Nasal Foreign Bodies

Updated: Dec 17, 2019
  • Author: Kristine Song, MD; Chief Editor: Steven C Dronen, MD, FAAEM  more...
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Overview

Overview

Nasal foreign bodies (NFBs) are a common complaint in the emergency department, especially among children, as well as adults with mental disabilities. Although NFBs rarely pose a true emergency, certain ones, such as batteries and magnets, can cause extensive, permanent damage and require emergency removal. Consideration of the most effective retrieval technique is essential, since a dislodged NFB can be displaced into the airway, resulting in aspiration or fatal airway obstruction. [1, 2, 3]

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 may include food, rubber, wood, and sponges and tend to be more irritating to the nasal mucosa; thus, they may produce earlier symptoms. Peas, beans, and nuts are among the more common organic NFBs. [4]

A study by Svider et al indicated that jewelry beads are the most common NFBs prompting emergency department visits in the United States, with paper products and toys being the next most common objects. [5]  The median patient age in the study was 3 years. [5]

In a study by Tong et al, 14% of all pediatric NFB cases were seen by physicians 48 hours after the time of insertion. [6] Therefore, to avoid complications and delayed treatment, clinicians must maintain a high index of suspicion for this diagnosis in patients from high-risk demographic groups.

Location of NFBs

The most common locations for NFBs to lodge are just anterior to the middle turbinate or below the inferior turbinate (see the illustration below). [7]  Because most people are right-handed, most NFBs are right sided. [8]

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

The most common presentation of an NFB is unilateral purulent rhinorrhea. Other signs and symptoms include the following:

  • Epistaxis
  • Pain
  • Irritation  
  • Chronic sinusitis
  • Unilateral nare obstruction
  • New-onset snoring
  • Sneezing
  • Wheezing
  • Stridor
  • Unilateral facial swelling

A retrospective study by Schuldt et al of 12,887 children and adolescents in the German population who received medical attention for aural or nasal foreign bodies showed a higher incidence in persons with a hyperkinetic disorder (14.1% of patients), a congenital malformation (50.8% of patients), or a psychological developmental disorder (52.7% of patients), [9]

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Physical Examination

The patient may present without any complaints after having been witnessed inserting the NFB. Alternatively, the patient may have unilateral nasal drainage, foul odor, sneezing, epistaxis, or pain. Patients often deny having placed the foreign body, so clinicians must maintain a high index of suspicion even in the context of such denials.

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/dissociation is often helpful in the pediatric population.

Maximal visualization of the nasal cavity is obtained by wearing a headlamp. Some authors recommend positioning children younger than age 5 years in a supine position and older children in a sitting "sniffing" position to allow optimal visualization. A nasal speculum may help in viewing the nasal cavity, although some authors report less patient anxiety and equally good visualization by using one's thumb to pull the nose upward.

The object can be found in any area of the nasal cavity, though an NFB will most often be lodged below the inferior turbinate or immediately anterior to the middle turbinate. [7]  There may occasionally be indications of local trauma, with findings, alone or in combination, of erythema, edema, and bleeding. After prolonged exposure, an increase in these findings is likely to be observed, as well as the presence of nasal discharge and a foul odor.

In addition to adequate inspection of the nasal cavity, assessing for complications associated with the foreign body is important. The tympanic membranes should be visualized for signs of acute otitis media; assessment should be made for sinusitis and, in the toxic child, nuchal rigidity; and the chest and neck should be auscultated for wheezing or stridor, which may suggest foreign body aspiration. 

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Differential Diagnosis

The following differentials should be included in the diagnosis of NFB: 

  • Sinusitis
  • Polyps
  • Tumor
  • Upper respiratory infection
  • Unilateral choanal atresia
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Complications

The most common complication of NFBs is minor epistaxis. Button batteries, magnets, and living foreign bodies can be particularly destructive. For example, small button batteries may, within hours, cause chemical burns, ulceration, and liquefaction necrosis, leading to septal perforation. [10, 11, 12]  Consideration of the type of foreign body, its shape, and the material it is composed of, as well as use of the most effective retrieval technique, is essential, since, as previously stated, an NFB can prove fatal if dislodged into the airway.

Although the foreign body itself may cause irritation, morbidity is primarily caused by the resulting inflammation and mucosal damage, as well as extension into adjacent structures. Reported complications include the following:

  • Sinusitis
  • Acute otitis media
  • Nasal septal perforation
  • Periorbital cellulitis
  • Meningitis
  • Acute epiglottitis
  • Diphtheria
  • Tetanus

Local inflammation from NFBs can result in pressure necrosis. This, in turn, can cause mucosal ulceration and erosion into blood vessels, producing epistaxis. Moreover, the swelling can obstruct sinus drainage and lead to secondary sinusitis. Organic foreign bodies tend to swell and are usually more symptomatic than are inorganic foreign bodies.

A delay in the diagnosis of NFB complications can result in prolonged morbidity. This outcome can be avoided by performing a thorough examination and by reexamining the nasal cavity after removal of the NFB. (See the images below.)

Foreign body is shown in the left nasal cavity wit Foreign body is shown in the left nasal cavity with surrounding inflammation. Image courtesy of Brian Reilly, MD.
View of the nasal cavity after removal of the fore View of the nasal cavity after removal of the foreign body. Note the rust from screw. Image courtesy of Brian Reilly, MD.

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 produce symptoms that lead to their discovery. NFBs tend to go unrecognized for longer periods of time than do foreign bodies in the ear because they usually produce fewer symptoms and are more difficult to visualize.

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Types of NFB

Button batteries

Button battery impactions account for over 3300 exposures reported annually to the American Association of Poison Control Centers and can result in clinically morbid or even fatal sequelae. [13]  In 2013, the incidence of button battery ingestion was estimated at 10.5 per million people, with a fatality rate of 0.5%. [13]  Button battery impaction has been a growing problem due to the increased production of smaller electronic products. [14]

Button batteries causes liquefactive necrosis by directional electrical discharge. [15, 16] The mucosal surface permits electron discharge, resulting in hydroxide ion formation near the negative pole, and subsequent basic pH further causes caustic burn. [16]  Gomes et al reported nasal cavity burn injury from a battery lodged in the nose for only 12 hours. [17]

Complications from a button battery NFB include mucosal damage, direct pressure necrosis, electrolysis, caustic exposures, and possible heavy metal toxicity.

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, in order to avoid spreading alkaline content that may have leaked out. Factors to consider when assessing the need for interval monitoring and long-term follow-up include the duration of battery impaction and concern for heavy metal toxicity. (See the image below.) [17]

Button battery in the right floor of nose causing Button battery in the right floor of nose causing electrical burn with necrosis of the inferior turbinate and septum. Image courtesy of Brian Reilly, MD.

Magnetic NFBs

Magnetic NFBs have been shown to cause pressure necrosis and even perforation of the nasal septal mucoperichondrium. Therefore, they require prompt removal. [18]

Living NFBs

Larvae and worms have been known to occasionally inhabit the nasal cavities of persons living in tropical environments. This can lead to the destruction of the nasal mucosa and subsequent necrosis of septal cartilage and turbinates and can spread 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.

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Imaging Studies

If an NFB is easily visualized on physical examination, imaging may not be necessary. However, if NFB placement was unwitnessed and the type of NFB is unknown, plain radiography should be ordered to rule out the presence of a button battery. Aside from metallic or calcified objects, NFBs tend to be radiolucent. A radiograph should also be obtained if possible ingestion or aspiration is a concern

Computed tomography (CT) scanning or magnetic resonance imaging (MRI) may be useful when the differential diagnosis includes a tumor or mass.

Although MRI has the advantage of involving no radiation, it is advisable to be cautious in considering MRI if concern exists that there is a magnetic component to the foreign body.

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Indications and Contraindications for Removal

Indications

Nasal foreign body removal may be attempted by an experienced clinician if the object can likely be extracted. If doubt exists about the reasonable probability of extraction, an otolaryngologist should be consulted. Repeated attempts at removal may result in increased trauma and potential movement of the item to a less favorable location. Mechanical removal of a foreign body should not be attempted if the item appears to be out of range of instrumentation.

Batteries and magnets must be removed as soon as possible, as soft tissue damage can occur within hours after their insertion.

Contraindications

If an NFB cannot be visualized, removal should not be attempted in the emergency department. In addition, NFB removal should not be performed without adequate sedation in an uncooperative patient whose head cannot be securely and safely stabilized; ideally, nonmechanical techniques such as positive air pressure should be attempted in this type of case. 

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Preparation

Good preparation is essential; removal of an NFB on first attempt is important, since multiple attempts may cause the object to become more deeply lodged. Emergency airway supplies should also be immediately accessible, in case removal attempts inadvertently cause aspiration of the foreign body. [2] Careful planning can reduce the complications associated with removal and associated distress and can limit the number of cases requiring surgical intervention. 

Premedication

Removal of an NFB may be facilitated by using a mixture of the following:

  • Topical decongestant - 0.05% oxymetazoline
  • Topical anesthetic agent - 4% lidocaine

Use 3-4 drops of the mixture 3-5 minutes before starting the procedure

Positioning

Proper positioning is vital in achieving optimal visualization of the NFB and stability of the head. Patients may be placed in the aforementioned sniffing position, either supine or on the parent's lap, with the chin elevated. Uncooperative patients may require procedural sedation and/or immobilization. Immobilization can be obtained by tightly wrapping a bed sheet around the child's torso, with the limbs tucked into the sheet. Even with a cooperative patient, assistance should be obtained to hold the child's head steady so that there is no unexpected movement during instrument use. Positioning and immobilization of children are critical steps for success in the removal of an NFB. 

Distraction tools

Distractions tools that can be utilized during the procedure include the following: 

  • Television
  • Incentive items - Stickers, popsicles, toys

Factors to consider for successful NFB removal

Factors to consider for successful NFB removal include the following: 

  • Patient’s age
  • Mental status/ability to cooperate with removal
  • Shape of object
  • Density of foreign body
  • Visibility of object
  • Size of object

Equipment

Equipment used in NFB removal includes the following:

  • Light source (headlamp)
  • Topical vasoconstrictor
  • Nasal speculum
  • Bag-valve mask
  • Alligator or bayonet forceps
  • Hooked probe
  • Balloon catheter (eg, Fogarty biliary catheter)
  • Curette
  • Suction apparatus (eg, Frazier catheter)
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Removal Techniques

Several removal techniques are exist, and the choice of a particular method depends upon the type of NFB, the supplies available, and the clinician's comfort with each removal method. The first attempt at removal of a foreign object is the one most likely to succeed.

Noninvasive techniques

Large occlusive foreign bodies are especially amenable to the positive-pressure technique. Strategies to expel NFBs via positive pressure include the following:

  • Forced exhalation - This can be accomplished by occluding the unaffected nostril and asking the child to blow hard out of his or her nose
  • Mother's kiss - Position the child lying down; the parent occludes the nonaffected nostril with a finger and provides a puff of forced exhalation (positive pressure) to the child’s mouth to expel the NFB; [19, 20]  this method has a success rate of nearly 50% [21]

If these techniques do not completely remove the object, they may at least dislodge it more anteriorly and allow for removal via direct instrumentation. 

Direct instrumentation

This technique is ideal for nonspherical, nonfriable foreign bodies. It should be attempted only with objects that are well visualized and within reach of available instruments. Recommended instruments include hemostats, alligator forceps, and bayonet forceps. 

Friable and spherical foreign bodies are particularly difficult to remove via direct instrumentation; friable objects may tear, and spherical objects may be difficult to grasp, resulting in posterior displacement.

Hooked probes

Hooked probes (eg, right-angle hooks) can be used to retrieve objects that are easily visualized but difficult to grasp. The hook is placed behind the NFB and is then rotated so that the hook angle is behind the bulk of the object. The object is then pulled forward. [7]

Kadish and Corneli reported on the use of a flexible endoscope to visualize the NFB, with the instrument then employed as a hook to pull the object out. [22]  This technique, referred to as the "hook-scope" method, may be useful provided that the patient is extremely cooperative and the clinician is highly adept at flexible nasopharyngoscopy.

A case report by Fundakowski et al described using smooth metallic wire grasped by a hemostat to create a snare, which was used to dissect adhesed tissue planes adjacent to the NFB and then pull the NFB anterior, with the leading snare edge posterior to the foreign body. [23]

Balloon catheters

This approach is ideal for small, round objects that are not easily grasped by direct instrumentation. The following catheters can be used for NFB removal

  • Foley catheters (eg, 5-8 French units)
  • Fogarty catheters (eg, no. 6 biliary or no. 4 vascular)
  • Katz Extractor Oto-Rhino Foreign Body Remover

Some authors have preferred the biliary Fogarty catheter over the vascular Fogarty catheter because its balloon is firmer and theoretically less prone to rupture. 

Regardless of catheter type, the extraction technique is similar. First, the balloon is inspected, and the catheter is coated with 2% lidocaine jelly. Then, with the patient lying supine, the balloon is inserted past the foreign body and inflated with air or water (2 mL in small children and 3mL in larger children). After inflation, the catheter is withdrawn, expelling the foreign body from the nose. (See the illustration below.) 

Use of a Fogarty catheter to remove a nasal foreig Use of a Fogarty catheter to remove a nasal foreign body.

Suction

This technique is ideal for easily visualized, smooth or spherical foreign bodies. The catheter tip is placed against the object, and a suction force of 100-140 mm Hg is used. The Frazier suction catheter with a segment of pliable tubing connected to its tip is recommended due to the strong seal it creates 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. However, this technique should be performed only in patients who can fully cooperate, as the nasal mucosa can be easily injured by misplaced glue. 

Magnet

Botma et al demonstrated successful removal of a loose ball bearing from a nasal cavity using a household magnet. [24]  Magnets may be especially useful for extracting button batteries, since these are associated with mucosal edema and, as a complication of direct instrumentation, significant bleeding, making visualization especially difficult.

Irrigation

This technique is not recommended due to significant risk of aspiration or choking. 

Posterior displacement

Rarely, a foreign body is positioned so posteriorly 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. However, due to the risk posed by a dislodged NFB in the airway, this method should only be used with general anesthesia and endotracheal intubation.

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Consultations

Indications for referral to an otolaryngologist include the following:

  • Dislodgement of a foreign body into the airway
  • Several unsuccessful attempts at removal
  • Button battery foreign body
  • Noncooperative child who needs sedation 
  • Difficulty in visualizing the NFB
  • Potential tumor or mass
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Patient Education

Education is key to the prevention of NFB impaction. Thus, a national, multidisciplinary Button Battery Task Force was created in 2012 to address preventative measures against button battery injuries. The task force published a 2013 update discussing strategies ranging from enactment of governmental legislation to manufacturer modification of packaging and labeling. [16]

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