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EN2.10 | ENT Emergency Simulation Workflow — SDL Guide (Part 2)

Foreign Body Removal Technique by Site

Foreign body removal in the ENT region requires site-specific technique because the same mistake — pushing the FB further inward — has catastrophically different consequences at different sites: a nasal FB pushed posteriorly may be aspirated into the larynx; a laryngeal FB converted to a bronchial FB removes it from easy retrieval; an oesophageal FB that reaches the stomach may perforate the bowel. The unifying principle across all ENT foreign body sites is therefore: always work anteriorly (toward the outside), never push inward. The instruments, the patient position, and the specific technique at each site are all designed to implement this principle safely. In addition to the direction principle, each site has a contraindication that overrides the standard technique: ear syringing is contraindicated if the FB is a seed (it swells on contact with water) or if TM perforation is suspected; nasal positive-pressure technique requires the child to be cooperative; laryngeal FB management escalates from coughing to Heimlich manoeuvre to emergency airway in a rapid stepwise sequence without time for hesitation. Knowing these contraindications in advance is what allows you to make the correct technique choice immediately, rather than starting a wrong technique and having to abandon it mid-procedure.

Ear foreign body:
Common FBs: beads, seeds, insects, cotton bud tips. Technique depends on the FB type:
- Hard inanimate FBs (smooth, round): Remove with a wax hook or a right-angled hook by passing the hook behind the FB and drawing it out — never use forceps (grasping a smooth FB with forceps pushes it deeper). Suction can also be used for small FBs.
- Insect: Kill the insect first with a few drops of olive oil or lidocaine before attempting removal — a live struggling insect causes pain and trauma. After killing, use suction or gentle syringing.
- Syringing (ear irrigation): Use warm water (body temperature — cold water causes caloric nystagmus and vomiting) with a syringe and nozzle directed at the posterosuperior canal wall. CONTRAINDICATED if TM perforation is suspected or if the FB is a seed (seeds absorb water and swell, making removal impossible).
- Button battery: REMOVE IMMEDIATELY — do not observe; electrical and chemical necrosis begins within 1–2 hours.

Nasal foreign body:
Most common in children aged 2–5 years; may present with unilateral purulent, offensive, bloodstained nasal discharge (FB lodged for days/weeks). Technique:
- Never push the FB posteriorly — risk of aspiration.
- Positive pressure technique ("parent's kiss"): The parent blows into the child's open mouth while occluding the unaffected nostril — positive pressure in the nasopharynx may expel the FB anteriorly. Requires a cooperative child and parent.
- Jobson-Horne probe / Tilley-Henkel forceps: Under headlamp vision, pass the probe behind (posterior to) the FB, then sweep it anteriorly to dislodge the FB. Forward traction, never posterior.
- Foley balloon catheter: Pass beyond the FB, inflate, then withdraw — brings the FB with it.
- Under GA: required for uncooperative children, impacted FBs, or suspected aspiration.

Throat and laryngeal foreign body:
A foreign body in the larynx is an IMMEDIATELY LIFE-THREATENING emergency. Signs: sudden onset coughing/choking, stridor, cyanosis, drooling, inability to speak or cry (complete obstruction). Initial management:
- Conscious patient: Encourage coughing. If coughing is ineffective: Heimlich manoeuvre (abdominal thrusts) in adults and children >1 year; 5 back blows + 5 chest thrusts in infants <1 year.
- Unconscious patient: Begin CPR; look in the mouth before each breath for a visible FB — remove only if visible and easily accessible (do NOT perform blind finger sweeps).
- If the airway cannot be cleared: cricothyroidotomy or emergency tracheostomy.
- Hospital management: rigid bronchoscopy under GA (Chevalier Jackson/Hopkins rod system) for FB below the vocal cords; forceps retrieval under vision.

Oesophageal foreign body:
Common FBs: fish bones, coins (especially at the level of the cricopharyngeus/Killian's dehiscence at C6, or at the aortic arch/left main bronchus level, or at the lower oesophageal sphincter). Presentation: dysphagia, drooling, pain on swallowing. X-ray: coins are visible on AP view (round, in coronal plane in oesophagus) — fish bones and soft tissues require barium swallow or CT. Management: rigid oesophagoscopy under GA — the instrument of choice for removal.

Interpreting and Prioritising ENT Emergency Presentations

Triage in ENT emergencies requires rapid integration of the presenting symptoms, vital signs, and anatomical level of the problem. The three-tier framework — immediately life-threatening, urgent, non-urgent — provides the decision structure for prioritisation when multiple ENT emergencies arrive simultaneously, as in the hook scenario. The interpretive skill here is not technical but clinical: it requires reading the whole patient (conscious level, colour, respiratory effort, haemodynamic state) simultaneously with the presenting complaint, and making a priority judgment in seconds. This is a skill that cannot be acquired purely from textbooks — it requires simulation, which is why EN2.10 is the one ENT competency that explicitly specifies a simulated environment as the standard. The principles below translate the three-tier framework into concrete, patient-specific priority decisions and provide the interpretive clues that determine when a clinical situation has escalated from one urgency tier to the next — the most practically important of which is recognising that anterior packing has failed and a posterior bleed is present, and recognising that a laryngeal FB is not clearing and emergency airway intervention is required.

The priority-ordering for the hook scenario:

1. The child with stridor and cyanosis (FB in larynx) — FIRST. Cyanosis = hypoxia = imminent cardiac arrest. Begin Heimlich manoeuvre / back blows immediately; call for anaesthesia and ENT simultaneously; prepare for emergency airway. Delay here means death within minutes.

1. The adult with facial trauma and failed intubation — SECOND (if both arrive simultaneously, this patient is also immediately life-threatening). Perform cricothyroidotomy. This is performed in parallel by a second clinician if available.

1. The hypertensive epistaxis patient — THIRD among the three presented. He is actively bleeding and requires urgent treatment, but is not immediately dying — he is haemodynamically compromised, not in arrest. Sit him forward, apply pressure, assess for posterior bleed, establish IV access, check BP. Anterior packing while monitoring vitals.

Clinical clues that an epistaxis is posterior (and cannot be controlled by anterior packing):
- Blood flowing from BOTH nostrils simultaneously
- Blood in the oropharynx despite anterior packing
- Elderly patient with hypertension
- Anterior packing placed correctly but bleeding continues
- High volume, arterial-type bleeding

Clinical clues that a laryngeal FB is not being cleared by the Heimlich manoeuvre:
- Patient becomes unconscious
- Cyanosis deepening
- Air entry inaudible on auscultation bilaterally
These are indications for emergency airway (cricothyroidotomy).

Applied Practice: ENT Emergency Simulation Scenarios

Simulation practice is the mandatory preparatory step for the EN2.10 OSCE because the standard expects not just knowledge but demonstrated skill in a simulated environment. Each scenario below should be acted out fully — state the diagnosis, state the urgency tier, and describe each step of your management as you would perform it.

Simulation 1 — Epistaxis in a hypertensive elderly patient:
A 70-year-old hypertensive male is brought by ambulance with severe bilateral epistaxis. BP 190/110, HR 96, SpO₂ 95%. He has been bleeding for 1 hour. First-aid measures by the ambulance crew have not controlled the bleeding. Blood is visible in the posterior pharynx.
Management: (1) Sit upright, lean forward. (2) Establish IV access; send FBC, coagulation screen, group and save. (3) Check anticoagulant medications. (4) Topical vasoconstrictor to nasal cavity. (5) Attempt anterior packing bilaterally with Merocel; check for posterior flow. (6) If anterior packing fails and blood continues in the posterior pharynx = posterior bleed: insert a Foley catheter (14 Fr) through the more severely bleeding nostril to the nasopharynx, inflate the balloon with 10–15 mL saline, and apply traction. Anterior pack over the Foley. (7) Admit; aggressive BP management; ENT review for endoscopic sphenopalatine artery ligation if packing fails.

Simulation 2 — Coin in the larynx (child):
A 2-year-old child is brought in choking. She is cyanotic, cannot cry, has inspiratory stridor. A coin is suspected.
Management: (1) Assess — this is a COMPLETE AIRWAY OBSTRUCTION. (2) Call for help immediately (paediatrics + ENT + anaesthesia). (3) Position: hold child face down along your forearm, head lower than the body. Apply 5 firm back blows between the shoulder blades. Flip to face-up: 5 chest thrusts (two fingers on the lower sternum, not the abdomen — Heimlich is for adults/children >1 year; chest thrusts for infants). (4) If partially effective and child regains partial airway — go to resuscitation room. Do NOT perform blind finger sweeps. (5) If unconscious: begin CPR; look in mouth for visible FB before each breath. (6) Partial obstruction + able to cough: encourage coughing, monitor; go to theatre for rigid bronchoscopy. (7) If no response and complete obstruction: emergency needle cricothyroidotomy as bridge to rigid bronchoscopy.

Simulation 3 — Button battery in the nose:
A 3-year-old has had a small disc ('button battery') placed in the left nostril by herself, discovered 2 hours ago. There is already a slight inflammatory reaction at the vestibule.
Management: This is a REMOVE IMMEDIATELY situation — do NOT wait for a specialist appointment or the next available theatre slot. The battery generates an electric current that causes liquefactive necrosis of the nasal septum, potentially within 4 hours. Attempt removal in the emergency department with adequate visualisation; if unable (deep, swollen tissue, uncooperative), take to theatre for immediate removal under GA. Document the time of insertion if known.