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Foreign Body, Nasal, Emergency Medicine

Basics

Description

- Object impacted in the nasal cavity - Most common site of foreign body insertion in children - Type of foreign body limited only by nostril size - Population at risk: - Children between 2-6 yr most common - Mental retardation - Psychiatric illness

- Complications: - Sinusitis is the most common complication - Foreign bodies may migrate into the sinuses - Septal perforation - Bronchial aspiration - High risk of complications with button batteries: - Ischemic mucosa - Turbinate or septal damage - Saddle-nose deformity

- Magnets: - Used to mimic nasal piercing - Often imbedded in nasal tissue, leading to difficult removal - May cause intestinal perforation if swallowed, especially newer high-powered neodymium magnets

- Congenital masses: - Dermoid - Encephalocele - Glioma - Teratoma

- Positive pressure for children: - Occlude contralateral nostril - Upright sitting position if possible - Positive pressure applied to mouth only (best done by parents) - Deliver brisk puff as child begins to inhale - Parent may tell the child he or she will be given a "big kiss."пїЅ - Placement of 4 пїЅ 4 gauze pads on caregivers cheek - Foreign body dislodges onto cheek of the provider or into room - Repeated as necessary - Can use straw in older children to create pressure without mouth to mouth - Alternatively, deliver puff with a bag-mask over the mouth and O2 at 10-15 L/min. - Alternatively, into contralateral nostril male-male adapter on oxygen tubing, deliver wall oxygen at 10-15 L/min. - Risk of barotrauma with sustained, unmodulated positive pressure

- Hooked probe, alligator forceps: - Anterior foreign bodies that are easily grasped - Headlamp, nasal speculum facilitate use - Risk of further posterior displacement

- Suction catheter: - Best for round, smooth objects - Optimal retrieval with suction catheter - Suction tip placed against the object - Suction turned up to 100-140 mm Hg - Catheter and object withdrawn

- Cyanoacrylate tissue glue: - Film of glue applied to cut end of hollow plastic swab handle - Apply against object for 60 sec, and then withdraw - Caution with nontissue cyanoacrylate glues; tissue irritation

- Balloon catheters: - Used primarily when instrumentation fails - 5F or 6F Foley or Fogarty balloon catheter lubricated with 2% lidocaine jelly - Advance catheter past object - Following inflation with 2-3 mL of air, gently withdraw catheter

- Magnet for removal of metal foreign body described; limited experience - Snare technique: - 24G wire made into a loop with a hemostat - Useful when size of object known - Thin wire can slip through swollen tissue, behind object, allowing it to be pulled free

- Parents should be instructed to seek medical care for the following: - Fever - Headache or facial pain - Persistent epistaxis - Persistent drainage of nasal fluid

  • Object impacted in the nasal cavity
  • Most common site of foreign body insertion in children
  • Type of foreign body limited only by nostril size
  • Population at risk:Children between 2-6 yr most commonMental retardationPsychiatric illness
  • Causes of worsening impaction and difficulties with removal:Organic material may expand if moistenedMucosal swelling over time
  • Complications:Sinusitis is the most common complicationForeign bodies may migrate into the sinusesSeptal perforationBronchial aspirationHigh risk of complications with button batteries:Ischemic mucosaTurbinate or septal damageSaddle-nose deformity

Etiology

  • Food
  • Beans
  • Seeds
  • Beads
  • Rocks
  • Paper
  • Pieces of toys
  • Sponge pieces
  • Vegetable matter
  • Insects and live worms
  • Button batteries:High risk of complications compared with other foreign bodies (tissue necrosis, septal perforation, saddle nose); require rapid removal
  • Magnets:Used to mimic nasal piercingOften imbedded in nasal tissue, leading to difficult removalMay cause intestinal perforation if swallowed, especially newer high-powered neodymium magnets
  • Glass fragments

Diagnosis

Signs and Symptoms

  • Most nasal foreign bodies are asymptomatic.
  • Unilateral nasal obstruction
  • Nasal pain
  • Difficulties with nasal breathing
  • Nasal discharge:Acute or chronicUnilateralFoul smellingHalitosis
  • Sinus discomfort
  • Persistent epistaxis
  • Local inflammation
  • Septal perforation
  • Ingestion or aspiration of foreign body

History

  • Child witnessed putting object into nose
  • Foreign body noticed by parent or caretaker
  • Many children are reluctant to admit to placing a foreign body for fear of adult disapproval
  • Delayed presentation:When placement of the object is unwitnessed, the child may present weeks after with nasal discharge and bleedingOften misdiagnosed at this stage as sinusitis

Essential Workup

Visualization of the foreign body in the nostril: Always check both nostrils пїЅ

Diagnosis Tests & Interpretation

Imaging

  • Fiberoptic visualization if foreign body cannot be visualized on rhinoscopy
  • Sinus films if present for extended period:Symptom persistence despite removal of the foreign body and antibiotics
  • May need chest or abdomen films for aspiration/ingestion

Differential Diagnosis

  • Sinusitis
  • Swollen inferior turbinate:May be mistaken for a pink bead
  • Rhinitis
  • Nasal polyp
  • Benign tumors:
  • Malignant tumors:LymphomaRhabdomyosarcomaNasopharyngeal carcinomaEsthesioneuroblastoma (also known as an olfactory neuroblastoma)
  • Congenital masses:DermoidEncephaloceleGliomaTeratoma
  • Retropharyngeal abscess
  • Traumatic dislocation of nasal bones or septum
  • Nasal deformity:Usually associated with cleft palate
  • Nasopharyngeal stenosis
  • Rhinitis medicamentosa:Rebound nasal mucosal edema caused by extended use of topical decongestants

Treatment

Pre-Hospital

  • Cautions:Transport in sitting position:To avoid posterior displacement and possible aspiration of foreign body
  • Avoid interventions that upset the child.Forceful negative inspiration from crying may lead to aspiration

Ed Treatment/Procedures

  • Topical vasoconstrictors:Presence of mucosal edema, or bleeding secondary to removal attemptsNebulized epinephrineCocaine: 4%Oxymetazoline: 0.05%Phenylephrine: 0.125-0.5%
  • Positive pressure for children:Occlude contralateral nostrilUpright sitting position if possiblePositive pressure applied to mouth only (best done by parents)Deliver brisk puff as child begins to inhaleParent may tell the child he or she will be given a "big kiss."пїЅPlacement of 4 пїЅ 4 gauze pads on caregivers cheekForeign body dislodges onto cheek of the provider or into roomRepeated as necessaryCan use straw in older children to create pressure without mouth to mouthAlternatively, deliver puff with a bag-mask over the mouth and O2 at 10-15 L/min.Alternatively, into contralateral nostril male-male adapter on oxygen tubing, deliver wall oxygen at 10-15 L/min.Risk of barotrauma with sustained, unmodulated positive pressure
  • Hooked probe, alligator forceps:Anterior foreign bodies that are easily graspedHeadlamp, nasal speculum facilitate useRisk of further posterior displacement
  • Suction catheter:Best for round, smooth objectsOptimal retrieval with suction catheterSuction tip placed against the objectSuction turned up to 100-140 mm HgCatheter and object withdrawn
  • Cyanoacrylate tissue glue:Film of glue applied to cut end of hollow plastic swab handleApply against object for 60 sec, and then withdrawCaution with nontissue cyanoacrylate glues; tissue irritation
  • Balloon catheters:Used primarily when instrumentation fails5F or 6F Foley or Fogarty balloon catheter lubricated with 2% lidocaine jellyAdvance catheter past objectFollowing inflation with 2-3 mL of air, gently withdraw catheter
  • Magnet for removal of metal foreign body described; limited experience
  • Snare technique:24G wire made into a loop with a hemostatUseful when size of object knownThin wire can slip through swollen tissue, behind object, allowing it to be pulled free

Medication

  • 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 necessary

Follow-Up

Disposition

Admission Criteria

Referral for ambulatory surgical removal: пїЅ

  • Foreign body cannot be recovered in ED
  • Removal under general anesthesia is required

Discharge Criteria

  • Ensure that there is no airway compromise
  • Return if bleeding, infection (nasal discharge)
  • If a button battery was removed, monitor for delayed sequelae as outpatient:Ischemic mucosaTurbinate or septal damageSaddle-nose deformity

Issues for Referral

  • Follow up with otolaryngologist if:Removal unsuccessful in EDConcern for nasal mucosa injury

Follow-Up Recommendations

  • Return to the ED immediately if:Coughing, wheezing, noisy, or difficult breathingVomiting, gagging, choking, drooling, neck or throat pain, or inability to swallow
  • Parents should be instructed to seek medical care for the following:FeverHeadache or facial painPersistent epistaxisPersistent drainage of nasal fluid

Pearls and Pitfalls

  • Consider nasal foreign bodies in children 2-6 yr presenting with what appears to be sinusitis
  • Parents are best suited to perform positive-pressure removal to avoid frightening the childOften successful, with little/no sedationCan make other techniques more likely to succeed, even if it fails
  • Mix equal parts Lidocaine 4% with oxymetazoline to deliver simultaneously

Additional Reading

  • Fundakowaski пїЅCE, Moon пїЅS, Torres пїЅL. The snare technique: A novel atraumatic method for the removal of difficult nasal foreign bodies. J Emerg Med. 2013;44:104-106.
  • Heim пїЅSW, Maughan пїЅKL. Foreign bodies in the ear, nose, and throat. Am Fam Physician. 2007;76:1185-1189.
  • Kiger пїЅJR, Brenkert пїЅTE, Losek пїЅJD.Nasal foreign body removal in children. Pediatr Emerg Care. 2008;24:785-792.
  • Purohit пїЅN, Ray пїЅS, Wilson пїЅT, et al. The "пїЅparents kiss': An effective way to remove paediatric nasal foreign bodies. Ann R Coll Surg Engl. 2008;90:420-422.
  • Soto пїЅF, Murphy пїЅA, Heaton пїЅH.Critical procedures in pediatric emergency medicine. Emerg Med Clin North Am. 2013;31:335-376.

Codes

ICD9

932 Foreign body in nose пїЅ

ICD10

T17.1XXA Foreign body in nostril, initial encounter пїЅ

SNOMED

  • 74699008 foreign body in nose (disorder)
  • 33890007 Foreign body in nostril (disorder)
  • 66050007 Foreign body in nasal sinus (disorder)