3.09 Nasal Foreign Bodies
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agk's Library of Common Simple Emergencies

Presentation
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Children may admit to parents that they have 
inserted something into their noses, but 
sometimes the history is obscure and the child 
presents with a purulent unilateral nasal 
discharge. Most commonly encountered are beans 
or other foodstuffs, beads, pebbles, paper 
wads, and eraser tips. These foreign bodies 
usually lodge on the floor of the anterior or 
middle third of the nasal cavity. Occasionally, 
caustic material was sniffed into the nose or 
coughed up into the posterior nasopharynx 
(e.g., a ruptured tetracycline capsule), the 
patient will present with much discomfort and 
tearing, and inspection will reveal mucous 
membranes covered with particulate debris.

What to do: 
----------- 
- Explain the procedure beforehand in detail to 
   patient and parents. Explain that it will be 
   a little uncomfortable, and that aspiration 
   of the foreign body into the trachea is a 
   real but remote possibility.
- After initial inspection using a nasal 
   speculum and bright light, suction out any 
   purulent discharge and insert a cotton 
   pledget soaked in 4% cocaine or a solution 
   of one part phenylephrine (Neo-Synephrine) 
   and one part tetracaine (Pontocaine) to 
   shrink the nasal mucosa and provide local 
   anesthesia. Be careful to avoid pushing the 
   foreign body posteriorly. Remove the pledget 
   after approximately 5-10 minutes.
- If the patient is able to cooperate, have him 
   try to blow his nose to remove the foreign 
   body. With an infant it is sometimes 
   possible to have the parent blow a sharp 
   puff into the baby's mouth whild holding the 
   opposite nostril closed to blow the object 
   out of the nose.
- Before attempting any removal using surgical 
   instruments, a potentially uncooperative 
   child must be firmly restrained and sedated 
   (see below)
- Alligator forceps should be used to remove 
   cloth, cotton, or paper foreign bodies. 
   Pebbles, beans, and other hard foreign 
   bodies are more easily grasped using bayonet 
   forceps or Kelly clamps, or they may be 
   rolled out by getting behind it using an ear 
   curette, single skin hook, or right angle 
   ear hook. A soft-tipped hook can be made by 
   bending the tip of a metal-shaft calcium 
   alginate swab (Calgiswab) to a 90 degree 
   angle. An additional approach is to bypass 
   the object with a Fogarty, biliary or small 
   Foley catheter, passing it superior to the 
   foreign body, inflating the balloon with 
   approximately 1ml of air and pulling the 
   object out through the nose.
- Any bleeding can be stopped by reinserting a 
   cotton pledget soaked in the topical 
   solution used initially.
- To irrigate loose foreign bodies and 
   particulate debris from the nasal cavity and 
   posterior nasopharynx, simply insert the 
   bulbous nozzle of an irrigation syringe into 
   one nostril while the patient sits up and 
   forward, ask the patient to close off the 
   back of his throat by repeating the sound 
   "eng" and flush the irrigating solution out 
   through the opposite nostril into an emesis 
   basin.
- After the foreign body is removed, inspect 
   the nasal cavity again and check for 
   additional objects that may have been placed 
   in the patient's nose. Look also for 
   unsuspected foreign bodies in the ears.

What not to do:
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- Do not ignore a unilateral nasal discharge in 
   a child. It must be assumed to be secondary 
   to a foreign body until proven otherwise.
- Do not push a foreign body down the back of a 
   patient's throat, where it may be aspirated 
   into the trachea.
- Do not attempt to remove a foreign body from 
   the nose without first using a topical 
   anesthetic and vasoconstrictor.

Discussion
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The mucous membrane lining the nasal cavity 
allows you the tactical advantages of 
vasoconstriction and topical anesthesia. In 
cases where patients have unsuccessfully 
attempted to blow foreign bodies out of their 
noses, they may be successful after instill- 
ation of an anesthetic vasoconstriction 
solution. If a patient swallows a foreign body 
that has been pushed back into the nasopharynx, 
this is usually harmless and the the patient 
and parents can be reassured (see [Swallowed 
foreign body]). If the object is aspirated into 
the tracheobronchial tree, it may produce 
coughing and wheezing and bronchoscopy under 
anesthesia will be required for retrieval. 
Button batteries can cause serious local damage 
and should be removed quickly.

References
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- Backlin SA: Positive-pressure technique for 
   nasal foreign body retrieval in children. 
   *Ann Emerg Med* 1995;25:554-555.

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