II. Epidemiology
- Common in children and developmentally disabled
III. Etiology
- Inorganic Materials (Beads, Pebbles, Wax, Button batteries)
- Organic Materials (Beans, Peas)
- Tend to swell and soften
- Makes removal more difficult
IV. Signs
- Unilateral foul smelling discharge
- Nasal obstruction
- Vasoconstriction makes foreign body more easily seen
V. Precautions
- Do not push posteriorly
- May result in aspiration or more difficult further removal
- Button batteries and magnets require immediate removal
- Risk of Septal perforation, nasal adhesions, saddle deformity
VI. Management: Patient attempts to expell foreign body
- Blow nose with opposite nare occluded
- Trial of insufflation
- Occlude opposite nostril (e.g. with finger)
- Parent blows into mouth (or with Ambu Bag)
- Avoid using excessive pressure or volume
- Forces air through nostril with foreign body (glottis typically closes as a reflex)
VII. Management: Clinician attempted removal in clinic or emergency department
- Pretreatment
- Phenylephrine 0.5% (Neo-Synephrine) or Oxymetazoline (Afrin)
- Avoid Oxymetazoline in young children (see One Pill Can Kill)
- Topical Anesthetic (e.g. Lidocaine via Intranasal Mucosal Atomization Device or MAD)
- Conscious Sedation may be required in young or developmentally delayed patients
- Exercise caution with sedation in Nasal Foreign Body (risk of posterior displacement)
- Consider deferring sedation and removal by otolaryngology in the operating room
- Phenylephrine 0.5% (Neo-Synephrine) or Oxymetazoline (Afrin)
- Airway protection
- Position the patient to reduce risk of posterior foreign body displacement
- Patient supine with head of bed at 30 degrees is most often used
- Procedures and Instruments
- See Ear Foreign Body for other techniques
- Nasal speculum
- May increase visibility
- Katz Extractor
- Fogarty or Foley Catheter (lubricated 5-6 french catheter)
- Insert behind foreign body, inflate balloon and then pull out with foreign body
- Avoid forcing the obstruction posteriorly
- Telescoping Magnet
- For removal of magnetic foreign bodies
- Forceps (Alligator or bayonet)
- Cerumen curette
- Special circumstances: Paired magnets
- Paired magnets in each nostril may attract one another across the septum
- Pressure on the septum between the magnets can result in tissue injury and perforation
- Techniques
- Cardiac Pacemaker magnets may be used at each nare to pull the magnets apart
- Flat or hooked instruments may be interposed between the magnet and the septum
- Paired magnets in each nostril may attract one another across the septum
VIII. Management: Referral
- Most foreign bodies may be safely deferred to ENT for removal in 1-2 days
- Batteries (esp. button batteries) and magnets should be removed emergently (local necrosis risk)
- Posterior foreign bodies may risk airway obstruction and may require more urgent removal
- Referral Indications
- Foreign body refractory to removal attempts (posterior or hidden)
- Chronic foreign body with significant localized reaction
- Young or developmentally delayed patients requiring Conscious Sedation
- Significant Trauma on attempted removal
- Sharp, penetrating or hooked foreign body
IX. References
- Claudius and Brown (2017) Crit Dec Emerg Med 31(12): 13-20
- Claudius, Behar and Stoner in Herbert (2015) EM:Rap 15(11):2-3
- Warrington (2024) Crit Dec Emerg Med 38(3): 20-1
- Chan (2004) J Emerg Med 26: 441-5 [PubMed]
- Heim (2007) Am Fam Physician 76: 1185-9 [PubMed]
- Kalan (2000) Postgrad Med J 76: 484-7 [PubMed]