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