A ProspectiveEvaluationofForeign

Bodies PresentingtotheEar,Noseand
ThroatClinic,HospitalKualaLumpur
SKHon*,TMIzam,FRCS**,CBKoay,FRCS*,ARazi,FacultyofMedicineandHealthSciences,
UniversitiPutt"aMalaysia,DepartmentofOtorhinolaryngology,KualaLumpu."

Summary
ultsofaprospectivestudyof94patientswithhistOlyofear,noseoraerodigestivetractforeignreanalee!.
Sixtysixto94%ofpatientspresentedwithin24hourstoaprimarycaredoctor,

wasr
totheENTDepartmentwithin24hoursand89to93%ofpatientshadthe
diesremo
within24hours.Overall,58%ofauralforeignbodies,67%nasalforeignbodi
and90 ofaerodigestivetractforeignbodieswereremovedwithin48hoursofinsertion.Asaresultoftheprompt
removalofforeignbodiesinthemajorityofpatients,nosignifiCantcomplicationsoccurred.
ignbodiesintheaerodigestivetr
ndtopre
ierandmorepromptlyremovedcompared
earandnoseforeignbodies.,
wasasig
higherproportionofforeignbodyinthe
rightearandnostrilcomparedtothe

Key Words: Ear,Nose,Aerodigestivetractforeignbodies,Clinicalpresentation

Introduction
Foreignbodyintheintheear,noseoraerodigestivetract
isacommonENTproblem.Whilemostforeignbodiesare
readilyremovedintheoutpatientclinics,aproportionof
theili may require rCllloval under general anaesthesia
(GA). Cases requiring GA are usually due to
uncooperative patient or foreign bodies not readily
accessiblesuchasthoseintheupperoesophagus,

There have been a number of previous studies on the

variousclinicalaspectsofearnoseandaerodigestivetract
foreignbodies,includingthetypesofforeignbodies,the
aetiology, the presenting symptoms, the relevant
investigations

and the methods of

relllova!J6,S,ll,14,16,
There
havealsobeenstudieson
ways of improving the
Inanagen1ent
outcomes7,14,17,22,
One of the factors which
may affect the
managementprocessisthe
time delay between
ingestion or insertion of
the foreign body to the
time of presentation,
diagnosis and eventual
removal. This potential

delaymaycauseunnecessarydistresstopatientsandmayWe studied prospectively

thepatternofpresentation
evenleadtopotentiallylifethreateningcomplications.
of patients with car, nose
and aerodigestive tract
Thisarticlewas
Vol56No4

MedJMalaysia

foreignbodiestotheENT
Department at Hospital
KualaLumpurwith

accepted:14October
Dec200I
463

2001

ORIGINAL ARTICLE
EarForeignBodies
specific attentions to the time delay between various
stages of presentation and treatment. We also studied
thecorrelationbetweenanydelayandthecomplications
thatmayhavearisenasaresultofthedelay.

MaterialandMethods

Atotalof97patientswere
admitted for removal of
ear~noseandaerodigestive
tract foreign body under
general anaesthesia during
the period of study. This
represented 9.5'Yo of the
total admissions to the
ENT ward 0022 patients)
in the oneyear period.
Three patients were

Atotalof26patientswereadmittedwithearforeign
body.Sixteen(61.5%)wereaged5orbelowwhile7
(27.0%)wereagedbetween6and9.Theagesofthe
otherthree01.5%)were13,22and28respectively.

SiteofEnlodgement

AllpatientsadmittedtotheENTWardwithhistOlYof
ear>noseoraerodigestivetractforeignbodiesovera
oneyearperiodbetweenApril1999toApril2000were
includedinthisstudy.Thesourcesofreferralincluded
direct referrals from casualty officers, general
practitioners and also transfer from other nearby
hospitals. A specially designed standard questionnaire
was used to collect data on each individual patient
(Refer Appendix 1). The data collected included
demographic information and details of the time
relationship[raIntheinitialsymptomandpresentationto
adoctor,toreferralmadetotheENTDepartment,the
wardadmissionandtheeventualremovaloftheforeign
body.Thetypeofforeignbodyandthepresenceofany
complications, such as otitis lnedia from ear foreign
body,airwayobstructionfromnasalforeignbodyand
mediastinitis from oesophagus perforation, were also
recorded.

Results

Age Distribution

Seventeenpatients(65.4%)presentedwithforeignbody
intherightearwhile9(34.6%)presentedwithforeign
body in the left ear. ChiSquare Test showed
significantlyhigher
proportionofforeignbodiesintherightearcomparedto
theleft(P<o.on.

TypesofForeignBodies
ThetypesofforeignbodiesremovedarelistedinTable
I

Timedelay

Ofthe26patients,19(73.1%)presentedtoadoctor
within 24 hours of insertion of the foreign body as
noticedbyanadultorasreportedbythechildhimself.
Fourpatients05.4%)presentedbetween24hoursand1
weekand3patients(11.5 %)presentedafter1week,3
weeksand4weeksrespectively.
excluded from the studyin the upper aerodigestive
due to incomplete data.tract.
T
There were 48 male
a
(51.1%) and 46 female
patients (48.9%). The age
bl
distributionwashetween2
e
and74years,withamean
I
age of 14.2. Twentysix
TypesofForeign
patients(27.7%)presented
BodiesLodgedin
with foreign body in the
theEar
ear, 12 patients 02.8%)
with foreign body in the
ORGANIC:
nose and 56 patients
(57.8%)withforeignbody

Vegelalive:

Nonvegetative:

Woodenbead
Seed
Flower
Paper
Insecl

NONORGANIC:

Rubber
Stone
Metal
TOTAL

4 (15.4%1
3 (11.6%)
1(3.8%)
26(100%1
464

Med J

Malaysia Vol 56 No 4 Dec 200 I

A PROSPECTIVE EVAlUTION OF FOREIGN BODIES PRESENTING TO THE EAR, NOSE AND THROAT CLINIC

Age distribution

Following presentation to the first doctor, 21

patients(80.8%)werereferredtotheENTClinic
within 24 hours. Four patients (15.4%) were
referredbetween24hoursand1week.Onepatient
(3.8%) was referred 1 week following initial
presentation.
After presenting to the ENT Clinic, 23 patients TypesofForeign
(88.6%)hadtheforeignbodyremovedwithin24 BodiesLodgedin
theNose
hours.Twopatients(7.6%)hadtheforeignbody
ORGANIC:
removed between 24 hours and 1 week. One
patient(3.8%)haditremovedafter2weeks.

T
a
b
l
e
I
I

Seed
Woodenbead
Overall,15patients(57.7%)hadtheforeignbody
NONORGANIC:
removedwithin48hoursofinsertion.
Metalobiect
Plasticobject
NasalFareignBodies

TOTAL

Age distribution

Atotalof12patientswereadmittedwithforeign
body in the nose. Eleven patients (91.7%) were
aged5andbelow.Theotherpatient(8.3%)was8
yearsold.

Following presentation
to the first doctor, 10
patients (83.3%) were
referred to the ENT
Clinic within 24 hours.
Two 06.7%) were
SiteofEnlodgement
referred after 4 and 6
Eightpatients(66.7%)presentedwithforeignbody daysrespectively.

intherightnasalcavitywhiletheother4patients
(33.3%) presented with foreign body in the left Following admission to
nasalcavity.ChiSquareTestshowedsignificantly the ENT ward, eleven
higher proportion of foreign bodies in the right (91.7%) of the 12
patients had the foreign
nasalcavitycomparedtotheleft(p<0.01).
bodies removed within
24hours.Theremaining
patient (8.3%) had the
TypesofForeignBodies
foreign body removed
Thetypesofforeignbodiesremovedarelistedin after4days.
TableII.
Overall, 8 patients
(66.7%) had the foreign
Eight (66.6%) of the 12 patients presented to a bodies removed within
doctorwithin24hoursofforeignbodyinsertion 48hoursofinsertion.
while 2 patients (16.7%) presented between 24
hours and 1 week. The remaining 2 patients
AerodigestiveTract
06.7%)presentedafter1week.

Timedelay

ForeignBodies

A total of 56 patients

were admitted with a

historyofforeignbodyof
the upper aerodigestive
tract, including the
pharynx, the oesophagus
and the bronchtis.
Twentytwo patients
C39.3%) were aged 5
and below, 8 (14.3%)
were between 5 to 12
years and 26 (46.4%)
wereabovetheageof12.

TypesofForeignBodies
Of the 56 patients who
undelwent examination
under anaesthesia, 52
patients were found to
have foreign bodies. In
the other 4 patients, no
foreign bodies were
fuunel. The types of
foreign bodies removed
arelistedinTableIII.

MedJMalaysia

Val56No4Dec 200I

465

ORIGINAL ARTICLE

TableIII
TypesofforeignBodiesLodgedintheAerodigestiveTract
foreignBody
Coins
1-cent
5-cent
lO-cent
20-cent
RM 1
Total
Fish bone
Chicken bone
Meat bolus
Denture
Nut
Chewing gum
FruitTOTAL

Timedelay

12yearsold&below
Above12yearsold Total
12yearsold 25yearsold 512yearsold
2
1
5
8

3
3
1
7
1

4
4
3
2

19(365 %)
14 126,9 %)
11 (21.1 %)
3 (5,8 %)
2 13,8 %)
1 11.9 %1
1 (l ,9 %)
1 11.9 %)

24

521100 %1

10
7
3
2
1

10

10

Complications

Allpatientswithear,nose
Ofthe56patients,24(42,9%)presentedtoadoctorwithin
or aerodigestive tract
1hourofingestionoftheforeignbodywhite29(51,8%)
foreign bodies were
presented between 1 and 24 hours, The other 3 patients
dischargedbetween1to3
(5,3%)presentedafter1,2and3daysrespectively,
days ofadmission and no
significant c01nplications
Following presentation to the first doctor, 53 patients
were recorded pre
(94,6%)werereferredtotheENTClinicwithin24hours,
operatively,

peri
Two patients 0,6%) were referred after 2 days and one
operatively or post
patient(1.8%)wasreferredafter4days,
operatively.
FollowingadmissiontotheENTward,52patients(92,9%) Discussion
underwent foreign bodyremovalwithin 24hours, Three
Ear, nose and throat
(5,3%)hadtheforeignbodyremovedafter2days,Inthe
foreign bodies may be
rClnainingpatient(1.8%),theforeignbodywasremoved
complicated by serious
after4.days.
complications such as
mediastinitis

from
oesophageal

perforation
Overall,53patients(94,6%)hadtheforeignbodyremoved
and airway obstruction
within48hoursofingestion.
466

frominhalationofanasal
foreign body amongst
othersl(l,24. One of our
main aims in conducting
this study was to
determine the patterns of
delayinpatientswithear,
nose and aerodigestive
tractforeignbodiesandto
ascertain if any
complications arose as a
direct result of the delay,
Our results showed that
the great majority of the
patients (66% to 94%)
presented promptly, i.e.
within 24 hours, to a
primarycare doctor.
Likewise, following
presentation to the first
doctor,

MedJ MalaysiaVol56No4Dec200I

A PROSPECTIVE EVALUTION OF FOREIGN BODIES PRESENTING TO THE EAR, NOSE AND THROAT CLINIC

foreign bodies especially

thegreatmajority(80%to94%)wasreferred to thoseintheaerodigestive
theENTClinicwithoutanyunduedelay. It also tractwerebothimportant
followed that very little delay occurred in the contributoryfactorsinthe
admissionofthepatientsandintherClllovalofthe avoidance

of
foreign bodies. Consequently, no significant complications in our
complicationsoccurredinourpatients.
seriesofpatients.
Furtherdetailedanalysisoftheresultsrevealedthat
patients with aerodigestive tract foreign bodies Foreign bodies in the
tendedtopresentearlierthanthosewithearornoseaerodigestive

tract
foreignbodies.NinetyfOUfpercentofpatientswithconstituted the majority
throatforeignbodiespresentedwithin24hoursof of the ENT foreign
ingestionoftheforeignbody,comparedwith73%bodiesinourstudywhile
for ear and 63% for nose foreign bodies. In lessthanathirdwereear
addition, 43% of the patients with aerodigestive foreign bodies and only
tract foreign presented within one hour of13% were nose foreign
ingestion. These are not unexpected findings asbodies. This finding was
aerodigestivetractforeignbodiesgenerallytendtoin keeping with many
causemorediscomfortandinflictmorcpainonthe previous

reportsll,l:'l.
patientsthanearornoseforeignbodies.
However, this was not a
true reflection of the
distribution of patients
with the respective
Removalofforeignbodiesfromtheear,noseor foreignbodiespresenting
aerodigestivetractcanbetechnicallychallenging.to our clinic as tnost of
It oftenrequirestheuseofspecialisedequipment the ear and nose foreign
such as microscopes, endoscopes and a range of bodies were readily
specialised forceps, which are usually only removed in the
available in the ENT clinics. lnappropriate outpatientsclinicwithout
instrumentation and unfamiliarity with therequiring a general
techniquescanfrequentlyresultinmoredamageto
anesthesia. Bronchial
the patients6 We strongly recommend thatforeign body is not a
removalofear,noseoraerodigestivetractforeign commonconditionandin
bodiesintheclinicbyanENTmedicalpersonnel, ourstudy,therewasonly
unlessitcanbereadilyremovedwithouttherisks one such case. In the
ofcausinginjuryorinflictingpaintothepatient. previous study overa 4
year period in our
institution,therewasonly
It isourcommonpracticetolistallcasesof foreignanaverageof4casesof
bodies that require removal under generalbronchial foreign body
anaesthesiaontheemergencylist.Hence,88%of
peryearlll
theearforeignbodiesandmorethan90%ofthe
nose and aerodigestive tract foreign bodies were
removed within 24 hours of admission. Overall,
58%oftheforeignbodyintheear,67%inthenoseThere was a clear
and94%intheaerodigestivetractwereremoved difference in the age
within 48 hours of insertion. In our opinion,distribution of patients
promptdiagnosisandearlyremovalof
with ear or nose foreign

bodies and those with

foreign bodies in aero
digestive tract. The
fonner

occurred
predominantly

in
children.Morethan90%
ofthenoseforeignbodies
occurred in children
under the age of five
while nearly 90% of the
ear foreign bodies
occurred in children
under the age of nine.
Sitnilar observations
werereportedinprevious
studiesbyDas3,Francios
etal? andTong etal lO ,
However, for foreign
bodies in aerodigestive
tract only 53% of
children were under the
ageof12.

It hasbeenproposedthat
preexistingnose diseases
such as rhinitis and
vestibulitis and ear
diseases such as chronic
otitis externa, chronic
suppurative otitis tnedia
or the presence of wax
are major aetiological
factors in ear and nose
foreignbodies3 Noneof
our patients showed
evidence of underlying
ear or nose diseases. It
was our impression that
fun making, boredom,
curiosity

and
experimentationwerethe
more likely causes in
mostofourpatients,

MedJMalaysia

Vol56No4Dec 2001

467

ORIGINAL ARTICLE

The significantly higher proportion of foreign

bodiesintherightnostrilandalsointherightear
comparedwiththeleftwasaninterestingfinding.
Francoisetalhadalsomadesimilarobservationin
theirstudyof72nasalforeignbodies.Wepostulate
thatrighthandednessmaybethecontributingfactor
tothisobservation.

The commonestforeign bodies foundin the ears

werebeads.Thismayhavebeenduetothefactthat
sphericalobjectsaretechnicallyllloredifficultto
remove especially in uncooperative children who
thus required admission for removal under
anaesthesiaJ,y, About 15% of the ear foreign
bodies in our study were insects compared to a
studybyBresslerandSheltonwhichshowedahigh
incidence(44%)ofcockroachesintheirseriesof
patients with ear foreign bodies. They put this
clown to the squalid living conditions of the
population that they studied. Our patients were
mainly from urban population~ hence common
householdobjectswerethemostcommonforeign
body.

There was an interesting correlation between the

type of aerodigestive foreign bodies and the age
groupofthepatients.Forchilw'enundertheageof
12,especiallytheagegroupofunder5,coinswere
the commonest foreign bodies in keeping with
previousreportsbyKpemissietat14andKruketat
". Asforpatientsabovetheageof 12, theforeign
bodieswerepredominantlyfishbonesandchicken
bones.

Thekeytothemanagementofoesophagealforeign
bodies,especiallythosewithsharpedges,isearly
rellloval to avoid serious complications such as
perforation19,2u,23.Hence,promptadmissionandearly
removal is essential H,lVI. Diagnosis of impacted
foreign body in the oesophagus is based on a
thorough histolY and examination of the patient.
Indirectlaryngoscopyhavebeenshownto

improvethedetectionrateofthroatforeignbodies
,'7. Radiological investigation are helpful in
supporting the diagnosis and more accurately
5

locatetheforeignbodt .1llHowever,insomecases,
thediagnosismaystillbeunclearevenafterfull
investigations i1). a proportion of cases. This is
particularlytrueofthosepatientswhocomplainof
residualdiscomfortinthethroataftertheforeign
bodyhaspassedbeyondtheoesophagus.In7%of
ourpatients,noforeignbodieswerefoundatthe
time of oesophagoscopy. In these patients, we
assumed that the foreign bodies had passed
spontaneouslyeitherbeforeorduringthetimeof
anaesthesia.Wefeelthata7%negativeexploration
rate is acceptable to avoid missing any foreign
bodythatlllightresultinpotentiallymoreserious
complications.

Conclusion
Ourstudyshowedthatcomplicationfr01llretained
foreignbodiesofthe ear~ noseandthroatcanbe
avoided by early presentation, effective referral
and pr01llpt removal. Aerodigestive tractforeign
bodiespresentearlierasitcausesmorediscomfort
tothepatients.Coinswerethecommonestforeign
bodiesintheaerodigestivetractalllongstchildren
whileinadultsitwasfishandchickenbones.Ear
andnoseforeignbocliesarepredominantlyfound
in children. There is a significantly higher
proportionofforeignbodiesintherightnostriland
intherightearcomparedtotheleft.

Acknowledgements
The authors would like tn thank all the medical
staU:,andallthenursingstaffsintheENTClinic
ofHospitalKualaLumpurforthegreatvaluablein
thedatacollection.

468

MedJMalay,;aVol56No4Dec2001

A PROSPECTIVE EVALUTION OF FOREIGN BODIES PRESENTING TO THE EAR, NOSE AND THROAT CLINIC

Appendix 1
QUESTIONNAIRE FOR ENT FOREIGN BODY
Demographic Information
Name:
Age:
Addressandtelephonenumber:
Registrationnumber:
I/Cnumber:

Date:
Sex:M/F

Consultation Information
Events
Firstnotedsymptom
Consultationwithfirstdoctor
ConsultationwithHKLdoctor
(if different from above)
ReferredtoENTdoctor
FirstseenbyENTdoctor
Removalofforeignbody

Date

Time

Data on foreign body

Region:Ear/nose/throat
Site:left/right(forearornoseonly)
Single/Multiple
Data on operation
Typeofanaesthesia:
Typeofoperation:
Data on discharge
Dateofdischarge:
Medicationsondischarge:
Complication (pleasestatel
Presenceofanycomplicationspre,periandpostoperatively:
MedJMalaysiaVal56No4Dec200I

469

ORIGINAL ARTICLE

2
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0
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2
1
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ng
M
e,
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ng
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an
d
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an

H
as
sc
lt
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as
al
fo
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ig
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bo 11. B
a
di
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es

k
l
i
n

S
.
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o
s
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t
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r
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r
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e
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c
hi
ld
re
n.
A
n
n
E
m
er
g
M
e
d
1
9
9
5;
2
5
(4
),
5
5
4
5
5
5.

12. L
o
pe
z
A
M
,
G
ar
ci
a
S
A,
H
er
rd
nz
G
B
an
d
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ar
ti
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z
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].
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or

e
i
g
n

b
o
d
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e
s
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a
n
a
l
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r
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n

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t
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o
l
a
r
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g
o
l
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b
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m

A
m

1
9
9
3
;
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0

(
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4
1

5
4
3
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13.Pe

t
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ri
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m

1
9
9
6
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5
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4
6
0
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re
z
O
J,
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ar
in
G
J,
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ic
en
te
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E
et
al
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E
N
T
e
m
er
ge
nc
ie
s
d
ue
to
fo
re
ig 14. K
n
p
b
e
o
m
di
i
es
s
at
s
a
i
te
E
rti
,
ar
D
y
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p
os
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ta
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d
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e
n
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O
R

,
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d
a
k
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n
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K

e
t
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o
r
e
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b
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d
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:
e
t
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a

pe
ut
ic
as
pe
ct
s.
Sa
nt
e
19
97
;
7
(5
);
33
8
34
0.

15. K

g
u
s
.
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t
o
l
a
r
y
n
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o
l
P
o
l
1
9
9
9
;
5
3
(
3
)
;
2
8
3

2
8
8
.

ru
k
Z
A
,
S
z
m
ej
a
Z,
W
oj
to
w
ic
z 16. M
a
.I
n
et
g
al
a
.
l
F
B
or
D
ei
,
g
M
n
a
b
n
o
g
di
a
es
l
in
Y
th

e
a
es
n
o
d
p
P
h
a
a
n

d
e
y
R
P
.
R
e
tr
i
e
v
a
l
o
f
f
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r
e
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g
n
f
r
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m

t
h
e
u
p
p
e
r
G
I
t
r
a
c
t
b
y
f
l
e
x
i
b
l
e
f
i
b
r
e
o
p
t
i
c
e

nd
os
co
pe

an
ex
pe
ri
en
ce
.

A
ss
oc
P
hy
si
ci
an
s
In
di
a
19
93
;
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);

11

13
.

17. G

au
ta
m
V
,
P
hi
lli
ps

.I,

n
b
o
d
i
e
s
i
n
t
h
e
t
h
r
o
a
t
.

A
c
c
i
d
E
m
e
r
g
M
e
d
1
9
9
4
;
1
1
(
2
)
,
1
1
3

1
1
5
.

B
o
w
m
er
H 18. R
a
an
z
d
i
R
A
ei
H
ch
,
i
S
M
a
.
i
F
or
d
ei
H
g
a

n
d

K
a
r
t
i
n
i
A
.
F
o
r
e
i
g
n
b
o
d
i
e
s
i
n
t
h
e
l
a
l
y
n
g
o
t
r
a
c
h
e
o
b
r
o
n
c
h
i
a
l
t
r
e
e
.
M
e
d

.
I

al
ay
si
a
1
9
8
8;
4
3
,
7
4
8
3.

19. N

oe
l
Y
T
L.
I
m
pa
ct
ed
de
nt
ur
es
in
th
e
oe
so
p
ha
g
us
.
M
ed

M
al
ay
si
a
1
9
8
2;
4,
3
4
4
3
4
8.

20. K
ri
sh
na

n
G
.
M
i
g
r
a
t
i
n
g
f
o
r
e
i
g
n
b
o
d
y

A
n

u
n
u
s
u
a
l
p
r
e
s
e
n
t
a
t
i
o
n
.
M
e
d
J
M
a
l
a
y
s
i
a
1
9

9
4
;
4
9
:
1
6
9

1
7
1
.

21. K
r
u
k
Z
A
,
S
z
m
e
j
a
Z
,
W
o
j
t
o
w
i
c
z
J
e
t
a
l
.
F
o
r
e
i
g
n
b
o
d
i
e
s
i
n

th
e
lo
w
er
re
sp
ir
at
or
y
tr
ac
t:
ex
pe
ri
en
ce
b'
ds
ed
o
n
m
at
er
ia
ls
ga
th
er
ed
in
th
e
E
N
T
D
ep
ar
t
m
en
t
of
P
oz
na
n
H
ig
he
r
S
ch
o
ol

o
f
M
e
d
i
c
a
l
S
c
i
e
n
c
e
s
b
e
t
w
e
e
n
1
9
4
5
a
n
d
1
9
9
7
.
O
t
o
l
a
I
y
n
g
o
l
P
o
l
1
9
9
8
;
5
2
(
6

)
;
6
8
3

6
8
8
.

22. D
i
o
p
E
M
,
T
a
l
l
A
,
D
i
o
u
f
R
a
n
d
N
d
i
a
y
e
I
e
.
L
a
l
y
n
g
e
a
l
f
o
r
e
i
g
n
b
o

di
es
:
m
an
ag
e
m
en
t
in
ch
il
dr
en
in
S
en
eg
al
.
A
rc
h
P
ed
ia
tr
2
0
0
0;
7
(l}

1
0
1
5.

23. Le

e
T
S.
D
el
ay
ed
co
m
pli
ca
tio
n
of
a
fo
rei
gn
bo
dy
ca

u
s
i
n
g
r
e
t
r
o
p
h
a
I
y
n
g
e
a
l
g
r
a
n
u
l
o
m
a

a
c
a
s
e
r
e
p
o
r
t
.
M
c
d

M
a
l
a
y
s
i
a
1
9
9
1
;
4
6
,
9
5

9
8
.

24. P
t
a
f
f
J
A

a
n
d

M
o
o
r
e

G
P
.
E
y
e
,
e
a
r
,
n
o
s
e

a
n
d

t
h
r
o
a
t
.
E
m
e
r
g

M
e
d

li
n
N
or
th
A
m
1
9

9
7
;
1
5

(
2
)

4
7
0

;
3
2
7

3
4
0
.

edJ
Malaysia
Vol56
No4
M Dec2001