Nasal foreign bodies are commonly seen in the emergency department mostly in the pediatric population but also in those with psychiatric illness or developmental disabilities.
Nasal foreign bodies are usually benign but have the potential to cause mucosal damage, bleeding, infection and at the extreme aspiration. The nasal foreign body may be obvious or may require a high index of suspicious.
Basically, foreign bodies are classified as organic or inorganic. In general, the organic foreign bodies tend to be more irritating to the nasal mucosa and tend to cause symptoms much early. The most common location for a nasal foreign body is just below the inferior turbinate or anterior to the middle turbinate. Foreign bodies are more common in the right nostril because most individuals are right-handed.
Children are the most common age group to place objects in the nasal cavities as they are interested in exploring their bodies. It is unusual to see nasal foreign bodies in children younger than nine months when they are not capable of a pincer grasp.
Foreign bodies tend to lie one of two locations in the nasal fossae: the floor of the inferior turbinate or anterior to the middle turbinate.
Nasal foreign bodies are classified as inorganic or organic. Inorganic include most commonly beads, pieces of toys, foam, batteries or magnets. Organic foreign bodies include paper, sponge, nuts, and beans. Rarely parasitic or larvae infections can be present in the nose.
Children aged two to five years of age are most likely to insert objects into the nose. There is a slightly higher incidence in boys. Unilateral foreign bodies are found on the right side twice as often as the left probably due to right-handedness.
Complications occur in approximately 9% of patients, most commonly epistaxis, sinusitis, and otitis media. Rarely, more severe complications can occur including preseptal cellulitis, meningitis, epiglottitis, diphtheria, and tetanus.
Failure to remove in the emergency department is higher with spherical or disk-shaped objects and if more than one attempt or instrument is used. The average time to removal is 9.7 hours, but close to 15% will present after 48 hours.
Children with autism spectrum disorder commonly repeatedly insert foreign bodies into various orifices. They may also have multiple objects on multiple sites.
Children with younger siblings in the home are more likely to insert objects in the nose.
Repeated insertion of objects into the nose or other orifices can be associated with psychiatric illness.
The foreign body produces local inflammation that can lead to pressure necrosis. Mucosal ulceration can then progress to erosion into blood vessels causing epistaxis. If the object becomes displaced posteriorly, it can enter the respiratory tract with secondary morbidities. Nasal foreign bodies can become calcified known as a rhinolith. They may be present for very long periods of time. Organic objects cause a brisk inflammatory response.
Button batteries are now ubiquitous in children's toys, remote controls, hearing aids, calculators, and many other places. Each year, more than 300 button batteries are ingested in the United States. They are small and shiny and very appealing to children. Tissue damage occurs as direct leakage causes corrosive damage. There are also direct current effects on the mucosa and pressure necrosis. Tissue fluids generate a current between the battery anode and cathode resulting in corrosion. Paired magnets also create a current with similar results. There may be a septal perforation in as little as 4 hours.
The child will often tell the parent that they placed an object in their nose, but the parent may witness the act. Often, the child may also present with unilateral purulent and foul-smelling nasal discharge. They may have been treated previously for sinusitis with no success. They may also be sneezing, snoring, fever or coughing. Younger children may only present with irritability.
On examination with good lighting and sniffing position, the object may be seen. There may be unilateral epistaxis or discharge ranging from clear to purulent. Every attempt must be made to thoroighly visualize the nasal cavity. In addition, the tympanic membrane should be assessed for inflammation and the lungs auscultated for wheezing.
The axiom that a unilateral, foul-smelling nasal discharge is a foreign body until ruled out holds true.
Laboratory evaluation is usually unnecessary.
Imaging may be needed for suspicion of battery or magnet if suspected or poorly visualized. Unfortunately many foreign bodies are radiolucent. If it is suspected that the foreign body has been aspirated into the airways, a chest x-ray is necessary.
Removal of nasal foreign bodies requires a bright light source, preferably a headlamp. It is important that a parent or caregiver firmly holds the child, for example in a papoose or with sheets in the sniffing position, and that the practitioner has suction readily available. Conscious sedation may be considered, but the foreign body has the potential to dislodge and cause aspiration under sedation posteriorly. Ability to provide for an advanced airway is a prerequisite. The use of a topical vasoconstrictor may help visualize the object, control bleeding and decrease secretions. This is not recommended when there is a concern for button battery as it may increase leakage of acids. A nasal speculum, various size probes, curettes, and alligator forceps are necessary.
There are various techniques used to remove nasal foreign bodies.
The most commonly used is direct visualization and extraction using instrumentation. Curettes, alligator forceps, or probes are best used in this fashion. The object can be pulled directly out using alligators as in the case of paper or sponge material. Smooth, more spherical objects are best removed with curette or probe inserted past the object and pulled forward.
Forced exhalation is another method that may utilize either the parent or a bag-valve-mask (BVM). The "parent's kiss" utilizes the parent to seal their mouth over the child's mouth with a firm seal, occluding the unaffected nare and blowing into the child's mouth in the hope of expelling the object. A BVM can be used in the same fashion with a tight seal.
Suction can be used to remove or bring an object lower into the nasal passages. Flexible suction catheters or Yankhauer can be used depending on the size of the patient. In addition, one may use hooks, balloon catheters and positive pressure to remove the foreign body.
Glue can be used in a very cooperative patient. A small amount of glue is placed on a cotton swab and applied to a spherical, well-visualized object and pulled forward. The one technique that should not be used is irrigation as it carries a high risk for choking or aspiration.
In children, removing a nasal foreign body requires experience and patients. Multiple attempts should not be made. In addition, emergency airway supplies should be in the room before making any attempt at removal.
While local anesthesia is not necessary, the use of a vasoconstrictor can make the examination easier. If the child is uncooperative, sedation is highly recommended.
If there is any doubt in the emergency department on how to remove the foreign body, an ENT surgeon should be consulted.
Other complications include nose bleeds, nasal obstruction and sinusitis. Sometimes the foreign body can be coated with magnesium, calcium or carbonate and turns into a rhinolith. These radio-opaque bodies often go undetected for months or years because they are difficult to visualize. Small button batteries have the high morbidity as they rapdily induce ulceration and necrosis leading to perforation of the nasal septum.
A patient should be referred to an otorhinolaryngologist (ENT) when button batteries, magnets, as well as posteriorly displaced objects are lodged. They may require nasal endoscopy or removal in the operating room.
Flushing is no longer recommended as there is an increased risk of choking and aspiration.
Caution should always be used for the removal of nasal foreign bodies.
Educating families about the risk of button batteries is important. Adult supervision is always the key to prevention.
Making a diagnosis and removal of a nasal foreign body requires an interprofessional team.
The majority of cases of nasal foreign bodies are seen in the emergency department. Besides children, the nasal foreign body may also be seen in adults with psychiatric illnesses. If the nasal foreign body dislodges, it can block the airway and lead to an immediate fatality; hence nurses and physicians in the emergency room have to be aware of the potential consequences of this diagnosis. The majority of nasal foreign bodies can be removed in the emergency department without any sequelae. However, if there is any difficulty in removing the foreign body an ENT consult should be made.
Before making any attempt at removal, airway resuscitation equipment must be in the room. Anesthesia should be notified because many children are not cooperative. A nurse should be dedicated to the monitoring of the child during removal, irrespective of whether anesthesia is used. After removal of the foreign body, the child should be observed in the emergency room for 30-60 minutes. The parent should be educated to keep loose items away from the reach of the child.
Small case series report that complications are rare when the foreign body is removed from the nose promptly but any delay can lead to a number of complications.
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