Nasal Foreign Bodies

3.10 Nasal Foreign Bodies

Presentation
Children may admit to parents that they have inserted something into their noses, but sometimes the history is obscure and the child presents with a purulent unilateral nasal discharge. Most commonly encountered are beans or other foodstuffs, beads, pebbles, paper wads, and eraser tips. These foesign bodies usually lodge on the floor of the anterior or middle third of the nasal cavity. Occasionally, caustic material was sniffed into the nose or coughed up into the posterior nasopharynx (e.g., a ruptured tetracycline capsule), the patient will present with much discomfort and tearing, and inspection will reveal mucous membranes covered with particulate debris.
What to do:



Explain the procedure beforehand in detail to patient and parents. Explain that it will be a little uncomfortable, and that aspiration of the foreign body into the trachea is a real but remote possibility.



After initial inspection using a nasal speculum and bright light, suction out any purulent discharge and insert a cotton pledget soaked in 4% cocaine or a solution of one part phenylephrine (Neo-Synephrine) and one part tetracaine (Pontocaine) to shrink the nasal mucosa and provide local anesthesia. Be careful to avoid pushing the foreign body posteriorly. Remove the pledget after approximately 5-10 minutes.



If the patient is able to cooperate, have him try to blow his nose to remove the foreign body. With an infant it is sometimes possible to have the parent blow a sharp puff into the baby's mouth whild holding the opposite nostril closed to blow the object out of the nose.



Before attempting any removal using surgical instruments, a potentially uncooperative child must be firmly restrained and sedated (see below)



Alligator forceps should be used to remove cloth, cotton, or paper foreign bodies. Pebbles, beans, and other hard foreign bodies are more easily grasped using bayonet forceps or Kelly clamps, or they may be rolled out by getting behind it using an ear curette, single skin hook, or right angle ear hook. A soft-tipped hook can be made by bending the tip of a metal-shaft calcium alginate swab (Calgiswab) to a 90 degree angle. An additional approach is to bypass the object with a Fogarty, biliary or small Foley catheter, passing it superior to the foreign body, inflating the balloon with approximately 1ml of air and pulling the object out through the nose.



Any bleeding can be stopped by reinserting a cotton pledget soaked in the topical solution used initially.



To irrigate loose foreign bodies and particulate debris from the nasal cavity and posterior nasopharynx, simply insert the bulbous nozzle of an irrigation syringe into one nostril while the patient sits up and forward, ask the patient to close off the back of his throat by repeating the sound "eng" and flush the irrigating solution out through the opposite nostril into an emesis basin.



After the foreign body is removed, inspect the nasal cavity again and check for additional objects that may have been placed in the patient's nose. Look also for unsuspected foreign bodies in the ears. Picture
What not to do:



Do not ignore a unilateral nasal discharge in a child. It must be assumed to be secondary to a foreign body until proven otherwise.



Do not push a foreign body down the back of a patient's throat, where it may be aspirated into the trachea.



Do not attempt to remove a foreign body from the nose without first using a topical anesthetic and vasoconstrictor.
Discussion
The mucous membrane lining the nasal cavity allows you the tactical advantages of vasoconstriction and topical anesthesia. In cases where patients have unsuccessfully attempted to blow foreign bodies out of their noses, they may be successful after instillation of an anesthetic vasoconstriction solution. If a patient swallows a foreign body that has been pushed back into the nasopharynx, this is usually harmless and the the patient and parents can be reassured (see Swallowed foreign body). If the object is aspirated into the tracheobronchial tree, it may produce coughing and wheezing and bronchoscopy under anesthesia will be required for retrieval. Button batteries can cause serious local damage and should be removed quickly.
References:



Backlin SA: Positive-pressure technique for nasal foreign body retrieval in children. Ann Emerg Med 1995;25:554-555.