!3.09 Nasal Foreign Bodies
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.
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.
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.
* Backlin SA: Positive-pressure technique for nasal foreign body retrieval
in children. Ann Emerg Med 1995;25:554-555.
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