THE ENT BEAT

BY DR HARDIP SINGH GENDEH

Dr Hardip Singh Gendeh is a lecturer at the Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia. Dr Hardip is also an ear, nose and throat( ENT) surgeon at Hospital Chancellor Tuanku Muhriz( HCTM), UKM.

We shall dive deeper and explore foreign bodies and choking. Having researched foreign bodies in Malaysia, I would like to contribute to the existing literature.

FOREIGN BODIES

A foreign body is an object that does not belong to one ' s body. It is easier to categorise into:

Organic- can be broken down or digested by the body. It includes cooked food, vegetables, wood etc.

Inorganic- processed substances that cannot be broken down, such as metal objects and plastic.

A study performed at the Faculty of Medicine, Universiti Kebangsaan Malaysia( UKM), demonstrated that despite inorganic foreign bodies being more common, children also share a fair share of organic foreign bodies.

Adults, on the other hand, presented with a higher rate of organic foreign bodies, owing to fish bone ingestions, a phenomenon more common in this region, as fish are often eaten whole with bones intact.

Surprisingly, many foreign body ingestions occur at home rather than in schools. Therefore, the risk of choking among children does not only involve food, such as soft candies but also other household objects. A large proportion of choking occurred when the child was playing and not witnessed despite having parents or guardians at home.

THE DATA

The Susy Safe project is an initiative in Europe to report and record the occurrence of choking in children

A bead in the right ear canal

involving multiple nations. According to the Susy Safe report, choking on foreign bodies( food or toys) is the highest cause of death among children under three years of age and is at risk of occurring in children up to the age of 14.

Evidence based data showed that children are also more likely to choke on peanuts, button batteries and magnets, items that may be lying around one ' s household. Furthermore, children may choke on beads and decorative items from clothing that is either being plucked from the guardians ' clothes upon a shoulder carry or strewn on the floor.

Button batteries do not only pose a choking risk but may cause ulceration and a hole formation within the airway or swallowing pipe if left for several hours. This occurs due to small electrical currents produced by the battery in a moist environment, as well as chemical burns from substances released due to higher body temperature.

The swallowing of magnets into the gut may attract each other across the gut wall and cause complications such as gut obstruction and the creation of abnormal pathways between the guts.( see Perspective Chapter: Classification and Complications of Aerodigestive Button Batteries and Magnets by Gendeh et al. Published by Intech open)

Lately, there have been many large and chewy sweets, or ' soft candy,' that have become viral on social media. Furthermore, we have recently lost a child, a decade old, from choking a soft candy in the shape of a human eyeball.

Consider this:

• Its chewy nature changes shape, making it difficult for the child ' s teeth to chew before it is swallowed into the stomach. Therefore, it is not suitable for small children who have not yet grown teeth or do not have strong teeth.

• Its elastic property also allows it to change shape without breaking into small sizes. Therefore, large and round chewy candies should be avoided because when swallowed whole before chewing, they may conform to the surrounding tissue, resulting in an obstruction to the airway,

A metallic object( coin) seen in the throat of a child. From a radiograph, it is sometimes difficult to differentiate a coin from a button battery.

particularly in children under five years old.

• Due to the increased effort in chewing, our salivary glands are being forced to produce large amounts of saliva. This further contributes to the risk of choking.

• Pliable and round objects, as well as food, have been shown to pose a higher risk of choking compared to solids.

Soft candies are made in interesting colours, with tasty flavours and a plethora of shapes, often becoming an object of envy and attraction to our children. The UKM study also concurred with others that spherical-shaped food is more likely to cause choking. Brightly coloured food or foreign objects are more likely to become foreign in the ear, nose or throat because it gives more attraction to the child.

Object size and shape are key factors in determining the risk of choking. Europe uses the ' cylinder test ' or ' small parts cylinder,' with a diameter of 3.7mm, to gauge the risk of choking. Suppose the object does not fit snugly and easily passes through the cylinder. In that case, it is deemed inappropriate for children aged three and below due to choking risk, necessitating a clear warning on the label.

WAY FORWARD

Circumventing choking incidences is a shared responsibility of all. There is a need to consolidate local or national data regarding the risk of choking and a mechanism for easy reporting of choking among children in Malaysia. Data is vital for evidence-based medicine in guiding the industry to produce age-appropriate food or toys in the need to reduce the risk of choking among children.- The HEALTH