Nose

Nasal Foreign Body

Background

1. Synopsis
   • Common to see in the emergency department
   • Mostly seen in pediatric patients and those w/ psychiatric/developmental disorders
   • Mostly benign
     • However, have potential to cause
       • Mucosal damage
       • Bleeding
       • Infection
       • Aspiration
   • Most common presentation is acute but may be missed and remain so for
     • Weeks, months or even years after insertion

Pathophysiology

1. Mechanism
   • Foreign body in the nasal cavity may be harmless but can also cause harm
     • Swelling of the mucosa leading to
       • Mucosal erosions
       • Ulceration
       • Epistaxis
   • Organic foreign bodies tend to absorb water from surrounding tissue and swell
     • May become hard objects from accumulating minerals (becoming rhinolith)
   • Batteries
     • Direct leakage leads to tissue damage (corrosive)
     • May see pressure necrosis as well from direct current effects
     • Can lead to septal perforation in < 4 hrs, beginning w/ liquefactive necrosis
   • Paired magnets
     • Show similar results to batteries
2. Etiology/Risk Factors
   • Most likely objects
     • Pebbles
     • Beads
     • Nuts
     • Chalk
     • Other small objects (e.g., corn kernel) (View image)
   • Animate objects
     • Fly maggot
     • Screwworms
   • Increased risk w/
     • Young children
     • Psychiatric disorders
     • Developmental disorders
3. Epidemiology
   • Incidence/Prevalence
     • Button batteries: > 300 ingested in USA/year
     • Children: MC group (aged 2-5 yo), as they are "exploring" their bodies
       • Incidence slightly higher in boys compared w/ girls
       • Not common to see in children < 9 months (pincer grasp undeveloped)
     • Unilateral foreign bodies
       • Found on the right side 2x more often as opposed to the left
         • Most likely due to predominant right-handedness

Diagnostics

1. History/Symptoms
   • Presentation
     • Foul-smelling purulent nasal discharge
       • Normally unilateral
     • Generally painless
       • Some children may have headaches on the same side as the foreign body
     • Bloody stained discharged/epistaxis may be seen
     • Nasal occlusion
     • Sneezing
   • History of insertion
2. Physical Exam/Signs
   • Purulent discharge/malodor, bleeding, usually unilateral
   • Examine both nares and ears for other FB
     • Look for additional foreign bodies behind each other
     • Note turbinates, mucosal edema
   • Anterior rhinoscopy should be performed
     • Fiberoptic nasopharyngoscopy can be used as well
   • Rhinolith w/in the nasal cavity
     • Examiner will visualize a gray-colored object on the floor of the nasal cavity
   • Assess tympanic membrane for any signs of inflammation
     • Should be auscultated for any signs of aspiration (e.g., wheezing)
   • Exam may need to be carried under general anesthesia for non cooperative patients
3. Labs/Tests
   • Unnecessary
   • In of animate objects
     • WBC count
       • May be increased
4. Imaging
   • For suspicion of battery or magnet
   • Unfortunate, however, many FBs are radiolucent
   • CXR
     • For suspected foreign body aspirated into the airways
   • CT scan/MRI
     • May be done if tumor suspected may be the cause of presentation
5. Differential Diagnosis
   • Choanal atresia
   • Polyp
   • Sinusitis
   • Tumor
   • Upper respiratory tract infection

Treatment

1. Initial/Prep/Goals
   • Most important: Prevent aspiration
   • Pre-procedure
     • Reassurance
     • Comfortable positioning of patient and physician
     • Good lighting
     • Pre-assemble equipment
   • Do not irrigate
     • Holds potential for risk of choking/aspiration
2. Medical/Pharmaceutical
   • Reduce edema with Neo-Synephrine and then apply topical anesthetic
   • Topical vasoconstrictor
     • May help visualize the object, control bleeding and decrease secretions
   • Sedation recommended for noncompliant patients
3. Surgical/Procedural
   • Direct visualization and extraction using instrumentation (curettes, alligator forceps or probes)
     • Alligator forceps are useful in the case of paper or sponge material
     • Curette or probe are best for removal of smooth, more spherical objects
       • Passing beyond the object and pulling forward
   • Forced exhalation
     • May utilize either the parent or a bag-valve-mask (BVM)
       • Can be used in the same fashion w/ a tight seal
     • "Parent's kiss"
       • Utilizes the parent to seal their mouth over their child's mouth
         • In hope of expelling the object
   • Suction
     • Can be used to remove or bring an object lower into the nasal passages
     • Flexible suction catheters or Yankauer
       • Can be used depending on size of pt
     • One may use hooks, balloon catheters and positive pressure to remove the foreign body
   • Glue
     • Can be used in cooperative pt
     • Small amount placed on cotton swab and applied to a spherical-well visualized object
       • Then pulled forward
4. Complications
   • Acute otitis media
   • Acute epiglottitis
   • Meningitis
   • Nasal obstruction
   • Nasal septal perforation
   • Nose bleeds
   • Periorbital cellulitis
   • Respiratory arrest
   • Sinusitis
   • Tetanus

Disposition

1. Admission Criteria
   • Admission generally not required unless infection or dislodgement necessitating further care
2. Consult(s)
   • ENT consult if FB not easily removed
3. Discharge/Follow-up Instructions
   • Chronic FB with associated drainage: Must cover with oral antibiotics after removal
   • Treat any epistaxis that occurs in the standard manner
   • Follow-up in 2-3 days if removal was traumatic or concerning

References

1. Nasal Foreign Body. StatPearls [Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK459279/. [Accessed February 2024]
2. Kalan A, Tariq M. Foreign bodies in the nasal cavities: a comprehensive review of the aetiology, diagnostic pointers, and therapeutic measures. Postgrad Med J. Aug 2000;76(898):484-7.
3. Patil PM, Anand R. Nasal foreign bodies: a review of management strategies and a clinical scenario presentation. Craniomaxillofac Trauma Reconstr. Mar 2011;4(1):53-8.

1. Singh, Ajaydeep, MD