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It’s a sunny Saturday afternoon and you are settling into your second cup of coffee when a young mother comes running into the emergency department clutching her 3-year-old son. She reports “I just took my eyes off of him for a second to answer the door. When I returned, he had a broken necklace on the floor, several small beads lying around him, and was crying.” You immediately turn your attention to the young son in her arms. You see a 3-year-old boy with tear-stained cheeks and dried blood on his nariss. Careful inspection of his airway reveals non-labored breathing, clear lungs, no stridor, and he giggles when you tickle his tummy. Looking up his nose, you are confronted with two shinny metal objects, one in each naris.

up-the-nare-1

Nasal foreign bodies (NFBs) are a common problem in pediatric emergency departments, occurring most frequently in children between the ages of 2 and 5 years old. NFBs can be classified as organic or inorganic. Organic NFBs usually produce a localized inflammatory reaction, and are not well visualized on plain film radiography. Inorganic foreign bodies are usually inert and can often go undetected. Common complications to NFBs include bleeding and local inflammation although sinusitis, acute otitis media and nasal septal perforation can occur with a delay in diagnosis and removal. The most common location for foreign bodies to lodge are just anterior to the middle turbinate or just below the inferior turbinate.

Numerous techniques exist for nasal foreign body removal. In older children, the patient can start by blowing their nose. In younger children, the “parent’s kiss” is commonly employed. In this technique, the parent places their moth over the child’s open mouth and blows until they feel resistance. At this point, they give a quick puff of air in an attempt to dislodge the object. Unfortunately, this technique had a 40% failure rate in a recent case series.

Other techniques include suction, balloon catheters, glue, and alligator forceps.

In order to evaluate and remove the nasal foreign body, you need to start with the basics. Aspiration or swallowing is a common complication of NFBs, and the first step should be assessing the patient’s airway. If clinical concern exists for a foreign body to other structures exists, imaging can be performed. If the NFB is a button, battery or magnet, plain films should be undertaken to ensure that they are isolated only to the nasal structures.

Procedure

The balloon technique works best for small round objects that cannot be well grasped with forceps, and do not contain sharp edges that could puncture the balloon. The supplies needed to perform this procedure include:

  • A balloon catheter (Fogarty biliary catheter, or pediatric Foley)
  • Lubrication jelly, or 2% lidocaine jelly
  • 5 cc syringe
  • Light source

The first step is to position the child. The child can be placed in a “burrito” wrap, laid supine, with the head in the sniffing position. A parent can be utilized to help stabilize the child’s head and provide reassurance during the procedure.

The balloon catheter should first be tested to insure the balloon inflates appropriately. Next it should be copiously covered with jelly. With the child’s head well stabilized, the catheter can be inserted in the naris adjacent to the foreign body.

The catheter should be slowly advanced until the balloon is posterior to the foreign body.

Once the balloon is inserted past the foreign body, it should be slowly inflated with air or water. Approximately 2 mL should be used in small children and 3 mL in larger children. Inflation of the balloon should be undertaken very carefully as over inflation of the balloon can lead to rupture or worsening nasal trauma. Once inflated, the catheter can be slowly pulled, applying direct posterior constant pressure to the foreign body. The foreign body should be slowly delivered from the naris.

After removal of the foreign body, the naris should be inspected for bleeding or localized trauma.

up-the-nare-2

Case Conclusion

In the case of the 3-year-old boy, as noted in the image, the foreign bodies were successfully removed from both nares. The patient tolerated the procedure well, with minimal nasal trauma. He happily tolerated an orange popsicle, and was discharged home with a satisfied parent.

Sedation

Foreign body removal should not be attempted unless the child is calm, or the child’s head can be adequately stabilized. If the child cannot be adequately mobilized by wrapping them in a sheet or blanket, conscious sedation can be considered. In order to attempt conscious sedation, the practitioner should have an appropriate knowledge of managing the child’s airway and the foreign body should seem secure. If the foreign body is not secure, conscious sedation can result in posterior dislodgement of the foreign body and aspiration.

Brown et al completed a retrospective review of conscious sedation for foreign body removal in children. In a single site, 312 patients presented with a foreign body to either the nose or ears. Conscious sedation was attempted in 23% of the cases. Ketamine was used in 92% of the cases, and nasal foreign bodies were successfully removed 95% of the time. Of note, conscious sedation increased the success rate of foreign body removal, and was frequently attempted after removal had failed without sedation.

Dr. Reno is a 3rd year EM Resident and Dr. Otten, MD is a 2nd year EM Resident at the Denver Health Emergency Medicine Residency Program. Dr. Peter Pryor is an Attending Physician at Denver Health and Assistant Professor of EM at the University of Colorado School of Medicine.

References

1. Francois M, Harioui R, Narcy P. Nasal foreign bodies in children. Eur Arch Otorhinolaryngol. 1998; 255: 132-4.

2. Cook S, Burton M, Glasziou P. Efficacy and safety of the “mother’s kiss” technique: a systematic review of case reports and case series. CMAJ. 2012 Nov; 184 (17): 904-12.

3. Fundakowski C, Moon S, Torres L. The Snaris Technique: A novel atraumatic method for the removal of difficult nasal foreign bodies. J Emerg Med. Jan; 44(1) 104-6.

4. Brown L, Denmark TK, Wittlake WA, Vargas EJ, Watson T, Crabb JW. Procedural sedation use in the ED: management of pediatric ear and nose foreign bodies. Am J Emerg Med. Jul 2004;22(4):310-4.

 

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