16 Foreign bodies

Introduction
Many different objects may enter body tissues and cavities under
a variety of circumstances. The main methods of entry are:

percutaneous
ingestion
inhalation
Photograph of samples of wood, glass and metal objects
insertion
transocular.
If the foreign body is non-metallic and a similar sample of the
object is available, then the sample may be placed in a few centi-
metres depth of water in a non-opaque container and radio-
graphed to establish its radio-opacity. The method adopted to
demonstrate the presence and position of a foreign body is gov-
erned by its size and degree of opacity and its location. Unless it
is radio-opaque or in a position where it can be coated with
opaque material to render it visible as, for instance, in the
alimentary tract then the foreign body cannot be shown on a
radiograph. Partially opaque foreign bodies, such as wood, some
Radiograph of the objects seen above X-rayed through a wax block note
types of glass and other low-density materials, may sometimes the thin sliver of wood and thorn wood is barely visible
be shown by suitable adjustment of the kVp.
Although the spatial resolution of computed radiography
(CR) and direct digital radiography (DR) may be inferior to
conventional imaging, the electronic post-processing capabil-
ities of these systems more than compensate. The ability to
adjust the image using image magnification, edge enhancement
and windowing tools make the presence of a foreign body more
easily visualized. Additionally, the contrast resolution of CR and
DR is greater than that of conventional imaging, making it pos- Images of a left knee acquired using a computed radiography system: left,
sible to visualize foreign bodies previously not seen on radio- windowed for normal viewing; right, windowed for soft tissues (here
graphs (e.g. splinters of wood). demonstrating more clearly a joint effusion in the suprapatellar bursa)
Removal of bulky dressings from soft tissue lacerations is rec-
ommended, especially when using CR and DR, as these artefacts
become more obvious on the image and can obscure radio-
opaque foreign bodies such as glass fragments. Matted blood in
the hair can also prevent glass splinters in the scalp from being
seen.
Ultrasound is useful in the localization of non-opaque subcu-
taneous foreign bodies and the genital system.
CT or magnetic resonance imaging (MRI) may be used when
it is necessary to demonstrate the relationship of a foreign body
to internal organs.

Notes
MRI must not be undertaken if there is any possibility that
the foreign body is composed of ferromagnetic material.
Before commencing any examination, it is important to
ensure that no confusing opacities are present on the cloth-
ing, skin or hair on the tabletop, Bucky, cassette or intensify- Lateral neck image showing the effect of braided hair with streak-looking
ing screens, or on the Perspex of the light-beam diaphragm. structures superimposed over the soft tissue neck region

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Antero-posterior and lateral images of a right elbow demonstrating
multiple needle insertions
Dorsiplantar and lateral images of the thumb showing embedded nail
in the distal soft tissues
Examples of glass foreign bodies illustrating that the density on the image
will vary depending on the thickness and lead content of the glass
Foreign bodies 16
Percutaneous foreign bodies
These are commonly metal, glass or splinters of wood associated
with industrial, road or domestic accidents and self-harm injuries.
Generally, two projections at right-angles to each other are
required, without movement of the patient between exposures,
particularly when examining the limbs. The projections will nor-
mally be antero-posterior or postero-anterior and a lateral of the
area in question, as described in the appropriate chapters.
A radio-opaque marker should be placed adjacent to the site of
entry of the foreign body. The skin surface and a large area sur-
rounding the site of entry should be included on the images, since
foreign bodies may migrate, e.g. along muscle sheaths, and high-
velocity foreign bodies may penetrate some distance through the
tissues.
Compression must not be applied to the area under examination.
Oblique projections may be required to demonstrate the rela-
tionship of the foreign body to adjacent bone. A tangential (pro-
file) projection may be required to demonstrate the depth of the
foreign body and is particularly useful in examination of the
skull, face, and thoracic and abdominal walls. Sometimes a sin-
gle tangential projection may be all that is required to show a
superficial foreign body in the scalp or soft tissues in the face.
The exposure technique should demonstrate both bone and
soft tissue to facilitate identification of partially opaque foreign
bodies and to demonstrate any gas in the tissues associated with
the entry of the foreign body.
The most usual exposure techniques for conventional radiog-
raphy are:
kVp sufficiently high to demonstrate bone and soft tissue on
a single exposure;
use of two film/screen combinations of different speeds or a
film/screen combination and non-screen film to demonstrate
bony detail on one film and soft tissue on the other film with
one exposure.
The use of digital image acquisition offers significant advantages
in the localization of foreign bodies. CR and DR both allow soft
tissue and bone to be visualized from one exposure using post-
processing. The use of features such as edge enhancement and
windowing enable much better demonstration of foreign bodies
that have radio-opacity similar to that of the surrounding tissue.
Tangential (profile) projection of the scalp showing glass embedded
in the soft tissues
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16 Foreign bodies
Ingested foreign bodies
A variety of objects, such as coins, beads, needles, dentures and
fish bones, may be swallowed accidentally, or occasionally
intentionally, particularly by young children. A technique used
to smuggle drugs through customs involves packing the sub-
stance into condoms, which are subsequently swallowed.
The patient should be asked to undress completely and wear
a hospital gown for the examination. The approximate time of
swallowing the object and the site of any localized discomfort Antero-posterior and lateral images showing a coin lodged in the upper
should be ascertained and noted on the request card, along with oesophagus of a child
the time of the examination. However, any discomfort may be
due to abrasion caused by the passage of the foreign body. It is
important to gain the patients cooperation, especially in young
children, since a partially opaque object may be missed if there is
any movement during the exposure. The patient should practise
arresting respiration before commencement of the examination.
If the patient is a young child, then the examination is usually
restricted to a single antero-posterior projection to include the
chest, neck and mid- to upper abdomen. The lower abdomen is
usually excluded, to reduce the dose to the gonads, as the
examination is usually performed to confirm the presence of a
foreign body lodged in the stomach unable to pass through the
pylorus. Care must be taken to ensure that the exposure
selected is sufficient to adequately penetrate the abdomen as
well as to visualize the chest.
The examination of older children and adults may require a
lateral projection of the neck to demonstrate the pharynx and
upper oesophagus, a right anterior oblique projection of the Watch battery in transit in the Antero-posterior abdomen image
alimentary tract showing multiple condoms filled with
thorax to demonstrate the oesophagus, and an antero-posterior drugs lodged in the lower abdomen
abdomen projection to demonstrate the remainder of the ali- causing small bowel obstruction
mentary tract, exposed in that order. Each image should, prefer-
ably, be inspected before the next is exposed, and the examination
terminated upon discovery of the foreign body, to avoid unnec-
essary irradiation of the patient. The cassette used should be
large enough to ensure overlapping areas on adjacent images.
Non-opaque foreign bodies may be outlined with a small
amount of barium sulphate. A few cases require a barium-
swallow examination. If no foreign body is demonstrated within
the alimentary tract, and particularly if there is doubt as to
whether the foreign body has been ingested or inhaled, then a
postero-anterior projection of the chest will be required to
exclude an opaque foreign body in the respiratory tract or seg-
mental collapse of the lung, which may indicate the presence of
a non-opaque foreign body in the appropriate segmental bronchus.
All projections should preferably be exposed in the erect posi-
tion. A fast film/screen combination and short exposure time
should be employed. Use of barium sulphate to outline fish bone lodged in the upper oesophagus

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 Foreign bodies 16
Inhaled foreign bodies
Foreign bodies may be inhaled. Infants and young children habitu-
ally put objects into their mouths, and these may be inhaled. Teeth
may be inhaled after a blow to the mouth or during dental surgery.
Such foreign bodies may lodge in the larynx, trachea or bronchi.
The adult patient should be asked to undress completely to
the waist and to wear a hospital gown for the examination. A pos-
tero-anterior projection of the chest, including as much as pos-
Lateral soft tissue image of the neck showing a fish bone sible of the neck on the image, and a lateral chest projection will
lodged in the larynx
be required initially. Alternatively, an antero-posterior chest
image is acquired when examining children. A lateral projection
of the neck, including the nasopharynx, may also be required. In
the case of a non-opaque inhaled foreign body, postero-anterior
projections of the chest in both inspiration and expiration will be
required to demonstrate air trapping due to airway obstruction.
This may manifest itself as reduced lung attenuation on expira-
tion and/or mediastinal shift. The kVp must be sufficiently high
to demonstrate a foreign body that might otherwise be obscured
by the mediastinum. A fast imaging system (film/screen combi-
nation) and short exposure time should be employed.
Cross-sectional imaging such as CT and MRI are additional
techniques that may provide useful information. NB: MRI is
contraindicated in cases of suspected ferrous materials, since the
examination may result in movement of the foreign body.
Bronchoscopy may be used to demonstrate the position of a
Antero-posterior and lateral chest images showing a screw lodged in the foreign body, since the foreign body may be removed during
right main bronchus this procedure.

Postero-anterior and lateral chest images demonstrating a tooth in left superior lobar bronchus and Antero-posterior chest image showing a foreign
atelectasis in the left lung body in the left main bronchus with obstructive
emphysema

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16 Foreign bodies
Inserted foreign bodies
Foreign bodies are sometimes inserted into any of the body ori-
fices. Infants and young children, for example, may insert
objects into the nasal passages or an external auditory meatus. In
these cases, radiography is required only occasionally, since most
of these objects can be located and removed without recourse to Lateral and postero-anterior facial images showing a screw in the right nasal
cavity
radiography.
When radiography is requested, two projections of the area
concerned at right-angles to each other will be required.
Swabs may be left in the body following surgery. Such swabs
contain a radio-opaque filament consisting of polyvinylchloride
(PVC) impregnated with barium sulphate for radiographic
localization.
Ultrasound should be the initial modality selected for the
detection of an intrauterine contraceptive device. It is also very
effective in the detection of soft tissue foreign bodies with the
advantage of incurring no radiation burden where it is available.
There have been incidents where objects such as vibrators
have become lodged in the rectum. In these cases, a single antero-
posterior projection of the pelvis may be required.
Patients who are prone to self-harm may insert a variety of
Antero-posterior pelvis showing a Stanley knife blade inserted in the vagina
objects into their body cavities and under the skin.

Ultrasound image of a needle in the superficial soft tissue

Antero-posterior pelvis showing a vibrator inserted in the rectum

Ultrasound image of an intrauterine contraceptive device Portable antero-posterior chest taken in theatre to locate missing swab

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Foreign bodies that enter the orbital cavity are commonly small
fragments of metal, brick, stone or glass associated with indus-
trial, road or domestic accidents.
Plain film imaging is the first modality for investigation of a
suspected radio-opaque foreign body in the orbit. For further
investigation, or assessment of a non-opaque foreign body, CT
scanning can be very useful. CT will give information about
damage to the delicate bones of the medial and superior orbital
CT image showing multiple foreign bodies
Modified occipito-mental image taken to detect the presence of a
radio-opaque foreign body (normal)
Foreign bodies 16
Transocular foreign bodies
margins, and evidence of any damage suffered by the brain if the
orbital roof has been breached. Ultrasound is useful for detect-
ing superficial foreign bodies and soft tissue damage but is less
useful in the orbit in detecting very small foreign bodies. Access
to ocular ultrasound expertise is less likely to be immediately
available, and there is the extra hazard of introducing coupling
gel into a possibly deep wound.
Radiographic localization may be carried out in two stages:
To confirm the presence of an intra-orbital radio-opaque
foreign body.
To determine whether the foreign body is intra- or extra-ocular.
Images showing fine detail are essential. A small focal spot
(e.g. 0.3 mm2), immobilization with a head band and a high-
definition film/screen combination is recommended. Metal
fragments down to 0.1 0.1 0.1 mm in size may be detected
by conventional radiography.
Intensifying screens must be scrupulously clean and free of
any blemishes producing artefacts that could be confused with
foreign bodies. A cassette with perfectly clean screens may be
set aside especially for these examinations.
Confirmation of a radio-opaque
foreign body
A modified occipito-mental projection with the orbito-meatal
base line(OMBL) at 30 degrees to the cassette is undertaken,
with the patient either prone or erect. Whichever technique
is adopted, the head must be immobilized. The technique is
described in detail on page 269. Ideally, a dedicated skull unit is
selected as this will provide the maximum degree of resolution
required for the visualization of a small foreign body.
The chin is raised so the OMBL is at 30 degrees to either the ver-
tical or horizontal beam. This position projects the petrous ridges
to just below the inferior, anterior orbital margin with the walls of
the orbit lying parallel to the cassette. Using a vertical or horizon-
tal beam, the central ray is directed to the interpupillary line. The
beam is either collimated to include both orbits or just the orbit
under examination, depending on the departmental protocol.
Notes
If it is suspected that a foreign body is obscured by the skull
then a soft tissue lateral image may be necessary.
It may be necessary to repeat the examination if the artefact
is suspected to be from a possible dirty screen.
If a radio-opaque foreign body is identified in the orbit,
before proceeding with any further localization images it may
be advisable to wait until the patient has been seen by the
ophthalmologist who may decide to remove the foreign body
or request CT or ultrasound in preference to radiography
localization.
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