II. Epidemiology

  1. Common in children and developmentally disabled

III. Etiology

  1. Inorganic Materials (Beads, Pebbles, Wax, Button batteries)
  2. Organic Materials (Beans, Peas)
    1. Tend to swell and soften
    2. Makes removal more difficult

IV. Signs

  1. Unilateral foul smelling discharge
  2. Nasal obstruction
  3. Vasoconstriction makes foreign body more easily seen

V. Precautions

  1. Do not push posteriorly
    1. May result in aspiration or more difficult further removal
  2. Button batteries and magnets require immediate removal
    1. Risk of Septal perforation, nasal adhesions, saddle deformity

VI. Management: Patient attempts to expell foreign body

  1. Blow nose with opposite nare occluded
  2. Trial of insufflation
    1. Occlude opposite nostril (e.g. with finger)
    2. Parent blows into mouth (or with Ambu Bag)
    3. Avoid using excessive pressure or volume
    4. Forces air through nostril with foreign body (glottis typically closes as a reflex)

VII. Management: Clinician attempted removal in clinic or emergency department

  1. Pretreatment
    1. Phenylephrine 0.5% (Neo-Synephrine) or Oxymetazoline (Afrin)
      1. Avoid Oxymetazoline in young children (see One Pill Can Kill)
    2. Topical Anesthetic (e.g. Lidocaine via Intranasal Mucosal Atomization Device or MAD)
    3. Conscious Sedation may be required in young or developmentally delayed patients
      1. Exercise caution with sedation in Nasal Foreign Body (risk of posterior displacement)
      2. Consider deferring sedation and removal by otolaryngology in the operating room
  2. Airway protection
    1. Position the patient to reduce risk of posterior foreign body displacement
    2. Patient supine with head of bed at 30 degrees is most often used
  3. Procedures and Instruments
    1. See Ear Foreign Body for other techniques
    2. Nasal speculum
      1. May increase visibility
    3. Katz Extractor
      1. http://www.inhealth.com/category_s/49.htm
    4. Fogarty or Foley Catheter (lubricated 5-6 french catheter)
      1. Insert behind foreign body, inflate balloon and then pull out with foreign body
      2. Avoid forcing the obstruction posteriorly
    5. Telescoping Magnet
      1. For removal of magnetic foreign bodies
    6. Forceps (Alligator or bayonet)
    7. Cerumen curette
  4. Special circumstances: Paired magnets
    1. Paired magnets in each nostril may attract one another across the septum
      1. Pressure on the septum between the magnets can result in tissue injury and perforation
    2. Techniques
      1. Cardiac Pacemaker magnets may be used at each nare to pull the magnets apart
      2. Flat or hooked instruments may be interposed between the magnet and the septum

VIII. Management: Referral

  1. Most foreign bodies may be safely deferred to ENT for removal in 1-2 days
    1. Batteries (esp. button batteries) and magnets should be removed emergently (local necrosis risk)
    2. Posterior foreign bodies may risk airway obstruction and may require more urgent removal
  2. Referral Indications
    1. Foreign body refractory to removal attempts (posterior or hidden)
    2. Chronic foreign body with significant localized reaction
    3. Young or developmentally delayed patients requiring Conscious Sedation
    4. Significant Trauma on attempted removal
    5. Sharp, penetrating or hooked foreign body

IX. References

  1. Claudius and Brown (2017) Crit Dec Emerg Med 31(12): 13-20
  2. Claudius, Behar and Stoner in Herbert (2015) EM:Rap 15(11):2-3
  3. Warrington (2024) Crit Dec Emerg Med 38(3): 20-1
  4. Chan (2004) J Emerg Med 26: 441-5 [PubMed]
  5. Heim (2007) Am Fam Physician 76: 1185-9 [PubMed]
  6. Kalan (2000) Postgrad Med J 76: 484-7 [PubMed]

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