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NASAL FOREIGN BODIES

Overview
Seen most commonly in younger pediatric patients, the presence of a nasal foreign body should be suspected in the young patient that presents with unilateral foul-smelling rhinorrhea, epistaxis, and nasal pain. Most often however, the patient presents asymptomatically with witnessed or confessed placement. While some foreign bodies can be removed by pediatricians or emergency physicians, otolaryngologists are typically consulted for deep foreign bodies, chronic foreign bodies with resultant inflammation, or corrosive or sharp objects that render removal difficult. While some foreign bodies can be easily removed at bedside, young patients or those with developmental delay more frequently require sedation for removal. Additionally, in cases of wedged or corrosive objects, such as button batteries, evaluation in operating room may be necessary for removal and to assess local tissue damage. Button batteries should be removed urgently as injury to the nasal mucosa can occur in less than one hour, resulting in harmful sequelae including mucosal scarring, synechiae, and septal perforation. 

Key Supplies for Nasal Foreign Body Removal

  • Appropriate PPE including masks, eye protection, gloves, gown

  • Headlight

  • Rigid or flexible endoscope and tower for recording

  • Antifog (FRED) solution

  • Topical anesthetic-decongestant spray

  • 12 Fr Frazier tip suction

  • Nasal speculum

  • Alligator forceps with large mouth

  • Bayonet forceps

  • Silver nitrate applicator sticks

  • Blunt right angle hook, large ear loop

  • Small Foley catheter and 5 cc syringe may be helpful in some cases

Management

  • Patience, good patient rapport, and atraumatic nasal examination and foreign body removal are often the most important facets of nasal foreign body removal

  • Imaging is indicated only if the foreign body is imbedded in tissue or the diagnosis is uncertain as in the case of rhinolith formation

  • Unless the foreign body is very anterior and easily visualized and removed, apply topical anesthetic and decongestant; for button batteries, generally attempt to avoid nasal sprays and moisture as this can cause increased tissue damage    

  • If the foreign body is anterior and not sharp, it may be removed using anterior rhinoscopy and nasal instruments

  • For more posterior foreign bodies, rigid endoscopy should be used for visualization and to ensure foreign body is not pushed back into the airway.

  • Larger sized ear curettes or right angle hooks can be useful for rounded objects

  • For objects that are unable to be grabbed such as marbles, may place a Foley catheter just distal to the object, inflate a few cc’s, and gently pull Foley. Many pediatric patients may not be able to tolerate this, requiring that the object be removed in the operating room.

Example Procedural Note
After discussion of risks and benefits, written consent was obtained for foreign body removal. The child was restrained by the mother, and visualization was obtained with a straight endoscope. The foreign body was seen to be resting in ____ anterior middle meatus. A right angle hook was gently passed just distal to the object and the object was gently extracted. After removal, the nasal cavity was visualized again with the endoscope and confirmed to have no active epistaxis and no septal perforation. The patient tolerated the procedure well.

References

1.      Baranowski K, Al-Aaraj MS, Sinha V. Nasal Foreign Body. In: StatPearls. Treasure Island (FL): StatPearls Publishing; July 8, 2020.

2.      Friedman EM. VIDEOS IN CLINICAL MEDICINE. Removal of Foreign Bodies from the Ear and Nose. N Engl J Med. 2016;374(7):e7. doi:10.1056/NEJMvcm1207469.