Case Report

NASAL FOREIGN BODY

Presentator : dr. Heribertus Diwyacitra Aribawa

Moderator : dr.

Otorhinolaryngology and Head Neck Surgery Departements

Medical Faculty of Gadjah Mada University / DR. Sardjito Hospital
Yogyakarta
2016
INTRODUCTION commonest. Nasal surgery and
penetrating wounds have been
NFBs are quite common among
reported as causes of nasal foreign
pediatric patients. The patients may
body [4]. Foreign bodies may be
present asymptomatically after
organic or inorganic, and principally
having been witnessed inserting the
affect children, especially aged
item. The presence of a FB in the
between 2 and 3 years of age [5].
nose may not be life-threatening but
Inorganic materials are typically
it may cause morbidity.
plastic [6], such as beads or buttons, or
Complications may arise from the FB
stones, paper or small parts from
itself or from attempted removal. The
toys; they are often asymptomatic and
method of removal usually depends
are usually discovered incidentally. On
on the type of FB, its position, and
the other hand, organic foreign
cooperation of the patient [1].
bodies may pro- duce earlier
If the foreign body is a battery or is symptoms because they tend to be
impacted, however, special more irritating to the nasal mucosa
precautions have to be taken. In [7]. Nasal foreign bodies may come to
addition, if the child is be lodged in any part of the nasal
uncooperative, general anesthesia is fossa, but the commonest location is
usually required to prevent just anterior to the middle turbinate
complications. Batteries are the type or below the inferior turbinate [8]. The
of foreign body most commonly rarest location was when a transnasal
associated with early complications foreign body had penetrated the
despite improvements in product anterior skull base through the
safety. Due to their small size, cribriform plate and passed between
batteries can easily be inserted into the frontal lobes. Removal of the
various orices such as nose, ear or nasal foreign body depends on its site
mouth [3]. There are various routes via and size and on the cooperation of the
which foreign bodies enter the nose, child. Different methods of foreign
the anterior nares being the body removal have been reported [9],
and depend on the preference of the other infectious diseases.3 It therefore
center. appears that foreign bodies in the nose can
create a real problem and should not be
Although more frequently seen in the
taken lightly.
pediatric setting, they can also affect adults,
especially those with mental retardation or Because nasal foreign bodies are
psychiatric illness.1 Children's interests in easier to remove than ear foreign bodies,
exploring their bodies make them more otolar yngology consultation occurs less
prone to lodging foreign bodies in their frequently. Otolar yngology should be
nasal cavities. In addition, they may also consulted when there is concern of a
insert foreign bodies to relieve preexisting tumor or mass, or when the foreign body
nasal mucosal irritation or epistaxis.1 As is unable to be removed by the treating
benign as an NFB may seem, it harbors the physician. Mucus, edema, granulations,
potential for morbidity and even mortality if or bony destruction may occur with
the object is dislodged into the airway. a chronic foreign body, making it
difficult to visualize and remove the
Foreign bodies are either animate or
foreign body. In those cases otolar
inanimate.2 The most commonly identified
yngology consultation is warranted.
inanimate foreign bodies include rubber
erasers, paper wads, pebbles, beads, Sedation is usually not recom-
marbles, beans, safety pins, washers, nuts, mended in most nasal foreign body
sponges, and chalk. Others are plasticine, cases because of the ease of removal,
pieces of wood, a door handle, metal hooks short length of the pro- cedure, and,
and eyes, pieces of cloth, bullets, thimbles, most importantly, the need for the
shrapnel, umbrella springs, iron bolts, corks, patient to have a good gag and cough
2
and coins. reflex to prevent aspirating the object
A loose foreign object in the postnasal space if it were to be pushed posterior into the
can accidentally be aspirated or pushed back oral pharynx. In our study, no patients
in an attempt at removal and may result in were sedated.4 If the patient is anxious,
acute respiratory obstruction. Foreign bodies intranasal versed may be used, but strict
in the nose have been implicated as carriers adherence to sedation guidelines should
of the causative organisms of diphtheria and be followed.
Local Anesthetic and This is one of the most com- mon
Vasoconstrictor methods used for nasal foreign
bodies, and in our study was used
All patients should be pre-
almost as commonly as alli- gator
medicated with several drops of both 1%
forceps.4 Depending on the size of
lidocaine without epi- nephrine, and
the patient, we use a 5 or 6
0.5% phenylephrine (Neo-
Synephrine ) instilled into the nostril Fr. Foley balloon catheter to re-
to provide local anesthesia and decrease move many foreign bodies. The
mu- cosal swelling, unless there are patient should be premedicated
contraindications to these med- ications with lidocaine without epinephrine
(allergies, chronic medical problems). and phenylephrine. The patient is
placed in the supine posi- tion.
Specific Techniques for Removal
After a check that the balloon
Graspable Instrument inflates properly, it is lubricated with
2% lidocaine jelly and advanced past
As in ear foreign bodies, alligator
the object. The balloon is inflated
forceps are excellent at removing soft,
with 2 or 3 milliliters of air and the
graspable foreign bodies, especially if
catheter withdrawn gently, pulling
they are lo- cated in the anterior
out the foreign body. The balloons
nares. 4,11
infla- tion may need to be varied
The disadvantage of this method is that de- pending on the size of the nasal
some for eign bodies (bread, paper) foreign body and the size of the
may pull apart leaving portions still in patients nares. This procedure
the nose. The possibility also exists of works well for foreign bodies that are
push- ing the foreign body further pos- in the posterior nasal pharynx, or
terior. Many parents report that they nasal foreign bodies that are round,
pushed the foreign body in farther while smooth, and nongras- pable. The
tr ying to remove it at home. Foley catheter may also be used
when direct visualiza- tion of the
foreign body is diffi- cult. The
Folley cathether Foley catheter tech- nique does not
work if the nasal foreign body is so nasal foreign bodies or foreign bodies that
big that it oc- cludes the nasal passage are tightly lodged.4
and the catheter cannot be passed
posterior to it.
Nasal Positive-Pressure Technique (Bag-mask,
Cur ved Hook
Male-male Tube Adapter, Parents Kiss)
A curved or right-angle hook is
There have been multiple re- ports in
excellent for removal of non-
the literature of using positive
graspable objects (beads, pop-corn
pressure to remove a nasal foreign
kernels), especially in the anterior
body. They all have the same concept,
nares.11 The hook is first passed
which is posi- tive pressure being applied
behind the object and the tip rotated to
to the patients contralateral nostril or
rest just behind the foreign body. The
mouth. The pressure will force the
hook is gradually removed withdrawing
nasal foreign body out of the affected
the for- eign body out the nose. In the
nostril. 4,12-14 This tech- nique works
case of beads with holes in them, the
best for round or cylindrical foreign
hook can be placed within the hole and
bodies that are occluding the nasal
gently removed
passage.
Suction (Schuknect FB Catheter)
When the bag-mask technique is used,
As previously discussed in the ear for the patient is placed in a supine position
eign body section, a Schuknect and restrained if needed. The
suction catheter is a metal suction contralateral nares is occluded with
catheter with a plas- tic umbrella at the external pressure. An anesthesia bag
tip. The plastic umbrella is placed against
connected to high-flow oxygen at 1015
the ob- ject and the suction applied. The liters per minute, with a mask that cov-
object is removed from the nose as the ers only the mouth, is allowed to expand
catheter is removed. This technique with the thumbhole cov- ered. If this
works best for round, smooth objects in pressure is not suffi- cient, the bag may
the anterior nares. The suction catheter be com- pressed, expelling the foreign
does not work as well for posterior body or at least moving the for- eign
body to a more anterior position allowing least moved anterior allowing for easier
for it to be grabbed by forceps. forceps removal. Botma et al13 reported
Although there is a theoretical potential 15 of 19 patients who had a nasal for- eign
for barotraumas to the tympanic body removed successfully with this
membrane or lower air way, a review of technique. There were no complications
the literature reveals no adverse side ef- in any of the pa- tients, and all parents
fects of this procedure. thought the technique was acceptable

The male-male tube adapter technique Nasal Wash

works in the same way as the bag-mask
technique except a male-male tube Lichenstein et al15 described 3
adapter hooked up to wall oxygen is patients in whom the nasal wash
place in the contralateral nares instead technique was used successfully. They
of a mask covering the patient s recommend filling a bulb syringe with

mouth. Navitsky et al12 reported 9 approximately 7 milliliters of sterile

patients who had a nasal foreign body normal saline and placing it in the

successfully removed with this contralateral nostril. The bulb syringe is

technique. There were no forcibly squeezed and the object is pro-

complications in any of the pa- tients, pelled out by the flow of saline back

and on follow-up, 5 of the 9 parents through the nasal passage. There were

described the procedure as less traumatic no complications in any of the

than a vaccine in- jection.12 patients.15 This method has many

A parents kiss technique works the
same way as the above- mentioned
techniques. A parent is instructed to
make a firm seal with their mouth over
the childs open mouth, and then give
a short, sharp puff of air into
childs mouth. The contralateral side of
the nose is occluded with a thumb. The
nasal foreign body is usually expelled or at
disadvantages. Forcibly irrigating saline
through the nose is uncomfortable and
carries a significant risk of aspiration.
This method of nasal foreign body re-
moval is not recommended, since there
are many less irritating and dangerous
the methods available for removal.
Cyanoacr ylate (Superglue)
 Cyanoacr ylate has also been 11 foreign bodies were rmly
described in the literature for the impacted and unidentiable (beads,
removal of nasal foreign bodies.16 nut fragments, sponge fragments in
Fig. 2) in time becoming rhinoliths.
The risks and disadvantages as discussed in
Button batteriesdeserve particular
the ear foreign body section also pertain
attention due to the severity of the
to nasal foreign bodies. For this reason
injuries they cause. We found 10 cases
cyanoacr ylate is not recommended for
of necrosis of the nasal mucosa and
nasal foreign body removal
two cases of septal perforation due to
Complications were seen (12%), button batteries. Three patients in this
epistaxis being the most common study underwent surgical debride-
(3.5%), followed by foul odor nasal ment. The most life-threatening
discharge and nasal vestibulitis complication was an intracranial
(3.4%), and mucosal irritation (1.6%). penetrating injury associated with a
Early complications (before 72 h) cerebrospinal uid stula [2]. It is
were due to the NFB itself (52%) or worth noting that, in our study, we did
prior removal attempts (48%). After not see any occurrence of an aspirated
prolonged exposure, an increase in nasal cavity-FB, thus becoming a
complications was seen due to the potential bronchial FB
NFB itself (88%) (Table 2). Prolonged
CASE REPORT
exposure signicantly increased the
complication rate due to the NFB A 4 years old girl came to the emergency
itself (p < 0.001, Risk Estimate Value department of Sardjito Hospital with a chief
3.85). Evidence of local trauma from complaint the insertion of bead in the right
earlier removal attempts may be nose. An hour before her mother saw her
present, with erythema, edema, playing with her toys and she didnt realize
bleeding, or a combination thereof. that her daughter used her beads as her toys.
However, NFBs located in part of When she looked the beads spread out on the
the airway both as a symptom or floor and her daughter came to her say that
complication of nasal obstruction the bead was inserted inside her nose her
were seen very rarely (1%). In total, mother tried to pull it out. But after some
tries and failed she decided to go to hospital. and the patient had been told not to insert the
Obstruction of the right nose (+), serous toy inside her nose, ear and mouth.
discharge (+), epistaksis (-), odorant rhinorea
DISCUSSION
(-). The patient had no fever. Ear and throat
complaints were denied A unilateral mucopurulent nasal
dischargewith foul odour is the most
On physical examination found that the
consistent findingsin patients with a nasal
general condition was good, compos mentis,
foreign body. Occasionally it can be
weight 9 kg, pulse 100x/ minute, respiratory
bloodstained.13 The ensuing unilateral
rate 23x/minute, temperature 36,7 Celcius
vestibulitis, specific of the paediatric
degree. On rhinoscopy anterior right nose
agegroup, is diagnostic (fig 2).
there was a bead foreign body in the upper
of inferior turbinate, hyperemic inferior Nasal foreign bodies are generallypainless.
turbinate (+), serous discharge (+), active
In fact some foreign bodies have
epistaksis (-), septum nasi intact and there
reportedly been present in the nasal cavity
was no deviation. Left nose there was no
epistaksis, slight serous discharge (+), no for years without symptoms.14 However
hyperemic turbinate, septum intact and rarely, pain and headache have been
deviation (-), The examination of experienced on the involved side with
oropharyng and ear within normal limits. intermittent epistaxis and sneezing reported

by others.13 Cases describing

Based on the anamnesis and physical
bromhidrosis (foul body odour)
examination the patient was diagnosed with
associated with nasal foreign bodies in
nasal foreign body in the righr nose.
Evacuation was done with curved hook and children have also been published.15
it succeed. The patient was given ibuprofen
In patients with animate nasal foreign
syrup to reduce the pain and as an
antiinflamation. Control to the ENT clinic bodies, the symptoms tend to be bilateral.

was not necessary unless there was a sequel

Nasal occlusion, headaches, and sneezing
complaint. The parents of the patient was
with serosanguinous discharge usually are
educated not to use a small object as her toys
the presenting symptoms. A rise in body
temperature occurs and a disagreeable fetid
odour emanates from the nasal passages.
Leucocytosis results from
accompanying secondary infection.
Examination of the nasal cavity may
reveal extensive destruction
surrounding mucous membranes, bone, and
cartilage and the mucosa is fragile and
bleeds easily. Constant motion and masses
of different worms may be observed. These
worms are firmly attached and difficult to
extract. Owing to the secondary infection
and bone destruction, complications are not
infrequent.13
the foreign object. However on occasions
the mucosal oedema or granulations tend to hide
it. In such cases the nose should be sprayed
with a vasoconstric- tor agent to shrink the
mucosa before re- examination. Many
of the
times the foreign body becomes apparent
with this manoeuvre.13 In younger or very
apprehensive children it may be necessary
for the search to be carried out under a
general anaesthetic.
In patients with parasitic and larvae infesta-
tion of the nose diagnosis is relatively easy
as the organisms are directly visualised.

Rhinoliths are initially symptomless and later Several unilateral lesions found in both chil-
dren and adults may produce obstruction of
cause nasal obstruction only if they become
the involved side. Such lesions would
enlarged. Examination of the nasal
include both benign and malignant tumours
cavity shows a greyish irregular mass,
of the nasal cavity, unilateral sinusitis,
usually along the floor of the nose that feels
unilateral cho- anal atresia, unilateral nasal
bony, hard and gritty on probing.
polyps, septal hae- matoma, and infections
Radiography usually confirms the diagnosis
like syphilis and diphtheria.16
and reveals the extent of the rhinolith.
A cooperative patient is needed to detect
Any patient who presents with a unilateral
and remove a nasal foreign body
nasal discharge should raise the suspicion of
successfully. The patient is usually
a nasal foreign body and in children this must
examined in the upright sitting position
be regarded the case until proved otherwise.
carried out for routine otorhinological
The physical examination of the nose
examination. A child may be best
involving anterior rhinoscopy and use of
examined by tilting the head back slightly so
either a fibreoptic nasopharyngoscope or a
0 degree rigid endoscope will often reveal
that the floor of the nose is visible to the
examiner. For this an adult may need to
restrain a child and hold the head steady.
Most inanimate foreign bodies, if visualised
well, can be removed easily through the
anterior nares with the use of cupped
forceps, haemostats, curved hooks, old
metallic eustachian tube catheters, and
suction. This can be done either with no
anaesthetic or after spraying with a local
topically acting anaesthetic solution such as
4% lignocaine (lidocaine). Removal of a
rounded object may be an arduous task
because of difficulty in grasping foreign
bodies of this shape. A curved hook is best
suited for this job. The hook is first passed
behind the object, the tip rotated to rest just
behind it and then the foreign body is gradually
drawn forwards and out through the
nose.17
Additionally, several suction methods
have been described that aid in the removal of
round foreign bodies.18 19 Plastic objects
and vegetable matter may be difficult to
extract because of their tendency to break
into small pieces.
However, it cannot be too strongly empha-
sised that unskilled attempts to remove the for-
eign body in accident and emergency depart-
ments by a person without appropriate
training may result in disaster. The foreign
body may be displaced backwards and may
even reach the nasopharynx with a risk of
inhalation.13 In a crying child the
foreign body whi l e bei ng r em oved
from t he nose can fal l i nt o t he
m out h with calamitous effects. Marked
epistaxis may occur or a docile child may
become terrified and require a general
anaesthetic, which might otherwise have
been avoided.13
In cases in which removal of a foreign body is
particularly diYcult, several alternative
proce- dures have been described. If the
patient can cooperate, they can be instructed
to take a deep breath through the mouth and
then forcibly exhale through the nose. The
attending doctor should occlude the
uninvolved nostril during this procedure.20
If the patient is not able to cooperative with
this manoeuvre, forced mouth-to-mouth
ventilation can be adminis- tered to the
patient by the doctor, again occluding the
uninvolved side.21 Both the success rate
and the incidence of complications associated
with the above mentioned proce- dures are
not well reported in the literature

An additional method described by some

authors is the use either of a Foley catheter or
a Fogarty biliary catheter for removal of
nasal foreign bodies. After ensuring that
the balloon is intact, the catheter is passed
into the nose beyond the foreign body. The
balloon is then inflated with 0.5 ml of water.
The catheter is withdrawn back through the
nose, pulling the foreign body in front of the
balloon.

In rare cases, the only successful method

of removing a nasal foreign body is to push

the object posteriorly into the pharynx.24

In these cases a general anaesthetic is
required and endotracheal intubation
performed to protect the airway.