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eMedicine Specialties > Emergency Medicine > Ear, Nose, & Throat

Foreign Bodies, Nose

Jonathan I Fischer, MD, Staff Physician, Department of Emergency Medicine, Yale New Haven Hospital
Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Updated: Sep 15, 2008

Introduction

Background

Nasal foreign bodies (NFBs) are commonly encountered in emergency departments. Although more frequently seen in the pediatric setting, they can also affect adults, especially those with mental retardation or psychiatric illness. Children's interests in exploring their bodies make them more prone to lodging foreign bodies in their nasal cavities. In addition, they may also insert foreign bodies to relieve preexisting nasal mucosal irritation or epistaxis. As benign as a nasal foreign body may seem, it harbors the potential for morbidity and even mortality if the object is dislodged into the airway.

Foreign bodies can be classified as either inorganic or organic. Inorganic materials are typically plastic or metal. Common examples include beads and small parts from toys. These materials are often asymptomatic and may be discovered incidentally. Organic foreign bodies, including food, rubber, wood, and sponge, tend to be more irritating to the nasal mucosa and thus may produce earlier symptoms.
 
The most common locations for nasal foreign bodies to lodge are just anterior to the middle turbinate or below the inferior turbinate. Unilateral foreign bodies affect the right side about twice as often compared to the left. This may be due to a preference of right-handed individuals to insert objects in their right naris.

Pathophysiology

Nasal foreign bodies can cause damage to the nasal cavity and surrounding structures. They can produce local inflammation, which may result in a pressure necrosis. This, in turn, can cause mucosal ulceration and erosion into blood vessels producing epistaxis. The swelling can cause obstruction to sinus drainage and lead to a secondary sinusitis. Organic foreign bodies tend to swell and are usually more symptomatic than inorganic foreign bodies.

Firmly impacted and unrecognized foreign bodies can in time become coated with calcium, magnesium, phosphate, or carbonate and become a rhinolith. Rhinoliths are radio-opaque and typically are found on the floor of the nasal cavity. Rhinoliths can remain undetected for years and only upon growth do they produce symptoms that lead to their discovery. In comparison to foreign bodies in the ear, NFBs often fail to be recognized for longer periods of time because they usually produce fewer symptoms and are more difficult to visualize. 

Button batteries, magnets, and living foreign bodies can be particularly destructive and are further discussed below (see Special Considerations).

All foreign bodies harbor the potential for swallowing or airway obstruction if displaced posteriorly.

Frequency

The frequency of nasal foreign bodies is not known.

Morbidity/Mortality

The foreign body itself may cause irritation to the patient; however, morbidity is primarily caused by the resulting inflammation, mucosal damage, and extension into adjacent structures. Reported complications include sinusitis, acute otitis media, nasal septal perforation, periorbital cellulitis, meningitis, acute epiglottitis, diphtheria, and tetanus.

Race

The prevalence of nasal foreign bodies by race is not known.

Sex

Some studies have demonstrated greater prevalence in males than in females (ie, 58% males1 ); however, this trend has not been universal.

Age

Among children, those aged 2-5 years have the highest incidence of NFBs. Children develop their pincer grip at about 9 months of age; in theory, this would be necessary for most cases of NFB insertion.

Clinical

History

In most cases, the insertion of the nasal foreign body (NFB) is witnessed, and the dilemma of diagnosis is eliminated. In one study, presentations over 48 hours after the time of insertion accounted for 14% of all cases.2 In addition to obtaining a thorough history from the patient and his or her primary guardian(s), it is important to interview all caretakers that have recently spent time with the patient (ie, babysitters, counselors). Once the diagnosis is missed, the foreign body may not be detected for days, weeks, or even years.

Among the delayed presentations, the most common clinical scenario is unilateral nasal discharge. Nevertheless, clinicians must entertain the diagnosis of NFB in all patients with nasal irritation, epistaxis, sneezing, snoring, sinusitis, stridor, wheezing, or fever. Some authors even report discovering NFBs as the etiology of more unusual patient presentations, such as irritability, halitosis, or generalized bromhidrosis (body malodor). Failure to recognize “occult” nasal foreign bodies can allow persistence for years inside a patient’s nasal cavity. To avoid complications and delayed treatment, clinicians must maintain a high index of suspicion for this diagnosis.

Physical

The physical examination is the main diagnostic tool, and a cooperative patient is essential for success. Parents and staff may be needed to comfort and immobilize a child to allow for a thorough otorhinolaryngologic examination. Sedation is often helpful in the pediatric population.
 
Maximal visualization of the nasal cavity is obtained by wearing a head-lamp. Some authors recommend positioning children younger than 5 years in a supine lying position and older children in a sitting "sniffing" position to allow optimal visualization. A nasal speculum may also help to view the nasal cavity, although some authors report less patient anxiety and equally good visualization by using one's thumb to pull the nose upward.

In addition to adequate inspection of the nasal cavity, assessing for complications of the nasal foreign body is important. Visualize the tympanic membranes for signs of acute otitis media, assess for sinusitis, check for nuchal rigidity in the toxic child, and auscultate the chest and neck for wheezing or stridor, which may be a clue of foreign body aspiration.

Lastly, looking for additional foreign bodies, whether they are in the nose or other body cavities, is important.

Differential Diagnosis

Epistaxis

Sinusitis

Polyps

Tumor

Upper respiratory infection (URI)

Unilateral choanal atresia

Workup

The extent of the workup depends on the clinical scenario. For most isolated nasal foreign bodies, no diagnostic testing is indicated. With the exception of metallic or calcified objects, most nasal foreign bodies (NFBs) are radiolucent. When an alternate diagnosis (ie, tumor, sinusitis) is being considered, imaging (ie, CT scan) may be helpful.

On the other hand, if concern for an ingested or aspirated foreign body exists, radiography of the chest/abdomen should be performed. An aspirated radiolucent foreign body may be inferred by postobstructive air trapping, and an ingested foreign body will show up if it is radiopaque, as most ingested foreign bodies are.

Treatment

Planning/Pretreatment

Repeated attempts at nasal foreign body (NFB) removal are likely to be successively more difficult, and the object may become more deeply lodged. Therefore, careful planning is important to maximize the likelihood of removal on the first attempt.  Having the necessary instruments at the bedside is essential, as is the clinician's knowledge of several techniques. In addition, emergency airway supplies should be readily available in the event that manipulation of the foreign body results in aspiration.
 
Pharmacological vasoconstriction of the nasal mucosa can facilitate both examination and removal of a NFB. Anesthesia and mucosal vasoconstriction can be accomplished by applying several drops of 1% lidocaine (without epinephrine) and 0.5% phenylephrine to the affected nostril. For the apprehensive patient, a nebulized solution of 1-2 mL of 1:1000 epinephrine has been used successfully for mucosal vasoconstriction. Of note, the author of the nebulized epinephrine case report only recommends its use if the NFB is large enough that posterior movement is unlikely and if the practitioners are experts at securing airways.

Specific Removal Techniques

Several removal techniques are available, and the choice of a particular method depends upon the NFB type, the supplies available, and the clinician's comfort with each method. For easily visualized nonspherical and nonfriable objects, most clinicians prefer direct instrumentation. If the object is poorly visualized, spherical, or unsuccessfully removed by direct instrumentation, balloon-catheter removal is a preferred method. For large, occlusive NFBs, positive pressure techniques are commonly used. All attempts at removal can be complicated by mucosal damage and bleeding. In addition, all failed attempts can result in posterior displacement of the NFB. Each method is described below.

Direct instrumentation  

This technique is ideal for easily visualized, nonspherical, and nonfriable foreign bodies. Previously described instruments include hemostats, alligator forceps, or bayonet forceps.  Friable and spherical foreign bodies are particularly difficult to remove by this technique: friable objects may tear, and spherical objects may be difficult to grasp and result in posterior displacement.

In addition, hooked probes (ie, right-angle hook) can be used for objects that are easily visualized but difficult to grasp. The hook is placed behind the NFB and then rotated so the hook angle is behind the bulk of the object. The object is then pulled forward.

Interestingly, some authors have suggested using the combination of direct instrumentation to grasp an object while having a balloon catheter (see next paragraph) placed behind the object to prevent posterior displacement during removal attempts.

Balloon catheters 

This approach is ideal for small, round objects that are not easily grasped by direct instrumentation. Authors have used Foley catheters (ie, 5, 6, or 8) or Fogarty catheters (ie, #6 biliary or #4 vascular), and the Katz Extractor oto-rhino foreign body remover (InHealthTechnologies, CA) is also an option. The biliary Fogarty catheter has been preferred over the vascular Fogarty catheter by some authors because its balloon is firmer and theoretically less prone to rupture.  Regardless of catheter type, the technique is similar. First, the balloon is inspected, and the catheter is coated with 2% lidocaine jelly. Then, it is inserted past the foreign body and inflated with air or water (2 mL in small children and 3 mL in larger children). After inflation, the catheter is withdrawn, pulling the foreign body with it.

Positive pressure  

Large and occlusive foreign bodies are especially amenable to the positive pressure technique. Several techniques have been developed to expel the NFB out by force provided in the form of positive pressure. The least invasive form, "forced exhalation," can be accomplished by occluding the unaffected nostril and asking the child to blow hard out his or her nose. If this fails, the positive pressure can be applied by either the parent's mouth ("parent's kiss"3 ) or a bag-valve-mask. With either method, a tight seal is formed around the child's mouth, while avoiding the nose. The unaffected nostril is then occluded, and a forceful puff of air is provided. If these techniques do not completely remove the object, they may at least dislodge the object more anteriorly and allow for removal using the previously described techniques.

Another positive pressure technique delivers air into the unaffected naris with the patient's mouth closed. In this technique, the patient is placed on his or her side (foreign body side down), and the delivery device (known as a "Beamsley Blaster") provides high-flow oxygen (10-15 L/min) into the unaffected naris. To set up the Beamsley Blaster, one end of oxygen tubing connects to the oxygen source and the other end is connected to a male-male oxygen tube adaptor that is placed in the patient's unaffected naris.

A potential complication unique to positive pressure techniques is barotrauma to the lungs or the tympanic membranes. However, to date, no cases of this have been reported.

Suction  

This technique is ideal for easily visualized smooth or spherical foreign bodies. The catheter tip is placed against the object, and suction is turned on to 100-140 mm Hg (readily supplied by standard medical suction equipment). A strong seal is important for success of this technique, and authors have recommended using a Schunkt-neck catheter with its plastic umbrella tip or a Frazier catheter with a segment of pliable tubing connected to its tip for a strong seal with the foreign body.

Glue  

This method is ideal for easily visualized smooth or spherical foreign bodies that are dry and nonfriable. A thin coat of cyanoacrylate adhesive is placed on the tip of a wooden or plastic applicator, which is then pressed against the foreign body for 60 seconds and removed. Without full cooperation of the patient, the nasal mucosa is easily injured by misplaced glue.

Posterior displacement 

Rarely, a foreign body may be so posterior that the above techniques will not work. In these cases, after consultation with a specialist, it may be necessary to induce further posterior displacement of the object into the oropharynx for removal. Of course, this would require general anesthesia, endotracheal intubation, and esophageal occlusion.

Magnet 

A case report demonstrated successful removal of a loose ball bearing from a nasal cavity using a household magnet.4  The authors believe that a strong magnet may be especially useful to remove button batteries, which are associated with mucosal edema and significant bleeding with direct instrumentation, making visualization especially difficult.

Irrigation
This technique has been strongly criticized for carrying a significant risk of aspiration or choking. The authors do not recommend use of this method; however, it will be reviewed so that clinicians can be aware of its existence. The irrigation technique is performed by forceful squeezing of a bulb syringe filled with 7 mL of normal saline into the unaffected naris.

For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center. Also, see eMedicine's patient education article Foreign Body, Nose.

Special Considerations

  • Metallic button batteries: Metallic button batteries are small and shiny and found in many toys making them strong candidates for nasal foreign body (NFB) insertion. Once inserted into the nose, they cause destruction by low-voltage electrical currents, electrolysis-induced release of sodium hydroxide and chlorine gas, and even liquefactive necrosis if their alkaline contents leak out. Complications from button batteries are relatively common, occurring in 6 of 11 cases reviewed in one series.5 In addition, they can occur rapidly, as discussed by Gomes et al, which reported nasal cavity burns from a battery that was in a nose for only 12 hours.6 Button batteries require prompt removal and a thorough inspection of the nasal cavity for complications. It is particularly important not to irrigate the nasal cavities to avoid spreading alkaline content that may have leaked out.6
  • Magnetic NFBs: Small magnets have been used recreationally as imitation earrings as well as therapeutically for splinting after septoplasty. In the literature, magnetic NFBs have been shown to cause pressure necrosis and even perforation of the nasal septal mucoperichondrium. Therefore, they require prompt removal.
  • Living NFBs: Larvae and worms have been known to occasionally inhabit the nasal cavities of those living in tropical and unhygienic environments. They can lead to destruction of the nasal mucosa and subsequent necrosis of septal cartilage and turbinates. Some authors have even reported extension to the orbit and paranasal sinuses. Because of the invasive nature of these NFBs, treatment typically consists of instillation of an agent to kill the larvae or worm, followed by surgical debridement and antibiotic therapy. These cases should be managed in conjunction with a specialist.

Miscellaneous

Consultation

In general, nasal foreign bodies can be safely removed by emergency physicians. However, an otolaryngological specialist should be promptly consulted for cases of failed removal or a NFB complicated by significant damage to adjacent structures. A nonemergent referral to a specialist be should made when there is concern for a tumor or mass.

Medical/Legal Pitfalls

  • It is crucial to have the supplies and staff needed to deal with an airway emergency during manipulation of the NFB.
  • Failure to consult a specialist when managing an NFB complicated by significant damage to nasopharynx (ie, button battery content leakage) is a pitfall.
  • Delay in diagnosis of complications of nasal foreign bodies, such as sinusitis and acute otitis media, can result in prolonged morbidity. This can be avoided by performing a thorough examination and by reexamining the nasal cavity after removal of the NFB.
  • Failure to search for additional foreign bodies in patients found to have one NFB is a pitfall.
  • Failure to contact a specialist when a tumor or mass is suspected can result in delayed diagnosis of a malignancy.

Multimedia

A button battery was removed from a child who pre...

Media file 1: A button battery was removed from a child who presented with unilateral nasal discharge. The battery contents were intact.

Common sites of impaction of foreign bodies in th...

Media file 2: Common sites of impaction of foreign bodies in the nasal cavity (IT = inferior turbinate; MT = middle turbinate; SS = sphenoid sinus; ST = superior turbinate).

Use of a Fogarty catheter to remove a nasal forei...

Media file 3: Use of a Fogarty catheter to remove a nasal foreign body.

References

  1. François M, Hamrioui R, Narcy P. Nasal foreign bodies in children. Eur Arch Otorhinolaryngol. 1998;255(3):132-4. [Medline].

  2. Tong MC, Ying SY, van Hasselt CA. Nasal foreign bodies in children. Int J Pediatr Otorhinolaryngol. May 1996;35(3):207-11. [Medline].

  3. Botma M, Bader R, Kubba H. 'A parent's kiss': evaluating an unusual method for removing nasal foreign bodies in children. J Laryngol Otol. Aug 2000;114(8):598-600. [Medline].

  4. Douglas SA, Mirza S, Stafford FW. Magnetic removal of a nasal foreign body. Int J Pediatr Otorhinolaryngol. Feb 1 2002;62(2):165-7. [Medline].

  5. Hong D, Chu YF, Tong KM, et al. Button batteries as foreign bodies in the nasal cavities. Int J Pediatr Otorhinolaryngol. Nov 1987;14(1):15-9. [Medline].

  6. Gomes CC, Sakano E, Lucchezi MC, et al. Button battery as a foreign body in the nasal cavities. Special aspects. Rhinology. Jun 1994;32(2):98-100. [Medline].

  7. Backlin SA. Positive-pressure technique for nasal foreign body removal in children. Ann Emerg Med. Apr 1995;25(4):554-5. [Medline].

  8. Baluyot ST. Foreign bodies in the nasal cavity. In: Paparella MM, Shumrick DA, eds. Otolaryngology. Vol 3. 2nd ed. Philadelphia, PA: W.B. Saunders; 1980:2009-2016.

  9. Chan TC, Ufberg J, Harrigan RA, et al. Nasal foreign body removal. J Emerg Med. May 2004;26(4):441-5. [Medline].

  10. D'Cruz O, Lakshman R. A Solution for the Foreign Body in the Nose Problem. Pediatrics. 1998;81:174.

  11. Davies PH, Benger JR. Foreign bodies in the nose and ear: a review of techniques for removal in the emergency department. J Accid Emerg Med. Mar 2000;17(2):91-4. [Medline].

  12. Douglas AR. Use of nebulized adrenaline to aid expulsion of intra-nasal foreign bodies in children. J Laryngol Otol. Jun 1996;110(6):559-60. [Medline].

  13. Figueiredo RR, Azevedo AA, Kos AO, et al. [Nasal foreign bodies: description of types and complications in 420 cases]. Rev Bras Otorrinolaringol (Engl Ed). Jan-Feb 2006;72(1):18-23. [Medline].

  14. Finkelstein JA. Oral Ambu-bag insufflation to remove unilateral nasal foreign bodies. Am J Emerg Med. Jan 1996;14(1):57-8. [Medline].

  15. Foster DL. Suction removal of foreign bodies (letter). Pediatr Emerg Care. 5:73.

  16. Fox JR. Fogarty catheter removal of nasal foreign bodies. Ann Emerg Med. Jan 1980;9(1):37-8. [Medline].

  17. Handler SD. Nasal wash technique for nasal foreign body removal. Pediatr Emerg Care. Aug 2000;16(4):307. [Medline].

  18. Hanson RM, Stephens M. Cyanoacrylate-assisted foreign body removal from the ear and nose in children. J Paediatr Child Health. Feb 1994;30(1):77-8. [Medline].

  19. Henry LN, Chamberlain JW. Removal of foreign bodies from esophagus and nose with the use of a Foley catheter. Surgery. Jun 1972;71(6):918-21. [Medline].

  20. Kadish HA, Corneli HM. Removal of nasal foreign bodies in the pediatric population. Am J Emerg Med. Jan 1997;15(1):54-6. [Medline].

  21. Kalan A, Tariq M. Foreign bodies in the nasal cavities: a comprehensive review of the aetiology, diagnostic pointers, and therapeutic measures. Postgrad Med J. Aug 2000;76(898):484-7. [Medline].

  22. Lancaster J, Mathews J, Sherman IW. Magnetic nasal foreign bodies. Injury. Mar 2000;31(2):123. [Medline].

  23. Lehman DA, Roy S. Septal perforation caused by nasal magnetic foreign bodies. Ear Nose Throat J. May 2005;84(5):266-7. [Medline].

  24. Lichenstein R, Giudice EL. Nasal wash technique for nasal foreign body removal. Pediatr Emerg Care. Feb 2000;16(1):59-60. [Medline].

  25. McMaster WC. Removal of foreign body from the nose. JAMA. Sep 14 1970;213(11):1905. [Medline].

  26. Morris MS. New device for foreign body removal. Laryngoscope. Jul 1984;94(7):980. [Medline].

  27. Nandapalan V, McIlwain JC. Removal of nasal foreign bodies with a Fogarty biliary balloon catheter. J Laryngol Otol. Sep 1994;108(9):758-60. [Medline].

  28. Navitsky RC, Beamsley A, McLaughlin S. Nasal positive-pressure technique for nasal foreign body removal in children. Am J Emerg Med. Mar 2002;20(2):103-4. [Medline].

  29. Rivello RJ. Otolaryngologic procedures. In: Roberts JR, Hedges JR, Chanmugam AS, Chudnofsky CR, Custalow CB, Dronen SC, eds. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, PA: Saunders; 2004:1312-1315, Chapter 65.

  30. Sculerati N. Foreign bodies of the nose. In: Bluestone CD, Stool SE, Kenna MA. Pediatric Otolaryngology. Vol 1. 3rd ed. Philadelphia, PA: W.B. Saunders; 1996:874-878.

  31. Stool SE, McConnel CS Jr. Foreign bodies in pediatric otolaryngology. Some diagnostic and therapeutic pointers. Clin Pediatr (Phila). Feb 1973;12(2):113-6. [Medline].

  32. Waters TA, Peacock WF. Nasal emergencies and sinusitis. In: Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. McGraw-Hill; 2004:1480, Chapter 241.

  33. Werman HA. Removal of foreign bodies of the nose. Emerg Med Clin North Am. May 1987;5(2):253-63. [Medline].

Keywords

nasal foreign bodies, nose foreign body, foreign body in the nose, foreign object in the nose, object in nose, foreign object in nasal cavity, removal of nasal foreign bodies

Contributor Information and Disclosures

Author

Jonathan I Fischer, MD, Staff Physician, Department of Emergency Medicine, Yale New Haven Hospital
Disclosure: Nothing to disclose.

Coauthor(s)

Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

Medical Editor

Edmond A Hooker II, MD, DrPH, FAAEM, Assistant Professor, Department of Health Services Administration, Xavier University; Associate Clinical Professor, Department of Emergency Medicine, University of Louisville; Assistant Clinical Professor, Department of Emergency Medicine, Wright State University
Edmond A Hooker II, MD, DrPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Public Health Association, Society for Academic Emergency Medicine, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Robert J Cox, MD, to the development and writing of this article.

Further Reading

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