) were over 5 years of age.In 88 cases (58.7%) the foreign bodies inhalations foreign bodies were peanuts and in 27 cases (18%) were watermelon seeds, and most of the foreign bodies were found in children under five years of age.
Pins and needles were found in 8cases (5.3%) mostly in teenage females and most of the FBs (82.7%) were radiolucent showing minimal or no X-ray findings [18].
Yagi H reported that in Sudanese patients, most common FBs in the bronchi are peanuts (Arachis hypogea), and roasted watermelon seeds (citrillus vulgaris) and there are three clinical phases with children presenting with foreign bodies inhalation, which consist of chocking, gagging and paroxysms of coughing or airway obstruction.Plain X-rays of the chest were not helpful in the diagnosis, except in few cases (9.5%)where the FBs were radio-opaque.Foreign body bronchus is usually removed successfully by rigid bronchoscopy [3].

Patients and Methods
It is a prospective hospital based descriptive study, conducted at Khartoum ENT, IbnSina and Africa Hospital in Sudan from March 2013 to January 2015.

Inclusion Criteria
Both males and females and patients of age groups below 16 years.

Data Collection
Data collection was achieved through well-designed questionnaire covering demographic clinical information.

Data Analysis
Data analysis was by using SPSS program.Data presentations were through tables, figures, percentages and cross tabulation (P.V ≥ 0.05).

Ethical Considerations
Ethical clearance was taken from the hospital administrations and then I explained verbally to any patient the aim of the study, data collection, the need of investigations and regular follow up.Privacy of patient is the most of our priority

Results
A total of 150 patients with F.Bs were studied in Khartoum ENT Hospitals.Twenty-seven patients (18%) were below 2 years of age, 96 patients 64% were between 3-6years, and 27 cases (18%) were above 6 years of age table (1).
Concerning the gender of patients 86 of them (57.3%) were male and 64 patients (42.7%) were female, and male to female ratio was 1.3:1 fig ( 1).
Regarding clinical presentation, 31 of patients (83.8%) brought to medical attention by their parents and complained that, their children inserted foreign bodies in their ears.Five of them (13.5%)presented with aural pain and heaviness in three patients (8.0%).Hearing impairment and Otorrhoea were present in four patients (10.8%) table (7).F.B nose was found in 42 cases (28%); 27 of them (64.3%)inserted vegetables, 11patients (26.2%) inserted plastic material and 4 patients (9.5%) inserted metallic material table (8).all admissions and almost two third of the surgical emergencies in the ENT hospitals.
This reflects a significant large work load exerted by this important age group [4,19].
Apart of the children neglected and disturbed the house environment are predisposing factor for foreign bodies impaction, this agree with Osman W.N. and Elmustafa [6,19].
Foreign bodies aspiration is a life-threatening condition.In this study, it was found that less than 2years (45.9%) are the most affected group and this agree with El-Mustafa O.M. and Sharfi A.O [4,8,18].Foreign bodies aspiration was the most common indication for surgical intervention in children below five years.This has been attributed to anatomical factors such as poor chewing ability, wide and high larynx compare with adult, physiological factors such as poor refluxes and protective mechanism, developmental factors as this the age of exploration of things, this agree with Osman W.N. and Elmustafa [11,19].
In our study (64.9%) were from rural areas, while 54 patients (35.1%) came from urban areas.This was naturally expected, as the peanuts which are common FBs in our series (56.8%), were planted.Mainly in rural areas and the community is not aware of the hazards of peanuts, and this agree with Sharfi A.O [18].
Peanuts were found in children below the age of 5 years,while plastic and metallic foreign bodies were encountered in older children and teenagers, and this agrees with Sharfi A.O [18].
Organic foreign bodies are liable to cause laryngotracheobronchitis and predispose to lung infection.Therefore, inhaled FB should be suspected in children with history of repeated chest infection not responding to antibiotics, this is also reported by Sharfi A.O [4,18].
Foreignbody esophagus was a common problem in the Sudanese children.There was 73.5% male preponderance and it was clear that the commonest type of foreign bodies was coins (67.9%), and this agrees with Silsuoa A [20].
Dysphagia was the commonest presenting symptom (94.1%), and patients presented immediately to the out-patient complaining of discomfort, especially when the foreign body was impacted in the hypopharynx or the cervical esophagus, this in agreement with Silsuoa A [20].
Foreign body nose was a common problem in children between (3-4) years and the commonest gender (64.2%) was female.The commonest type of foreign bodies were vegetables, and this is similar to Kadish H.A [5].
Nasal obstruction is a major presenting symptom in the first three days (85.7%), after that children presented with unilateral offensive discharge (21.9%), and this was similar to Kalan A [9].
Foreign body ear was common in children more than six years and (59.4%) were female, which was the commonest gender, this in agreement with Balbani A.P [7].
The commonest type of foreign bodies in the ear of Sudanese children were Adasia (37.8%) which is different from Balbani A.P, et al who report that, small toys being the most common objects in (43%) [7].
As for the ear this perhaps the only site that early patients were asymptomatic, but reported with a positive history of insertion of foreign body (56.8%) by one self or by another.Patient may present with multiple foreign bodies, this agree with Thompson S.K. et al [10].
F.B bullet Rt nose F.B on the Ear F.B bone in the hypopharynx

Conclusion
F.Bs in ear, nose and throat are a common problem in Sudanese children.In this study the authors found , the nose was the commonest site for FBs, while the second sites were the ear and inhaled foreign bodies but the ingested foreign bodies were the least.It is noted that there was no highly gross difference in the percentages.The commonest inhaled foreign body (56.8%) were peanuts.As for the ear, nose and ingested foreign bodies ,Adasia, plastic materials and coins were the most encountered foreign bodies respectively.As for the commonest presenting symptoms cough in inhaled F.Bs,dysphagia in ingested ,obstruction in the nose.Most patients (82%) were below the age of 6 years and most (70.7%) were of low socioeconomic status.

Figure 1 :
Figure 1: Gender distribution among the patients.

Figure 2 :
Figure 2: Residence distribution among the patients.

Figure 3 :
Figure 3: Socio-economic status of the patients.