M2E Too! Mellick's Multimedia EduBlog
The M2E Too! Blog by Larry Mellick, MD, presents important clinical pearls using multimedia.

By its name, M2E Too! acknowledges that it is one of many emergency medicine blogs, but we hope this will serve as a creative commons for emergency physicians.

Tuesday, September 3, 2013

Pediatric Nasal Foreign Bodies
Many of my pediatric patients with nasal foreign bodies present to the emergency department for chief complaints unrelated to the nose. The young man shown below, for example, presented several years ago for the evaluation of dog bite wounds to the face. I could see the telltale signs and symptoms of a chronic unilateral nasal drainage the minute I walked in the room. (Figure 1.)

Figure 1. Nasal drainage is the telltale sign of a nasal foreign body.
I questioned the patient and his father, and they offered no history to confirm insertion of a nasal foreign body. Nevertheless, a wad of mummified Halloween candy wrappings inserted a month earlier was removed after significant effort that required the assistance of our ENT colleagues. (Figure 2.)

Figure 2.
The family will uniformly complain that the patient has an offensive body odor after the nasal foreign body has been present for weeks to months. A purulent unilateral nasal drainage will also be observed and reported. The foreign body can be found in any area of the nasal cavity, but will most predictably be located below the inferior turbinate or immediately anterior to the middle turbinate.
Three different types of techniques are used to remove a foreign body: manual removal with a curette, forceps, hemostats, or suction; positive air pressure techniques, and balloon catheter techniques. The equipment that may be required for the different techniques are:

• Bulb syringe
• Katz extractor
• Alligator forceps
• Bayonet forceps
• Suction tip (e.g., Frazier)
• Curette
• Bag-valve-mask
• Mother’s mouth
• Topical skin adhesive
Patient cooperation and preparation are crucial. Procedural sedation is often required in the ED, but sedation with nasal midazolam alone may be sufficient. Apply it with an atomizer. The affected naris should be treated with a topical nasal vasoconstrictor such as oxymetazoline, and the mucosa should be anesthetized with a patient-weight-appropriate amount of 4% lidocaine, again using the atomizer.
A nasal speculum, otoscope, and head lamp are other essential tools for visualizing and performing the procedure. The patient should be positioned and his head immobilized, and then various tools — alligator or bayonet forceps, wire loops, or right-ankle hooks — can be used to remove the object manually. Bending the tip of an 18-gauge needle will create a cheap and effective right-angle hook. (Figure 3.)

Figure 3. Right-angle hook made from the tip of an 18-gauge needle.
A suction tip catheter may be used if the object is smooth and round. Positive air pressure techniques can be performed with a bulb syringe, the mother’s mouth, or a bag-valve-mask. This video effectively demonstrates the positive air pressure techniques. Use caution during positive air pressure techniques to avoid barotrauma. Balloon catheter removal of the foreign body can be accomplished with a small Foley or Fogarty catheter or a commercially prepared catheter specifically for foreign bodies, the Katz extractor. Click here to watch of video demonstrating how to use the Katz extractor.

Common complications are bleeding, barotrauma, and dislodged foreign bodies that can be aspirated or swallowed. Mucosal trauma and epistaxis are common occurrences, but can often be avoided or minimized by careful preparation of the nasal mucosa. (Figure 4.)
Dislodged foreign bodies are a real concern, and airway compromise is always a risk. I clearly remember one such event early in my career. I had successfully removed wood screws from the nose of a screaming toddler, but they dropped from my hemostat directly into her open mouth. She promptly swallowed them, and after a few anxious moments, we were able to confirm that the screws had safely made their way to the child’s stomach and not the right main stem. Safe passage of the screws occurred several days later.

Figure 4: Epistaxis following attempts at removing a well-entrenched foreign body.
Pediatric nasal foreign body removal is clearly within the realm of emergency medicine, but if you encounter a stubbornly entrenched foreign body that resists all your tricks, it is important to request that your ENT colleagues help out with their tools of the trade.