Nasal Foreign Bodies

Nasal foreign bodies are a common and challenging presentation to manage in the emergency department. A recent online article in Emergency Medicine Journal has shown that the “kissing” technique is effective 50% of the time at removing the object from the nasal cavity. The following post looks at a practical approach to nasal foreign bodies, and explores the use of the “kissing” technique further.

Case Study

Its 5pm on a Friday afternoon. You’re about to finish working for the day in the minor injury unit when the nurse brings in one last patient. She’s a disgruntled 3 year old girl with a complaint of green, offensive and malodorous discharge coming from her right nostril.

On inspection of the rightnasal cavity you visualise a silver bead sitting just out of reach.  The child reluctantly ‘agrees’ to sit on her mum’s lap  for a cuddle. You then ask her mother to seal her mouth over the child’s, whilst occluding the unaffected nostril. The mother then rapidly exhales into the child’s mouth, shooting the little bead out across the room, resulting in great amusement for the child and an ear full of snot for the mother. After a quick check of the other nostril, the child is on her way home and you make it to the Friday after-work sundowner.

 

Nasal Foreign Bodies

• Nasal foreign bodies are a common complaint presenting to emergency departments, predominately affecting the paediatric population under 5 years of age.
• Often the child will admit to putting something in their nose, or have been witnessed doing it. However sometimes this history can be obscured and the child may present with localised pain, purulent unilateral discharge, epistaxis, a voice change (with a “nasal” character), or a foul body/ breath odor.
• The most commonly encountered foreign bodies are, beads, beans, peanuts, toy parts, pebbles, paper wads, and eraser tips.
• The two most concerning foreign bodies are  button batteries and magnets as they have the ability to cause localised necrosis and septal perforation in a relatively short period of time.
• Nasal foreign bodies are commonly located just anterior to the middle turbinate or below the inferior turbinate, and affect the right side twice as often as the left. This may be related to right -handed individuals favouring the right side of the body.
• Nasal foreign bodies generally result in local inflammation, bleeding and purulent discharge.

Differential Diagnosis

• Epistaxis
• Sinusitis
• Polyps
• Tumor
• Upper respiratory tract infection
• Unilateral choanal atresia

Assessment of Nasal Foreign Bodies

Investigations and imaging may not be necessary of the foregin body is visualised. Otherwise lateral x-rays of the head/neck/chest amy be helpful to locate the foreign body.

Pre-removal

• Nasal foreign bodies can generally be seen on direct visualisation, with the assistance of a nasal or otoscope speculum.
• Always apply personal protective equipment, as spraying of projectile body fluids often occurs during removal.
• Topical application of lignocaine and adrenaline can aid in assessment and removal, by relieving pain, and providing lubrication.
• A head lamp or over head light will greatly assistant in examination.
• Have suction ready during examination to help remove debris — sometimes it can even help remove the foreign body.

Post-removal

• Always attempt (child permitting) to visualise to nasal cavity post removal, to assess for complete removal and localised trauma.
• Epistaxis can occur post removal. Click here for a guide to the management of epistaxis.
• Objects can be aspirated sometimes during removal, always assess the airway, breathing and circulation should this occur

Emergency Department Management

Direct Instrumentation

• Manual removal can be attempted in a cooperative or sedated child if the object is easily visualised, and able to be grasped.
• Right-angled hook probes can be passed alongside and past larger objects, rotated and gradually drawn back, removing the object.
• Forceps can be used (alligator or bayonet), and are useful for objects near the anterior nares.

Suction

• The use of wall suction can assist in retracting the object from the nasal cavity.
• The noise from the suction can scare young children. T oavoid this try using  the tubing without the suction catheter to decrease the noise made.

Positive pressure

• Start by asking the child to blow their nose, occluding the unaffected nostril as they do this. Sometimes, this alone may expel the foreign body.
• A nasal positive-pressure technique has been described as follows. Topical anaesthetic is applied to both nares, then a male-male oxygen adapter with tubing, using an oxygen flow rate of 10-15L/min, is the placed into the unaffected nostril. The pressure generated may force the object out. However, good co-operation from the child or procedural sedation may be needed.

The kissing technique has been around since 1965 and recent  studies have shown that the technique has a 50% success rate, doesn’t cause increase distress to the child or require sedation. This also means clinicians spend 50% less time playing aaround with snot!!

The technique is performed by a parent by placing their mouth over the child’s (giving a ‘big kiss’), while they occlude the unaffected nostril. The parent then exhales into the child’s mouth, generating positive pressure, similar to that of nose blowing.

Magnets

• Metal objects (ball bearings, nose piercings, magnets) have been successfully removed in the past using strong house hold magnets.
• The magnet is held 1cm away from the affected nostril and is used to guide the object out of the nasal cavity.
• There limited reports of the success of this method documented in the literature.

Other

• Another method involves the use of a cotton tip applicator with super glue or dermabond applied to the tip. the tip is then carefully placed against the foreign body for 20-30secs, then gently rotated and removed bringing the foreign body out with it. For more on this see the Academic Life in Emergency Medicine post: Trick of the trade: Ear foreign body removal.
• Depending on the size of the nasal cavity and location of foreign body, it may be possible to gently insert a small size foley catheter past the foreign body, before inserting 1-2ml of water into the balloon, and gently retracting the catheter to dislodge the foreign body.
• Rarely objects will be located so posteriorly that all of the above techniques will be futile, and these patients should be referred to ENT for removal in theatre.

Procedural Sedation

When the above measures fail to remove the foreign body, or the child is to combative to attempt, its time to consider procedual sedation. Some of the tricks and traps of procedural sedation and the removal of foreign bodies are discussed in Anaesthetic Addler 001: Nasal foreign body, ketamine and laryngospasm.

Medico-legal Pitfalls

These include:

• Failing to promptly remove button batteries or magnets from the nose to prevent necrosis and septal perforation.
• Failing to consult ENT specialist when there is suspected or proven damage to the nasopharynx requires ongoing management.
• Not looking for other foreign bodies in the other nostril, when one has been located.
• Not considering nasal foreign body in the diagnosis, when a child present with unilateral odor and discharge.

Reference

• Cameron, P. Jelinek, G. Everitt, I. Browne, G. & Raftos, J. (2006). Textbook of Paediatric Emergency Medicine. Google Books Preview
• Taylor, C. Acheson, J. Coats, T. (2010). Nasal foreign bodies in children: kissing it better. Emergency Medicine Journal. PMID:20581404
• Fischer, J. & Tarabar, A. (2008). Foreign Bodies, Nose. emedicine
• Koppuravuri, M. & Makeham, J. (2010). Parent’s kiss to remove nasal foreign bodies in children. BestBETs
• Navitsky, R. Beamsley, A. & McLaughlin, S. (2002). Nasal positive-pressure technique for nasal foreign body removal in children. American Journal of Emergency Medicine. 20(2), 103-104. PMID: 11880873