Nasal Foreign Body

An object lodged in the nasal cavity, most commonly in children aged 2 to 5 years, and in adults with cognitive or psychiatric impairment. Most are benign and easily removed, but two categories are emergencies: button batteries and paired magnets.

Common objects

Beads, small toy parts, paper, foam, food including beans and peas, pebbles, tissue, sponge, and in adults, cotton wool, retained packing and displaced dental material.

Button battery, which is the critical emergency

A disc battery in contact with moist mucosa generates an external electrolytic current, producing hydroxide ions at the negative pole with liquefactive necrosis. Injury begins within 1 hour and full thickness septal necrosis occurs within 3 to 4 hours. The consequences are septal perforation, saddle nose deformity, synechiae, nasal stenosis, and in severe cases penetration into the orbit or the anterior skull base. Removal must occur within hours, not the next day, and never on a routine list.

Paired magnets, particularly high strength neodymium magnets placed in each nostril or one in each side of the septum, produce pressure necrosis of the septum with perforation within hours. They must be removed urgently.

Organic material such as beans and peas absorbs moisture, swells and becomes more difficult to remove, and provokes an intense inflammatory reaction. Irrigation is therefore contraindicated.

Rhinolith: a long retained foreign body that acts as a nidus for progressive deposition of calcium and magnesium carbonate and phosphate salts, forming a hard concretion over months or years. It presents with chronic unilateral foul discharge, obstruction and occasionally epistaxis in an adult who has no recollection of an inserted object.

The clinical rule: unilateral, foul smelling, purulent nasal discharge in a child is a foreign body until proven otherwise, and the same applies in adults with cognitive impairment. This is the presentation that is misdiagnosed as sinusitis and treated with repeated antibiotic courses.

• Frequently asymptomatic and witnessed, presenting immediately.
• Unilateral purulent, foul smelling and sometimes bloodstained nasal discharge, which is the classic delayed presentation.
• Unilateral nasal obstruction.
• Epistaxis.
• Sneezing and nasal irritation.
• Mouth breathing.
• Excoriation of the nasal vestibule and upper lip from chronic discharge.
• In battery injury, rapid onset of pain, bleeding, black or grey discharge, and visible necrotic tissue.
• Systemic illness is unusual and suggests complication.

Examination

• Anterior rhinoscopy with a good light and nasal speculum, after suction of discharge, which is necessary to see the object at all.
• Endoscopy where the object is not visible anteriorly or where a posteriorly displaced object is suspected.
• Always examine both nasal cavities, both ears, and consider the airway and oesophagus, since children insert multiple objects and may have swallowed or aspirated a similar item.
• Assess for signs of aspiration: stridor, cough, unilateral wheeze, reduced air entry.

• Direct visualisation is diagnostic. Suction and topical decongestion are usually needed first.
• Radiography is not required for most objects, but a lateral and anteroposterior plain film is indicated where a battery is suspected, showing the characteristic double ring or halo sign that distinguishes a battery from a coin, and identifying its orientation, since the negative pole causes the greatest injury.
• Chest and neck radiography where aspiration or ingestion is suspected.
• Computed tomography for rhinolith, suspected posterior displacement into the nasopharynx, or complications including orbital or skull base involvement.
• Consider intracranial pathology in the differential of unilateral nasal discharge: an encephalocele or meningocele presents as a soft compressible mass that transilluminates, increases with crying or straining, and must never be removed as a polyp. Any unilateral nasal mass in a child requires imaging before instrumentation.

Differential diagnosis of unilateral nasal discharge

• Foreign body and rhinolith.
• Choanal atresia, unilateral, presenting with persistent unilateral clear discharge.
• Encephalocele, meningocele and glioma.
• Dermoid cyst with a pit on the dorsum.
• Antrochoanal polyp.
• Sinonasal tumour.
• Odontogenic sinusitis and a dental fistula.
• Cerebrospinal fluid rhinorrhoea.

The single attempt principle

The first attempt has by far the highest success rate. Each failed attempt causes oedema, bleeding, distress and posterior displacement, converting a simple procedure into a general anaesthetic. In a child who will not cooperate, do not attempt removal in the clinic or emergency department. Refer for removal under anaesthesia.

Preparation

• Position the child sitting upright on a parent's lap with appropriate restraint, or supine with a papoose where necessary.
• Topical decongestion with xylometazoline or phenylephrine, plus topical anaesthesia with lidocaine, which reduces mucosal swelling and improves both visualisation and comfort.
• Good lighting with a headlight, adequate suction, and the correct instruments prepared before starting.

Removal techniques

• Positive pressure techniques, tried first for anterior objects in cooperative children since they are atraumatic:
• Parent's kiss: the parent occludes the unaffected nostril and blows a short sharp puff into the child's mouth, expelling the object. Explain it as a big kiss to reduce anxiety.
• Bag valve mask or a high flow oxygen jet applied to the mouth with the unaffected nostril occluded.
• Ask an older child to blow the nose while occluding the unaffected side.
• Instrumental removal under direct vision:
• Crocodile or Tilley forceps for graspable irregular objects such as paper, foam and sponge.
• A right angled hook or a wax curette passed above and beyond a smooth round object, then withdrawn. Forceps must not be used on smooth spherical objects, since they push them posteriorly.
• Suction with a wide bore catheter for soft or small objects.
• A small balloon catheter such as a Fogarty or a lubricated 5 to 8 French Foley catheter passed beyond the object, inflated with 1 to 2 mL of saline or air, and withdrawn.
• Cyanoacrylate applied to the blunt end of a probe and held against a smooth object for 60 seconds, then withdrawn, which is effective but risks adhering to the mucosa.
• Do not irrigate the nose, since organic material swells and there is a risk of aspiration.

Button battery, which overrides all of the above

• Immediate removal, ideally within 1 to 2 hours of presentation. Escalate directly to otolaryngology and do not defer to a routine list.
• Do not irrigate and do not instil any liquid, since moisture accelerates hydrolysis.
• Remove under direct vision with forceps, using general anaesthesia if there is any doubt about cooperation, and preferring general anaesthesia to a failed awake attempt.
• After removal, inspect the septum and lateral wall for necrosis and perforation, debride necrotic tissue, and consider a silastic splint to prevent synechiae.
• Antibiotic cover with co amoxiclav, and topical antibiotic ointment.
• Arrange close follow up at 48 hours, 1 week and 1 month with endoscopy, since perforation, synechiae and stenosis develop over days to weeks.
• Warn the family that septal perforation and cosmetic deformity are possible, and document this discussion.

Indications for removal under general anaesthesia

• Uncooperative child or adult.
• Object impacted, posteriorly placed, or in the nasopharynx.
• One or more failed attempts with resulting oedema or bleeding.
• Sharp objects and impacted organic material.
• Rhinolith.
• Battery where atraumatic immediate removal is not possible awake.
• Any suspicion of a vascular lesion, encephalocele or tumour rather than a foreign body.

After removal

• Inspect the nasal cavity fully for a second object, which is common.
• Examine both ears.
• Nasal saline irrigation for a few days.
• Topical antibiotic ointment such as mupirocin where the mucosa is excoriated, or a short course of co amoxiclav where there is established secondary infection or battery injury.
• Analgesia as needed.

Complications

• Epistaxis, mucosal laceration and adhesions.
• Posterior displacement with aspiration into the airway, which is the most serious immediate risk during removal and is the main argument for controlled removal under anaesthesia in an uncooperative child.
• Secondary sinusitis and, rarely, orbital or intracranial extension.
• Septal perforation, synechiae, nasal stenosis and saddle nose deformity after battery injury.
• Toxic shock syndrome from retained packing.

Prevention

Counsel parents about small objects and about the specific danger of button batteries in remote controls, toys, hearing aids, watches and greeting cards, and about high strength magnets. Reinforce that a battery in the nose or ear is an emergency requiring immediate attendance.