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
- Causes of worsening impaction and difficulties with removal:
- Organic material may expand if moistened
- Mucosal swelling over time
- 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
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 piercing
- Often imbedded in nasal tissue, leading to difficult removal
- May 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 chronic
- Unilateral
- Foul smelling
- Halitosis
- 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 bleeding
- Often misdiagnosed at this stage as sinusitis
Essential Workup
Visualization of the foreign body in the nostril: Always check both nostrils �
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:
- Lymphoma
- Rhabdomyosarcoma
- Nasopharyngeal carcinoma
- Esthesioneuroblastoma (also known as an olfactory neuroblastoma)
- Congenital masses:
- Dermoid
- Encephalocele
- Glioma
- Teratoma
- 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 attempts
- Nebulized epinephrine
- Cocaine: 4%
- Oxymetazoline: 0.05%
- Phenylephrine: 0.125-0.5%
- 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."�
- Placement of 4 � 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
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: �
- 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 mucosa
- Turbinate or septal damage
- Saddle-nose deformity
Issues for Referral
- Follow up with otolaryngologist if:
- Removal unsuccessful in ED
- Concern for nasal mucosa injury
Follow-Up Recommendations
- Return to the ED immediately if:
- Coughing, wheezing, noisy, or difficult breathing
- Vomiting, gagging, choking, drooling, neck or throat pain, or inability to swallow
- Parents should be instructed to seek medical care for the following:
- Fever
- Headache or facial pain
- Persistent epistaxis
- Persistent 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 child
- Often successful, with little/no sedation
- Can make other techniques more likely to succeed, even if it fails
- Mix equal parts Lidocaine 4% with oxymetazoline to deliver simultaneously
Additional Reading
- Fundakowaski �CE, Moon �S, Torres �L. The snare technique: A novel atraumatic method for the removal of difficult nasal foreign bodies. J Emerg Med. 2013;44:104-106.
- Heim �SW, Maughan �KL. Foreign bodies in the ear, nose, and throat. Am Fam Physician. 2007;76:1185-1189.
- Kiger �JR, Brenkert �TE, Losek �JD.Nasal foreign body removal in children. Pediatr Emerg Care. 2008;24:785-792.
- Purohit �N, Ray �S, Wilson �T, et al. The "�parents kiss': An effective way to remove paediatric nasal foreign bodies. Ann R Coll Surg Engl. 2008;90:420-422.
- Soto �F, Murphy �A, Heaton �H.Critical procedures in pediatric emergency medicine. Emerg Med Clin North Am. 2013;31:335-376.
Codes
ICD9
932 Foreign body in nose �
ICD10
T17.1XXA Foreign body in nostril, initial encounter �
SNOMED
- 74699008 foreign body in nose (disorder)
- 33890007 Foreign body in nostril (disorder)
- 66050007 Foreign body in nasal sinus (disorder)