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.
Discussion
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.
References:
Backlin SA: Positive-pressure technique for nasal foreign body
retrieval in children. Ann Emerg Med 1995;25:554-555.
