Chapter 10: Removal of Foreign Bodies

Failure to diagnose the presence of a foreign body has emerged as a common cause of malpractice actions against general practitioners. It is particularly important to locate and remove foreign bodies, especially splinters in children, glass slivers after motor vehicle accidents and pub brawls and metal objects such as needles in the feet of children.

The larvae of the common blowfly can find their way into the most unexpected corners of the body, and can be extremely difficult to remove.

This unusual problem is more likely to occur in unkempt people, such as alcoholics and itinerants, and in those with exposed wounds. Examples of sites that can become infested are the eye, the ear, traumatic wounds in comatose victims, and rodent ulcers.

The eye

The presence of maggots should be suspected when an unkempt person presents with a red eye and with marked swelling (Fig. 10.1). When disturbed, the maggots crawl for cover and are difficult to see and remove.

Method

1. Instil LA (e.g. amethocaine).

2. Instil two drops of eserine or pilocarpine to ‘paralyse’ the maggots.

3. Remove the maggots with fine forceps or flush out.

Wounds

A writhing mass of maggots can be a difficult problem, and has to be rendered inactive. The old ‘trick’ was to use chloroform, but ether is just as effective.

Method

1. Irrigate the infested wound with the anaesthetic until the activity ceases.

2. Carefully remove all the intruders.

Using dextrose

Apply 10% dextrose to the maggots. If unsuccessful apply 50% dextrose.

There are several varieties of leeches in this country, but the most troublesome are the small, black leeches that inhabit the damp forests of New South Wales, Victoria and Tasmania. The major problem is the difficulty of removing a parasite adhering firmly to such awkward anatomical sites as the eye, or the urethral meatus in men.

No attempt should be made to extract the leech manually. There are several methods of inducing leeches to ‘jump off’ rapidly:

• application of hot objects

• application of salt

• application of a detergent

• application of toothpaste

• slicing the leech in half with a knife.

Method

1. Carefully apply a hot object near the end of the leech. The object could be the hot tip of a snuffed out match (Fig. 10.2) or the heated end of a paper clip.

2. The leech soon lets go!

Some species of ticks notably the paralysis tick (Ixodes holocyclus), can be very dangerous to human beings, especially to children. If they attach themselves to the head and neck, a serious problem is posed. As it is impossible to distinguish between dangerous and non-dangerous ticks, early removal is mandatory. Severe toxicity may require assisted ventilator. The tick should be totally removed, and the mouthparts of the tick must not be left behind. Do not attempt to grab the tick by the body and tug. This is rarely successful in dislodging the tick, and more toxin is thereby injected into the host.

As an office procedure, many practitioners grasp the tick’s head as close to the skin as possible with fine forceps or tweezers, and pull the tick out sideways with a sharp rotatory action. There are proprietary tick removal devices that may be effective. This is acceptable, but not as effective as the methods described here.

First aid bush removal method

1. Saturate the tick with petrol, kerosene or insect repellent such as Rid^®, and leave for 3 minutes.

2. Loop a strong thread around the tick’s head as close to the skin as possible, and pull sharply.

Alternative methods

• Apply tea tree oil 12 hourly—leave 24 hours and remove.

• Apply 5% acetic acid firmly onto the tick with a cotton bud. Wait 30 seconds, then slowly turn the end of the bud anticlockwise until the tick is dislodged.

Shock freezing

Freeze the tick with liquid nitrogen Kryospray and remove it in toto.

Lidocaine anaesthetic method

Infiltrate 1% lidocaine under and around the head of the tick. It should then be easily extracted because of immobilisation and eversion of the mouth parts. If not, move on to the office procedure.

Loop of suture material method

1. Select a long length of 3/0 nylon or silk or dental floss.

2. Loop it over the tick and tie a single knot.

3. Holding the nylon flush with the skin, slowly tighten the knot over the neck of the tick.

4. Pull off the tick with a sharp rotatory action.

Office procedure

1. Infiltrate a small amount of LA in the skin around the site of embedment.

2. With a no. 11 or 15 scalpel blade make the necessary very small excision, including the mouth parts of the tick to ensure total removal (Fig. 10.3).

3. The small defect can usually be closed with a Band-Aid (or Steri-Strips™).

Punch biopsy method

A very practical method is to inject local anaesthetic and then use a punch biopsy to remove the entire tick. If the punch will not fit over the tick cut it behind its head and then punch out the head parts. Use a cross pulley stitch (Fig. 1.14) to close the wound.

From time to time one is faced with the need to remove a ring from a swollen finger. Destruction of a possibly valuable piece of jewellery can often be avoided by the following.

Method

1. Using a needle, bent paper clip or bobby pin, pass a length of dental tape (the best), cord or string (or Mersilk) under the ring (Fig. 10.4a). The ring should be over the narrowest part of the phalanx for this.

2. Liberally apply petroleum jelly or moistened soap paste to the finger, distal to the ring. Wind about six turns of the string around the finger close to and immediately distal to the ring (Fig. 10.4b).

3. While holding the end (B) of the cord firmly, pull the proximal end (A) over the ring, roughly parallel to the long axis of the finger, unwinding it steadily in the same direction in which the distal coils were wound originally (Fig. 10.4c). The pressure of the cord is thus applied successively around the periphery of the ring, forcing it distally. The distal cords, by applying pressure, also help to reduce the oedema of the finger.

In many cases the ring slides off with little or no discomfort and without damage to ring or finger.

Sometimes a digital block may be necessary.

The splinter under the skin is a common and difficult procedural problem. Instead of using forceps or making a wider excision, one method is to use a disposable hypodermic needle to ‘spear’ the splinter (Fig. 10.5) and then use it as a lever to ease the splinter out through the skin.

Reactive objects such as thorns, spines and wood should be removed as soon as possible.

Superficial horizontal splinters

These are usually readily palpated under the skin. Apply antiseptic and infiltrate with local anaesthetic. Incise the skin over the length of the splinter using a no. 15 scalpel blade, to completely expose the splinter. Lift it out with the scalpel blade or with forceps.

Alternatively, the overlying skin can be deroofed with a sterile 19-gauge needle in a feathering motion and then speared out with the aid of fine forceps.

The vertical splinter¹

This is more difficult but can be removed by making a superficial circular excision over the splinter followed by a deeper encircling incision to undermine the sides of the wound. The free central block of tissue containing the object can be picked out with fine forceps (Fig. 10.6).

Gently apply an adhesive dressing such as Fixomull^® or Mefix^®. Then remove the prickles by pulling in the direction that they are pointing out of the skin with the grain, otherwise they will break at skin level.

Problem

Finding fine foreign bodies in the skin that are difficult to see, such as cactus spurs and glass slivers.

Method

1. Spread soft soap very lightly over the skin. The soap permits easier identification of the foreign bodies.

2. Remove the foreign bodies with splinter (or other types) forceps.

Alternatively they can be removed with hair removal wax applied to the skin.

High-resolution ultrasound imaging by experienced operators can assist in both the diagnosis and removal of these foreign bodies. Table 10.1 shows the comparative efficacy of X-rays and ultrasound.

CT scans are also very effective.

Identify the 4 cm long rod in the subcutaneous tissue by palpation and the insertion scar. (If not palpable, arrange ultrasound examination.) Infiltrate around the rod with LA. Palpate to identify one end of the rod with your finger. Then manipulate and depress it so that the opposite end ‘tents’ the skin. Make an incision over this pointing end and then blunt dissect around the rod until it is sufficiently exposed to remove with forceps. Also making an incision just prominal to the tenting helps facilitating the tip of the rod out.

A simple tip for detecting subcutaneous metal pieces is to use a magnet and run it over the skin (the larger the magnet the better). If the metal ‘tents’ the skin, this is the site to make the incision.

Six methods of removing fishhooks are presented here, some relying on removal in a direction continuous with their direction of entry to conform with the nature of the barb, others requiring removal in the reverse direction, against the barb. Method 4 or 5 is recommended as first-line management.

Method 1

1. Inject 1–2 mL of LA in front of and then below the hook.

2. Cut the shank with wire cutters or pliers below the eye (Fig. 10.7a). Alternatively, repeated bending at this point will cause the shank to snap.

3. With a needle holder grasp the shank, press the point of the barb through the skin and remove.

Method 2

1. A sharp pull in the direction shown (Fig. 10.7b) will in most cases make the barb continue on its natural path and come out through the skin.

2. It can then be cut off easily and the rest of the hook extracted.

No surgical instruments are required, simply a pair of pliers or wire cutters, but all personnel present should close their eyes when the barb is cut off.

Method 3

1. Inject 1–2 mL of LA around the fish hook.

2. Grasp the shank of the hook with strong artery forceps.

3. Slide a D11 scalpel blade in along the hook, sharp edge away from the hook, to cut the tissue and free the barb (Fig. 10.7c).

4. Withdraw the hook with the forceps.

Method 4

This method, used by some fishermen, relies on a loop of cord or fishing line to forcibly disengage and extract the hook intact. It requires no anaesthesia and no instruments—only nerves of steel, especially for the first attempt.

1. Take a piece of string about 10–12 cm long and make a loop. One end slips around the hook as a double loop, the other hooking around one finger of the operator.

2. Depress the shank with the other hand in the direction that tends to disengage the barb.

3. At this point give a very swift, sharp tug along the cord. (Some find that using a ruler in the loop to flick out the hook is ideal.)

4. The hook flies out painlessly in the direction of the tug (Fig. 10.7d).

Note: You must be bold, decisive, confident and quick, as half-hearted attempts do not work.

For difficult cases, some local anaesthetic infiltration may be appropriate. Instead of a short loop of cord, a long piece of fishing line double-looped around the hook and tugged by the hand will work.

Method 5

This method, regarded by some as the best, involves ‘flicking’ the hook out by traversing its path of entry into the skin.

1. Loop a length of fishing tackle around the eye of the hook.

2. Loop a length of string around the front curve of the hook.

3. Keep the fishing tackle taut by holding it firmly in a straight line with the non-dominant hand.

4. Now pull sharply outwards with the dominant hand so that it flicks the hook out (Fig. 10.7e).

Caution: Take care not to let the hook fly off uncontrollably.

Method 6: The Irish (Castletownbere) method

Principle

Cover the barb of the hook with the bevel of the needle, which must be large enough (e.g. 17G, 19G) to accommodate the tip of the barb. There is then no resistance to its removal.

Method

1. Inject 0.5 to 1 mL of local anaesthetic using an insulin-type syringe into the actual puncture wound, wait 10 minutes.

2. Insert a 19G needle into the entrance wound and feed it along the hook until it is stopped by the barb (ensure that the bevel of the needle is directed towards the hook). The sharp tip of the hook is now inside the lumen of the needle (Fig. 10.8a).

3. Reverse out the hook and needle. Withdrawal is easy as the barb is covered by the stylus of the needle and there is no resistance to bringing it out (Fig. 10.8b).

Helpful tips

• Some barbs are deflected slightly to one side (left or right) on the way back. It is helpful if the patient can bring a sample of the fishhook.

• It can help to practise on a cooked sausage first to convince you how easy it is.

Injuries to the body from various types of guns present decision dilemmas for the treating doctor. The tips below represent guidelines including special sources of danger to tissues from various foreign materials discharged by guns.

Gunshot wounds

Airgun

The rule is to remove subcutaneous slugs but to leave deeper slugs unless they lie within and around vital structures (e.g. the wrist). A special, common problem is that of slugs in the orbit. These often do little damage and can be left alone, but referral to an ophthalmologist would be appropriate.

0.22 rifle (pea rifle)

The same principles of management apply but the bullet must be localised precisely by X-ray. Of particular interest are abdominal wounds, which should be observed carefully, as visceral perforations can occur with minimal initial symptoms and signs.

0.410 shotgun

The pellets from this shotgun are usually dangerous only when penetrating from a close range. Again, the rule is not to remove deep-lying pellets—perhaps only those superficial pellets that can be palpated.

12 gauge shotgun

This powerful gun can produce extensive damage at a range of several metres and are difficult to deal with. Stray pellets are a common finding in rural patients and can be left.

Pressure gun injuries

Injection of grease, oil, paint and similar substances from pressure guns (Fig. 10.9) cause very serious injuries, requiring decompression and removal of the substances.

Grease gun and paint gun

High-pressure injection of paint or grease into the hand requires urgent surgery if amputation is to be avoided. There is a deceptively minor wound to show for this injury, and after a while the hand feels comfortable. However, ischaemia, chemical irritation and infection can follow, with gangrene of the digits, resulting in, at best, a claw hand due to sclerosis. Treatment is by immediate decompression and meticulous removal of all foreign material and necrotic tissue.

Oil injection

Accidental injection of an inoculum in an oily vehicle into the hand also creates a serious problem with local tissue necrosis. If injected into the digital pulp, this may necessitate amputation. Such injections are common on poultry farms, where many fowl-pest injections are administered.

Removal of foreign bodies (FBs) from the nose in children is a relatively urgent procedure because of the risks of aspiration. The same mechanical principles of removal apply to the ear.

The nose should be examined using a nasal speculum under good illumination. The tip of the nose should be raised and pressed with the tip of a thumb. Do not attempt to remove foreign bodies from the nose by grasping with ‘ordinary’ forceps.

Summary of methods of removal

1. It is best to pass an instrument behind the FB and pull it forward. Examples of instruments are:

   • a eustachian catheter (Fig. 10.10a)

   • a probe to roll out FB, e.g. bent wax curette

   • a bent hairpin

   • a bent paper clip.

2. Snaring the FB is the method most suitable for soft foreign bodies (e.g. paper, foam rubber, cotton wool). It is more applicable to the nose. Examples of instruments are:

   • a foreign-body remover (Fig. 10.10b)

   • crocodile forceps (Fig. 10.10c).

3. Application of suction that uses instruments such as:

   • a rubber catheter

   • a fine sucker.

4. Irritation of FBs in nose (e.g. white pepper sprinkled in nose to induce sneezing).

5. Blowing techniques.

Soft foreign bodies

The snaring technique is most suitable for soft objects such as paper, foam rubber and cotton wool.

Method

Under good light and being careful not to push the object further back into the nose, snare the material with either crocodile forceps or a foreign-body remover and gently remove.

Probe technique

The method shown in Figure 10.11 simply requires good vision, using a head mirror or head light and a thin probe.

Method

1. Insert the probe under and just beyond the FB (Fig. 10.11a).

2. Lever it in such a way that the tip of the probe ‘rolls’ the FB out of the obstructed passage (Fig. 10.11b, c).

This technique seems to be successful with both hard and soft foreign bodies.

Bent hairpin technique

This method requires an old-fashioned hairpin (the type with crinkly edges) bent to an angle of about 30°.

Method

1. Push the pin back beyond the FB.

2. Depress the pin to ensnare the object.

3. Gently withdraw the FB (Fig. 10.12).

This method is relatively painless and highly effective; other methods of removing FBs may push them deeper into the nares.

Bent paper clip technique

A simple, effective and disposable instrument can be made with a paper clip.

Method

1. As demonstrated in Figure 10.13, open the paper clip with the hairpin bends at both ends intact.

2. Angulate the smaller end of the clip. The sharp ends of the hairpin bends should be bent towards the straight stems of the clip so that they do not cause trauma. The degree of angulation can be increased by the use of small-artery forceps if desired. The larger loop acts as a handle to get an effective grip.

3. The angulated end, passed gently over the foreign body in the nose or ear canal, acts as a scoop to remove the foreign body.

Note: It is important to remember that only foreign bodies that can easily be seen in the ear or nose could be removed by this method. The paper clip instrument is not suitable for the removal of deeper foreign bodies. Patient cooperation is also very important.

Rubber catheter suction technique

The following is a relatively simple and painless way of removing foreign bodies from the ears and noses of children.

The only equipment required is a straight rubber catheter (large type) and perhaps a suction pump. The procedure causes minimal distress to a frightened child, avoids the need for a general anaesthetic, and is less traumatic than mechanical extraction for objects such as a round bead.

Method

1. Cut the end of the catheter at right angles (Fig. 10.14a).

2. Smear the rim of the cut end with petroleum jelly.

3. Apply this end to the FB and then apply suction.

Oral suction may be used for a recently placed or ‘clean’ object, but gentle pump suction, if available, is preferred (Fig. 10.14b).

It is advisable to pinch closed the suction catheter until close to the foreign body, as the hissing noise may frighten the child.

Pneumatic otoscopic attachment vacuum technique

The following method is ideal for the removal of a foreign body from the nose or ear of a child where it can be very difficult to extract without the use of a general anaesthetic. The method is similar to using a rubber catheter with the end cut off, and applying it to the foreign body using oral suction.

Method

• Use the pneumatic otoscope attachment by removing the end fitting.

• Squeeze the bulb to create a vacuum effect.

• Place the end of the rubber tubing against the foreign body (Fig. 10.15).

• Release the hand-squeeze on the bulb in order to create suction.

• Extract the object.

This method works very well for smooth, round foreign bodies such as beads.

Tissue glue and plastic swab technique

Method

This technique employs the simple method of applying a rapidly setting adhesive to bond the FB to the extracting probe. It works best in dry conditions and for a smooth non-impacted foreign body.

1. Apply a thin coat of cyanoacrylate or tissue glue to the end of a hollow plastic swab stick or orange stick.

2. Insert the stick into the ear canal (or nostril) to allow the glue to bond with the FB (if clearly accessible and suitable) for about 1 minute.

3. Remove the FB using gentle traction, perhaps assisted by external pressure from the fingers.

Caution: Avoid touching the skin or mucous membrane.

If glue is accidentally applied to the skin, dissolve the glue with acetone.

First line blow technique

Press the ‘normal’ nostril and encourage a seated cooperative child to blow out (snort) from the nose.

The ‘kiss and blow’ or ‘mother’s kiss’ technique

This method, also known as the ‘mother’s kiss’ technique, is used for a cooperative child with a firm, round foreign body such as a bead or hard pea impacted in the anterior nares.^2,3

Method

1. Gently occlude the normal (not affected) nostril with a finger. Place the mouth over the child’s mouth, blowing into the mouth until a slight resistance is felt. (This indicates that the glottis is closed.)

2. Then give a sharp high velocity blow (exhalation) to cause the foreign body to ‘pop out’.

To encourage cooperation with the technique the child can be asked to give the doctor a ‘kiss’ (or any ruse to allow placement of the lips over the child’s open mouth). Better still, explain the technique to the child’s parent and encourage the parent to perform it. (Mother is best!)

On all occasions that this technique has been used (adapted from an article in The New England Medical Journal), the foreign bodies ‘popped out’ after two attempts, thus avoiding general anaesthetic with intubation.

If stubborn:

• instill nasal decongestants in the nose, leave 20 minutes and try again.

Cautionary tips:

• Beware of a disc (button) or battery and refer for expert management.

• Be mindful of the risk of aspiration of the foreign body.

The main danger of a foreign body in the ear lies in its careless removal.

Syringing is very effective and safe for small foreign bodies.

Vegetable foreign bodies, e.g. peas, swell with water and are better not syringed.

Insects commonly become wedged in the meatus, especially in the tropics. They can be syringed or removed with forceps under vision.

Maggots cause a painful ear and their removal is difficult—insufflation of pulv. calomel is usually effective treatment.

Live insects should be enticed out or killed by first instilling warm water (first option), saline or olive oil, then syringing the ear with warm water if necessary. The neatest method is to gently drip 4–5 mL of warm water or saline into the ear canal with a syringe, and then snare the insect with forceps as it crawls to the opening. Dead flies that have originally been attracted to pus are best removed by suction. Maggots are best killed by eserine drops, although other fluids should work. Syringing the ear is then appropriate.

Note: 2mL of 1% lidocaine introduced by the blunt end of a syringe or via a cut-off ‘butterfly’ needle (or other piece of plastic tubing) is also effective.

Note: The ingredients in Waxsol^® drops can be a problem. Olive oil can be difficult to syringe so water or saline is preferable.

A moth in the ear

This is a very distressing sensation for the patient, who invariably telephones urgently at night with the problem.

First aid method at home

Instruct the patient to insert drops of lukewarm water, olive oil or a similar preparation into the ear to immobilise the moth (Fig. 10.16a).

Note: Ideally, olive oil should be gently warmed, e.g. by placing the bottle under running hot water from a tap for a short while.

Office procedure

Simply syringe the moth out of the ear with tepid water (Fig. 10.16b).

A common problem is the finding of the cotton wool tip of a ‘cotton bud’ which has become dislodged from injudicious self ear toilet. It can be seen deep in the ear canal.

Method

Obtain a dental broach and fashion a very small hook on the end. When inserted in the ear canal under vision, this hook can easily engage some threads of cotton and then extraction of the foreign body is simple (Fig. 10.17).

Take a history to include the type of fish (cod bones are dangerous!), whether the meal was finished, if the pain is localised and can the patient swallow (water and/or dry bread) without severe pain. After spraying the throat with local anaesthetic, use a frontal mirror and dental mirror to find the bone.

A fish bone usually lodges in the tonsil or at the base of the tongue, in which case it can be seen on oral examination. If it cannot be seen, more thorough examination by nasopharyngoscopy is required.

To overcome the difficulty of not having a spare hand to remove the bone, use a laryngoscope, having localised the bone, and remove with packing forceps or intubation forceps.

If there is severe pain and muscle spasm, or a positive X-ray, give an intramuscular antibiotic and refer to an ENT service.

The patient has accidentally entrapped the foreskin of his penis in his ‘fly’ zipper. He will already have tried to extricate himself, and further manoeuvring will not only be painful but will continue to impact the skin. It is worthwhile initially to lubricate the zipper with mineral oil and make one attempt to unzip it.

The following are simple and effective techniques, which free the skin but ruin the zipper.

Simple ‘first pass’ method

Grasp the upper free zip lines with each hand, then rapidly and forcefully separate them outwards and downwards. The zipper usually falls down and releases the entrapped foreskin. It is usually quite painless.

Instrumental methods

Method A

1. Cut the zipper from the trousers for access.

2. Infiltrate LA beneath the entrapped foreskin, or infiltrate the skin at the base of the penis (ring block).

3. Grasp the zip fastener with pliers or any similar ‘crushing clamp’. Apply pressure until the zip breaks and the skin is freed (Fig. 10.18a).

Method B

Alternatively, cut across the closed section of the zipper, keeping as close as possible to the fastener (Fig. 10.18b), with a suitable instrument such as a sharp scalpel, and the zipper will fall apart.

Method C

After infiltrating the area with LA, obtain a diagonal type wire cutter and cut the median bar on the top of the zipper slider (Fig. 10.19). The slider then falls apart into two pieces and the zipper teeth can be readily separated.⁴

The problem associated with this procedure is the unpleasant odour that envelops the surgery, causing considerable embarrassment to both patient and doctor.

Management

Under good vision, the tampon is seized with a pair of sponge-holding forceps and quickly immersed under water. A bowl of water (an old ice-cream container is suitable) is kept as close to the introitus as possible. This results in minimal malodour.

Method

1. Inspection: usually in the Sims position with a Sims speculum (other positions can be used).

2. Removal: the tampon is grasped with a sponge-holding forceps (dorsal position; Fig. 10.20a).

3. Disposal: the tampon is quickly plunged under water without releasing the forceps (Fig. 10.20b). The tampon and water can be immediately flushed down the toilet (except in septic tank systems or where drainage problems exist).

It may be preferable to use another disposal method, such as taking the forceps and tampon outside and inserting the tampon into a self-sealing plastic bag.

Note: The Master Plumbers Association warns against flushing tampons down toilets because of their tendency to block systems.

Gloved and extraction method

The tampon can be grasped with the gloved hand and then invaginated into the glove, which acts as a receptacle for disposal.

Faecal impaction, manifested as an aggregation of hard faeces in the rectum on rectal examination and associated with constipation or spurious diarrhoea, can be a difficult problem. It often presents in children and the elderly. A good method of doing a rectal examination on a home visit (in the absence of gloves in the doctor’s bag) is to apply moist soap around the finger and caked under the nail (in case of breakage), then plastic wrap and finally petroleum jelly (e.g. Vaseline^®).

Before resorting to a good, old-fashioned ‘3H’ enema (hot water, high, and a hell of a lot) use a Microlax^® 5 mL enema. This can be carried in the doctor’s bag, is very easy to insert and most effective.

Manual disimpaction

Rarely, one has to resort to manual disimpaction, which is a most offensive procedure for all concerned. However, the procedure can be rendered virtually odourless if the products are milked or scooped directly into a pan or preferably a container of water with a fragrant disinfectant such as Pine O Cleen. A large plastic cover helps to restrict permeation of the smell.

Discomfort and embarrassment are reduced by this and adequate premedication (e.g. intravenous diazepam, or even IV morphine if hard faecoliths are present).

Manual removal of a vibrator or similar object from the vagina usually presents no problem, but removal from the rectum (if high) can be difficult without general anaesthesia.