Emergency Medicine

NON-TRAUMATIC CONDITIONS OF THE THROAT

406 ENT emergencies

2 Otherwise, attempt to remove a fish bone from the tonsil or the back of the

tongue using Tilley’s curved forceps.

(i) Refer the patient immediately to the ENT team if this fails in a

patient with pain or who is salivating excessively.

3 Alternatively, the pharyngeal mucosa may only have been scratched. If

symptoms are minimal, prescribe an antibiotic such as amoxycillin 500 mg

orally t.d.s. and ask the patient to return in 24 h for review.

Swallowed foreign body

DIAGNOSIS

1 Coins are the most common objects swallowed by pre-school children,

although small children swallow almost anything, and the elderly may

swallow their dentures.

2 Oesophageal impaction, usually around the cricopharyngeus at the level of

C6, causes dysphagia, excessive salivation, local tenderness or retrosternal

pain, but may be asymptomatic.

3 Occasionally, airway obstruction occurs from upper oesophageal impaction,

or t he object may in fact have been inha led, not swa llowed (see p. 354).

4 Button batteries

These pose a particular risk, as they may cause local corrosive effects or

mucosal perforation with later stenosis, particularly in the oesophagus, and

sometimes in the stomach if they disintegrate.

5 Request X-rays of the neck and chest to look for oesophageal impaction.

(i) Include anteroposterior (AP) and lateral views to avoid missing

a radio-opaque object superimposed over the skeletal or cardiac

shadows on the AP view, and to differentiate tracheal lodgement.

(ii) Also request an abdominal X-ray in button-battery ingestion

and/or for symptoms such as abdominal pain, distension,

diarrhoea or gastrointestinal bleeding.

MANAGEMENT

1 Refer the following patients immediately to the ENT team:

(i) Airway obstruction or foreign body inhalation (rather than

ingestion).

(ii) Oesophageal impaction suspected clinically.

(iii) Oesophageal lodgement seen on X-ray or inferred from pre-

vertebral soft-tissue swelling, soft-tissue gas, or air in the upper

oesophagus.

(iv) Button battery seen in the oesophagus or stomach.

2 Allow the patient home, if the patient is asymptomatic, and neck and chest

X-rays are normal.