Nasal foreign body

Background

Nasal anatomy.

• Common foreign bodies include food (beans, nuts, gum), marbles, batteries, beads, magnets, jewelry, stones, tissue, etc.
• Suspect foreign body in a patient with unilateral purulent or bloody nasal discharge or unilateral sinusitis even if no history of foreign body insertion.
• Small children may need procedural sedation for removal efforts.
• Radiographic imaging unlikely to be helpful.
  • Exception: if suspect nasal foreign body but do not see one, consider radiography to rule out button battery or magnets across septum prior to discharge and follow-up with ENT
• Always check other nare and ears - may have multiple foreign bodies

Foreign Body Types

• Ear foreign body
• Nasal foreign body
• Ocular foreign body
• Aspirated foreign body
• GI
  • Ingested foreign body
    • Bezoar
    • Body packing
    • Esophageal foreign body removal with foley catheter
  • Rectal foreign body
• Soft tissue foreign body

Clinical Features

Intra nasal view of a right nasal button battery foreign body.

• History of foreign body insertion
• Foreign body seen on exam

Differential Diagnosis

Rhinorrhea

• Upper respiratory infection, influenza
• Sinusitis
• Juvenile nasopharyngeal angiofibroma
• Nasal polyp
• Nasal mass
• Nasal foreign body
• CSF leak (e.g. basilar skull fracture)
• Toxic inhalation (e.g. selenium toxicity, neurotoxic shellfish poisoning)

Evaluation

Plain X-ray: a right nasal button battery foreign body. (a) Lateral view (double contour), (b) Anteroposterior view.

Sagittal view of calcified nasal packing foreign body

Workup

• Typically not indicated

Diagnosis

• Typically clinical, based on history and exam

Management

• Consider afrin spray or atomized lidocaine with epinephrine prior to removal efforts.
• Keep patient upright to avoid foreign body going back into airway
  • Can sit on parent's lap with parent hugging / restraining arms
  • Can use a c-collar to prevent side to side motion
• Options:
  1. "Parent's Kiss" - like performing mouth to mouth. Have parent close contralateral nare, form tight seal over child's mouth. Perform short, sharp blow of air into patient's mouth to expel foreign body (best for foreign bodies occluding the whole nostril)
  2. BVM technique - similar to "Parent's Kiss" technique - close opposite nare, use BVM with tight fit over mouth only, squeeze bag to provide short, sharp blow of air
  3. Alligator forceps or Bayonet forceps
  4. Curette (lighted may be helpful)
  5. Dermabond on end of long q-tip (Can use a disposable speculum to shield the nares so you do not accidentally glue the q-tip to the skin)
  6. Balloon catheter (e.g. foley catheter or fogarty catheter or commercial Katz extractor) - snake catheter into nare past the foreign body → gently inflate balloon → gently pull catheter out of nare
  7. Suction (can make own with small caliber ETT cut short or 14 Fr suction catheter cut short)

Disposition

• Most patients can be discharged
• If unable to remove foreign body, or if complications → refer to ENT
• If foreign body is button battery or multiple magnets (especially strong rare earth magnets), requires immediate removal in ED. Consult ENT if needed.
• Short course prophylactic antibiotics if foreign body was present for a long time or there is edema - risk of sinusitis

Complications

• Barotrauma from "Parent's Kiss" or BVM technique
• Bleeding or other nasal trauma
• Displacement of foreign body into airway
• Dermabond method: gluing swab to skin
• Tissue necrosis (batteries and magnets)
• Prolonged foreign body or extensive edema increases risk of sinusitis

See Also

• Foreign body

External Links

• Trick of the Trade: Nasal foreign body removal using foley catheter

Videos

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References

• Harwood-Nuss, Roberts and Hedges