Foreign Body, Nasal
Description
 Types of foreign bodies:
o Limited only by nostril size and imagination, activity of the child
o Food
o Paper
o Pieces of toys
o Beads
o Rocks
o Button batteries: high risk of complications compared with other foreign bodies (tissue
necrosis, septal perforation, saddle nose); require rapid removal
o Magnets:
 Used to simulate nasal piercing
 Often imbedded in tissue, leading to difficult removal
 May cause intestinal perforation if swallowed
 Sinusitis is the most common complication.
 Average patient age: 2–4 years
 Age not associated with particular type of foreign body
Diagnosis
Signs and Symptoms
 Most nasal foreign bodies are asymptomatic.
 Someone witnesses child putting object into nose.
 Foreign body noticed by parent or caretaker.
 Nasal discharge:
o Acute or chronic
o Unilateral
o Foul smelling
o Halitosis
 Sinus discomfort
 Epistaxis
 Local inflammation
 Septal perforation
 Ingestion or aspiration of foreign body
Essential Workup
Visualization of the foreign body in the nostril:
 Always check both nostrils
Tests
Imaging
 Fiberoptic visualization if foreign body cannot be visualized on rhinoscopy
 Sinus films if present for extended period:
o Symptom persistence despite removal of the foreign body and antibiotics
Differential Diagnosis
 Sinusitis
 Epistaxis
 Intranasal mass
 Swollen inferior turbinate:
o May be mistaken for a pink bead
Treatment
Pre Hospital
 Cautions:
o Transport in sitting position.
 Avoid posterior displacement, possible aspiration of foreign body.
 Avoid interventions that upset the child.
ED Treatment
 Topical vasoconstrictors:
o Presence of mucosal edema, or bleeding secondary to removal attempts
o Nebulized epinephrine
o Cocaine: 4%
o Oxymetazoline: 0.05%
o Phenylephrine: 0.125–0.5%
 Positive pressure:
o Occlude contralateral nostril.
o Positive pressure applied to mouth only
o Deliver brisk puff as child begins to inhale.
o Parent may tell the child he or she will be given a “big kiss.”
o Placement of 4 × 4 gauze pads on caregiver's cheek
o Foreign body dislodges onto cheek of the provider or into room
o Repeated as necessary
o Alternatively, deliver puff with a bag-mask over the mouth and O2 at 10–15 L/min.
o Alternatively, into contralateral nostril male-male adapter on oxygen tubing, deliver wall
oxygen at 10–15 L/min.
o Nasal wash with 7 ml saline via bulb syringe contralateral nostril described; controversial;
aspiration risk?
 Hooked probe, alligator forceps:
o Anterior foreign bodies that are easily grasped
o Headlamp, nasal speculum facilitate use
o Risk of further posterior displacement
 Suction catheter:
o Best for round, smooth objects
o Optimal retrieval with suction catheter
o Suction tip placed against the object
o Suction turned up to 100–140 mm Hg
o Catheter and object withdrawn
 Cyanoacrylate tissue glue:
o Film of glue applied to cut end of hollow plastic swab handle
o Apply against object for 60 seconds, then withdraw.
o Caution with nontissue cyanoacrylate glues; tissue irritation
 Balloon catheters:
o Used primarily when instrumentation fails
o 5F or 6F Foley or Fogarty balloon catheter lubricated with 2% lidocaine jelly
o Advance catheter past object
o Following inflation with 2–3 mL of air, gently withdraw catheter gently withdrawn
 Magnet for removal of metal foreign body described; limited experience
Medication (Drugs)
 Cocaine: 4% solution, 2 drops affected nares
 Lidocaine: 4% solution, 2 drops affected nares
 Oxymetazoline: 0.05%, 2–3 drops/sprays affected nares
 Phenylephrine: 0.125–0.5%, 2–3 sprays affected nares
 Procedural sedation may be of immense importance
Follow-Up
Disposition
Admission Criteria
Referral for ambulatory surgical removal:
 Foreign body cannot be recovered in ED
 Removal under general anesthesia is required
Discharge Criteria
 Ensure that all foreign bodies are removed from both nares.
 Return if bleeding, infection (nasal discharge)
 If a button battery was removed:
o Mandatory follow-up with ear/nose/throat specialist
o Monitor for delayed sequelae
o Ischemic mucosa
o
o
Turbinate or septal damage
Saddle-nose deformity
Advantages and Disadvantages of Different Foreign Body Removal Techniques
Technique
Advantages
Disadvantages
Foley catheter
Foreign body does not have to be
Traumatic to patient.
round or solid.
Removes posterior foreign body.
Epistaxis more common.
Forceps/hooked
Easy to perform.
Foreign body may pull apart.
probe
Foreign bodies close to the
May push foreign body posterior.
anterior nares.
Positive pressure
Large, occluding foreign bodies.
Theoretical risk for barotrauma to
Non-traumatic to the patient.
the tympanic membrane or lower
airway.
Suction catheter
Easy to perform.
Need a solid seal.
Foreign bodies close to the
Posterior foreign body difficult to
anterior nares.
remove.
Round, smaller foreign bodies.
Cyanoacrylate glue
Easy to perform.
Not widely available.
Non-traumatic to the patient.
Accidental adhesion to the
Easily visualized foreign bodies.
patients' nasal mucosa.