Otolaryngology

Foreign Bodies: Nose

Background

1. Definition
   • Organic or inorganic objects lodged in the nasal cavity
2. Synopsis
   • With the exception of button batteries and two or more disc magnets, most objects can be removed on a non-urgent basis
   • If the FB is smooth or soft and completely occludes the anterior nasal cavity, positive-pressure removal is preferred
   • Non-occlusive FBs in the anterior cavity usually require instrument-assisted removal

Pathophysiology

1. Etiology
   • Usually the result of child intentionally placing the object(s) in nares
2. Predisposition/Risk Factors
   • Predominantly toddlers and preschoolers
   • Usually in right nostril since most children are right-hand dominant
3. Pathology
   • Porous FBs (e.g., paper or foam): nidus for infection
   • Button batteries: alkaline tissue necrosis, septum perforation within hours
   • Paired magnets (one in each nostril): septum breakdown and perforation (days to weeks)
4. Epidemiology
   • Mortality/Morbidity
     • Complications from removal: provider experience, adequate lighting and proper equipment, sufficient restraint of the patient
     • Aspiration during attempts at removal
   • Incidence/Prevalence
     • Most common FB location in children

Diagnostics

1. History/Symptoms
   • Often the child will admit to placing the object, or the caregiver witnessed the event
   • Frequently asymptomatic
     • May remain undetected for weeks or months
   • High suspicion if unilateral purulent nasal discharge (black discharge indicates necrosis consistent with button batteries)
   • Occasionally epistaxis, nasal obstruction or mouth-breathing
2. Physical Exam/Signs
   • FB visualized in the anterior nasal cavity (may be difficult to visualize posterior FBs)
   • Facial pain or swelling (rare)
3. Labs/Tests
   • None indicated or required
4. Imaging
   • Plain radiographs are NOT routine, but may help with posterior FBs, button batteries, or magnets
   • CT/MRI
     • Consider if suspicion of tumor as cause of presentation
5. Differential Diagnosis
   • If nasal discharge is present, but unable to visualize FB on exam, may need to consider other etiologies (e.g. sinusitis)
   • Munchausen's by-proxy

Treatment

1. Initial/Prep/Goals
   • To prevent aspiration or ingestion, start with patient in sitting or slightly upright position
   • Prepare sufficient lighting and restraints (if necessary) to ensure steady positioning
   • Consider topical anesthetic (i.e. 1% lidocaine without epi) ~10min prior to starting procedure
   • Topical vasoconstrictors may be beneficial for large, well-visualized objects
   • Sedation may be required if child is uncooperative
2. Medical/Pharmaceutical
   • Oral antibiotics after removal for chronic FBs with associated drainage
3. Surgical/Procedural
   • Positive pressure:
     • Object must completely occlude nasal passage
     • Have pt exhale forcefully out the affected nostril while occluding the opposite side and with mouth closed
     • Works best with children > 3 year old who can follow instructions
   • "Parents Kiss":
     • Parent seals his or her mouth over the child’s and delivers a small amount of positive pressure while occluding the unobstructed nostril
     • Other methods include inducing positive pressure with a bag-valve mask, or directed high-flow oxygen (10-15L/min) in the contralateral side using oxygen tubing with a male-to-male adapter at one end
   • Instrumentation options:
     • Use non-dominant hand to push the tip of the nose up for better visualization
     • Forceps: grasp and remove object
       • Works best with soft objects
     • Right-angled hook: pass instrument beyond the object and rotate the instrument head to guide the object out
       • Works best with hard objects
     • Foley or other small balloon catheter: pass catheter above and beyond the object, inflate the balloon slightly, and apply gentle traction to guide the object out
     • Cyanoacrylate glue: apply a small amount of glue to the wooden tip of a cotton swab. Hold against object for 20-30 seconds to ensure bonding and remove the object
       • Works best if FB is dry and there is little or no drainage

Complications

1. Minor trauma to nasal passage
2. Object may be pushed farther up the nasal passage and become lodged
3. Aspiration or ingestion of object during removal
4. Other:
   • Epiglottitis
   • Sinusitis
   • Periorbital cellulitis
   • Meningitis

Prevention

1. Anticipatory guidance/counseling for parents as child becomes more mobile and curious

Disposition

1. Admit if
   • Failure to remove any object with potential airway compromise
2. Consult
   • ENT consult if object difficult to remove
3. Discharge/Follow-up instructions
   • Follow-up to ENT if removal traumatic or concerning
   • Chronic FB with drainage: oral antibiotics after removal
     • Amoxicillin

References

1. Heim SW, Maughan KL. Foreign Bodies in the Ear, Nose and Throat. Am Fam Physician. Oct 15 2007; 76(8):1185-1189
2. Falcon-Chevere JL, Giraldez L, Rivera-Rivera JO, Suero-Salvador T. Critical ENT Skills and Procedures in Emergency Medicine. Emergency Medicine Clinics of North America. Feb 2013:31(1); 29-58
3. Batzakakis D, Karkos PD, Papouliakos S, Leong SC, Bardanis I. Nasal actinomycosis mimicking a foreign body. Ear Nose Throat J. 2013;92(7):E14-16
4. Kamat A, Tabaee A. Chronic foreign body of the nasal cavity and sphenoid sinus: surgical implications. Cleft Palate Craniofac J. 2012;49(1):114-117
5. Kiger JR, Brenkert TE, Losek JD. Nasal foreign body removal in children. Pediatr Emerg Care. 2008;24(11):785-792; quiz 790-782
6. Webb BD, Pereira KD, Fakhri S. Nasal foreign body as the cause of a subperiosteal orbital abscess in a child. Ear Nose Throat J. 2010;89(2):E11-13
7. Yasny JS, Stewart S. Nasal foreign body: an unexpected discovery. Anesth Prog. 2011;58(3):121-123
8. Yeh B, Roberson JR. Nasal magnetic foreign body: a sticky topic. J Emerg Med. 2012;43(2):319-321
9. Kalan A, Tariq M. Foreign bodies in the nasal cavities: a comprehensive review of the aetiology, diagnostic pointers, and therapeutic measures. Postgrad Med J. 2000 Aug;76(898):484-7.
10. Tasche KK, Chang KE. Otolaryngologic Emergencies in the Primary Care Setting. Med Clin North Am. 2017 May;101(3):641-656.
11. Koehler P, Jung N, Kochanek M, Lohneis P, Shimabukuro-Vornhagen A, Böll B. 'Lost in Nasal Space': Staphylococcus aureus sepsis associated with Nasal Handkerchief Packing. Infection. 2019 Apr;47(2):307-311.

Contributor(s)

1. Hilbert, SueLin, MD
2. Ballarin, Daniel, MD

Updated/Reviewed: November 2022