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8/2/2018 0 Comments

Pediatric Nasal Foreign Bodies


Background:
  • Most common site of foreign body insertion in children
  • Can be missed and remain for weeks or months
  • Population at risk:
    • Children between 2–6 years-old most common
    • Mental retardation
    • Psychiatric illness
  • Complications:
    • Sinusitis is the most common complication
    • Septal perforation
    • Bronchial aspiration
  • High risk of complications with button batteries:
    • Mucosa ischemia
    • Turbinate or septal damage -> Saddle-nose deformity
Etiology:
  • Organic vs. Inorganic
  • Button batteries: High risk of complications compared with other foreign bodies (tissue necrosis, septal perforation, saddle-nose deformity); require rapid removal!
    • Septal perforation can occur in as little as 4 hours
  • Magnets (Used to mimic nasal piercing)
    • May cause intestinal perforation if swallowed, especially newer high-powered neodymium magnets
Signs & Symptoms:
  • Most nasal foreign bodies are asymptomatic
  • Unilateral nasal obstruction with nasal pain
  • Purulent/foul-smelling nasal discharge
  • Persistent epistaxis
History:
  • Child witnessed putting object into nose or FB noticed by parent/caretaker
  • Many children are reluctant to admit to placing a foreign body for fear of adult disapproval
  • Child may present weeks after with nasal discharge and bleeding
  • *Often misdiagnosed at this stage as sinusitis
Diagnosis:
  • Laboratory studies usually unnecessary
  • Fiberoptic visualization if foreign body cannot be visualized on rhinoscopy
  • Sinus films if present for extended period or suspicion of battery or magnet
  • May need chest or abdomen films for aspiration/ingestion
Treatment:
  • Keep in sitting position to avoid posterior displacement and possible aspiration of foreign body
  • Avoid interventions that upset the child
  • Topical vasoconstrictors:
    • Nebulized epinephrine
    • Cocaine: 4%
    • Oxymetazoline: 0.05%
    • Phenylephrine: 0.125–0.5%
*NOT recommended for button batteries as may increase leakage of caustic materials
  • Hooked probe, alligator forceps
    • Used for anterior foreign bodies that are easily grasped
  • Headlamp, nasal speculum will facilitate use!
  • Suction catheter can be used for round, smooth objects
  • Balloon catheters (or Katz extractor) can be used primarily when instrumentation fails
    • Can use a 5F or 6F Foley or Fogarty balloon catheter lubricated with 2% lidocaine jelly
  • Positive pressure for children or the “parent’s kiss”
    • Positive pressure applied to mouth only 
    • Parent may tell the child he or she will be given a “big kiss.”
    • Deliver brisk puff as child begins to inhale
    • Alternatively, deliver puff with a bag-valve mask over the mouth and O2 at 10–15 L/min.
  • Procedural sedation may be necessary
    • Need availability of advanced airway as foreign body has potential for dislodgment posteriorly and aspiration!
  • Snare technique (for you MacGyver’s out there):
    • 24-gauge wire made into a loop with a hemostat
    • Slip through swollen tissue, behind object, pulling it free
Disposition:
  • Admission Criteria:
    • Foreign body cannot be recovered in ED or posteriorly displaced
    • Removal under general anesthesia is required
    • Mucosal ischemia or turbinate/septal damage
  • Discharge Criteria
    • Ensure that there is no airway compromise
    • If a button battery was removed, monitor for delayed sequelae as outpatient
    • May require follow-up with ENT if removal unsuccessful in ED or concern for nasal mucosa injury
 
 
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