Continuing Education Activity

Nasal foreign bodies are commonly seen in the emergency department, mostly in the pediatric population but also in those with psychiatric illness or developmental disabilities. Nasal foreign bodies are usually benign but have the potential to cause mucosal damage, bleeding, infection, and aspiration. The nasal foreign body may be obvious or may require a high index of suspicion. Nasal foreign bodies often present acutely but can be missed and remain for weeks, months, or even years after insertion. This activity reviews the evaluation of suspected nasal foreign bodies and highlights the role of the interprofessional team in treating this condition.

Objectives:

• Describe the most common settings in which a nasal foreign body is likely to be identified.
• Discuss the morbidity and mortality associated with a nasal foreign body.
• Outline the management of a patient with a nasal foreign body.
• Summarize the interprofessional team's responsibility in considering and evaluating for a nasal foreign body.

Introduction

Nasal foreign bodies (NFB) are commonly seen in the emergency department mostly in the pediatric population, however, they might be seen in adults with psychiatric illness or developmental disabilities. NFBs are usually benign and do not require urgent intervention, however, some objects can cause severe damage and need to be removed urgently, these include things like batteries and magnets. The nasal foreign body may be obvious or may require a high index of suspicion as they may present acutely but can be missed and remain for weeks, months, or even years after insertion. Basically, foreign bodies are classified as animate and inanimate or organic and inorganic. In general, the organic foreign bodies tend to be more irritating to the nasal mucosa and tend to cause symptoms much earlier. [1][2][3]  

Etiology

The most likely objects to be found are pebbles, beads, nuts, chalk, and other small objects.

Animate objects that are likely to be found include the fly maggot and screw warms, with the former being more common and more aggressive. 

Foreign bodies tend to lie in one of two locations in the nasal fossae: the floor of the inferior turbinate or anterior to the middle turbinate.

While some foreign bodies remain in the nasal cavity without causing any harm, other objects might startup to cause swelling of the mucosa, leading to mucosal erosions, ulceration, and epistaxis. This is usually seen with organic foreign bodies as they tend to absorb the water from the surrounding tissue and swell. These foreign bodies tend to turn into hard objects due to the accumulation of minerals and thus become a rhinolith, causing more harm. 

Batteries can affect the nasal septum, causing septal perforation when they start producing a local inflammatory response associated with liquefactive necrosis. [4]

Epidemiology

Button batteries are now ubiquitous in children's toys, remote controls, hearing aids, calculators, and many other places. Each year, more than 300 button batteries are ingested in the United States

The pediatric age group is the most commonly involved in placing objects in the nasal cavities, as they are interested in exploring their bodies. It is unusual to see nasal foreign bodies in children younger than nine months of age, before developing a pincer grasp.[5]

Children aged two to five years of age are the most likely to insert objects into their nasal cavities. The incidence is slightly higher in boys than in girls. 

Unilateral foreign bodies are found on the right side twice as often as the left probably due to right-handedness.[6][7]

Children with autism spectrum disorder commonly repeatedly insert foreign bodies into various orifices. They may also have multiple objects on multiple sites.

Children with younger siblings in the home are more likely to insert objects in the nose.

Repeated insertion of objects into the nose or other orifices can be associated with psychiatric illness.

Pathophysiology

While some foreign bodies remain in the nasal cavity without causing any harm, other objects might startup to cause swelling of the mucosa, leading to mucosal erosions, ulceration, and epistaxis. This is usually seen with organic foreign bodies as they tend to absorb the water from the surrounding tissue and swell. These foreign bodies tend to turn into hard objects due to the accumulation of minerals and thus become a rhinolith, causing more harm. 

In batteries, tissue damage occurs as direct leakage causes corrosive damage. There are also direct current effects on the mucosa as well as, pressure necrosis. Tissue fluids generate a current between the battery anode and cathode resulting in corrosion.  Paired magnets also create a current with similar results. which can end up in a septal perforation in as little as 4 hours.

History and Physical

Patients usually present with foul-smelling purulent nasal discharge that is usually unilateral. NFBs are usually painless, however, some children present with headaches on the same side of the foreign body. Moreover, bloody stained discharge or even epistasis might be witnessed in these cases.

On the other hand, the child will often tell the parent that they placed an object in their nose. Younger children may only present with irritability.

If the foreign body in the nasal cavity was alive, the presentation might vary, with the symptoms more likely to be bilateral. Patients usually present with nasal occlusion, sneezing, and headaches in addition to nasal discharge. As these objects might end up causing a secondary infection, the white blood cell count in the affected individuals might be increased in response to the infection. Patients might present febrile as well. 

On examination, the examiner must have good lighting to ensure visualizing the object, and the patient should be in a sniffing position, a vasoconstrictor agent can be used to shrink the nasal membranes prior to examination. 

Anterior rhinoscopy should be performed, which might be enough, a fiberoptic nasopharyngoscope can be used as well.

In patients with an alive object in the nasal cavities, which are usually detected easily, the examination will show widespread destruction in the nasal mucosa, cartilage, and bones. This might be associated with unilateral epistaxis or discharge ranging from clear to purulent.

In the case of a rhinolith within the nasal cavity, the examiner will visualize a gray-colored object on the floor of the nasal cavity.

In addition, the tympanic membrane should be assessed for any signs of inflammation, and the lungs should be auscultated for any signs of aspiration such as wheezing.

In patients who are not co-operative, examination under general anesthesia must be carried. [4]

Evaluation

Laboratory evaluation is usually unnecessary. However, in the case of animate objects, the white blood cell count might be increased.

Imaging may be needed for suspicion of battery or magnet if suspected or poorly visualized. Unfortunately, many foreign bodies are radiolucent.

If it is suspected that the foreign body has been aspirated into the airways, a chest x-ray is necessary.

CT scan or MRI might be done if a tumor is suspected to be the cause of the presentation.

Treatment / Management

Removal of nasal foreign bodies requires a bright light source, preferably a headlamp. It is important that a parent or caregiver firmly holds the child, for example in a papoose or with sheets in the sniffing position, and that the practitioner has suction readily available. Conscious sedation may be considered, but the foreign body has the potential to dislodge and cause aspiration under sedation posteriorly. The ability to provide for an advanced airway is a prerequisite. The use of a topical vasoconstrictor may help visualize the object, control bleeding, and decrease secretions. This is not recommended when there is a concern for the button battery as it may increase leakage of acids. A nasal speculum, various size probes, curettes, and alligator forceps are necessary.[8][9]

There are various techniques used to remove nasal foreign bodies. 

The most commonly used is direct visualization and extraction using instrumentation. Curettes, alligator forceps, or probes are best used in this fashion. The object can be pulled directly out using alligators as in the case of paper or sponge material. Smooth, more spherical objects are best removed with a curette or probe inserted past the object and pulled forward.

Forced exhalation is another method that may utilize either the parent or a bag-valve-mask (BVM). The "parent's kiss" utilizes the parent to seal their mouth over the child's mouth with a firm seal, occluding the unaffected nare and blowing into the child's mouth in the hope of expelling the object. A BVM can be used in the same fashion with a tight seal.

Suction can be used to remove or bring an object lower into the nasal passages. Flexible suction catheters or Yankhauer can be used depending on the size of the patient. In addition, one may use hooks, balloon catheters, and positive pressure to remove the foreign body.

Glue can be used in a very cooperative patient. A small amount of glue is placed on a cotton swab and applied to a spherical, well-visualized object, and pulled forward. The one technique that should not be used is irrigation as it carries a high risk for choking or aspiration.

In children, removing a nasal foreign body requires experience and patience. Multiple attempts should not be made. In addition, emergency airway supplies should be in the room before making any attempt at removal. 

While local anesthesia is not necessary, the use of a vasoconstrictor can make the examination easier. If the child is uncooperative, sedation is highly recommended.

If there is any doubt in the emergency department on how to remove the foreign body, an otolaryngologist should be consulted.

Differential Diagnosis

The differential diagnosis of the foreign bodies in the nasal cavity include:

• Sinusitis
• Tumor
• Polyp
• Choanal atresia
• Upper respiratory tract infection

Prognosis

The patients are not usually affected by nasal foreign bodies in the long term.

Complications

Complications occur in approximately 9% of the patients, these include:

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

Other complications include nose bleeds, nasal obstruction, and sinusitis.

Radiolucent bodies often go undetected for months or years because they are difficult to visualize. Small button batteries have high morbidity as they rapidly induce ulceration and necrosis leading to perforation of the nasal septum.  Failure to remove in the emergency department is higher with spherical or disk-shaped objects and more than one attempt or instrument is usually used.

If the object becomes displaced posteriorly, it can enter the respiratory tract leading to secondary morbidities.

Deterrence and Patient Education

Parents of young kids should be aware of the danger of lodged objects in the nose, therefore, they should be looking after their kids while playing with small toys and batteries. Moreover, the parents' kiss technique might help the parents to remove the stuck object without the need to come to the emergency department.

Pearls and Other Issues

A patient should be referred to an otorhinolaryngologist (ENT) when button batteries, magnets, as well as posteriorly displaced objects are lodged. They may require nasal endoscopy or removal in the operating room.

Flushing is no longer recommended as there is an increased risk of choking and aspiration.

Caution should always be used for the removal of nasal foreign bodies.

Educating families about the risk of button batteries is important. Adult supervision is always the key to prevention.

Enhancing Healthcare Team Outcomes

Making a diagnosis and removal of a nasal foreign body requires an interprofessional team.

The majority of cases of nasal foreign bodies are seen in the emergency department. Besides children, the nasal foreign body may also be seen in adults with psychiatric illnesses. If the nasal foreign body dislodges, it can block the airway and lead to an immediate fatality; hence nurses and physicians in the emergency room have to be aware of the potential consequences of this diagnosis. The majority of nasal foreign bodies can be removed in the emergency department without any sequelae. However, if there is any difficulty in removing the foreign body an ENT consult should be made.

Before making any attempt at removal, airway resuscitation equipment must be in the room. Anesthesia should be notified because many children are not cooperative. A nurse should be dedicated to the monitoring of the child during removal, irrespective of whether anesthesia is used. After removal of the foreign body, the child should be observed in the emergency room for 30 to 60 minutes. The parent should be educated to keep loose items away from the reach of the child.

Small case series report that complications are rare when the foreign body is removed from the nose promptly but any delay can lead to a number of complications.[8]