Pediatric patients frequently put foreign bodies into their mouths, noses, and ears. The spectrum of foreign bodies that children place into their facial orifices are impressive. Paper, vegetable matter (such as peanuts), toys, beads, metal screws, and Play-Doh are just a few examples.
The insertions are often done surreptitiously, only to be discovered days or sometimes weeks later. Occasionally, the retained foreign nasal bodies will ferment and present with a purulent, unilateral nasal drainage, accompanied by an unrelentingly repulsive odor. Sometimes an occasional cockroach wanders into the external auditory canal looking for a dark, moist cavity for sleeping or laying eggs. There appears to be a preference for the right nostrils or right external auditory canal, which correlates with a higher percentage of right-handed children.
The classic techniques for removing foreign bodies from the nose and ears include using the following:
- Alligator forceps
- Balloon-tipped catheters
- Frazier suction tips
- Ear curettes
- Bulb syringe
- Mother's breath
Tension with ENT Colleagues
An ongoing low-grade tension between otolaryngologists and emergency physicians always seems to be brewing about attempts to remove foreign bodies. It is understandable because our ENT colleagues only see our failures and our failures often slightly traumatize our patients and their orifices. If every patient with a foreign body required an otolaryngologist, however, the demand would probably outstrip the specialty's availability.
Thankfully, emergency physicians are increasingly experienced at managing these cases. And, in MacGyver fashion, we do a good job of developing our own tools for removing foreign bodies like the right-angled hook, improvised suction catheters, the application of topical skin adhesive, and the use of rare earth magnets.
Many of the classic techniques are not easily reproduced, and often fail in my hands. Besides failures, other risks include trauma-induced bleeding of the orifice's skin or mucosa, pain, perforated tympanic membranes, and unwanted displacement of the foreign body. Dislodgement may include pushing the foreign body deeper into the orifice, making access and removal even more difficult. It can also result in aspiration or ingestion of the foreign body.
My most memorable case was one where I had to remove two small screws from a child's nose with forceps. Just as I was transporting the screws across the open mouth of the crying child, I dropped both screws directly into his mouth. A subsequent x-ray demonstrated the two screws sitting safely in his stomach. Thankfully, our patient had no complications and passed the two screws uneventfully several days later.
Pain is another risk. The external auditory canal is a sensitive area containing multiple nerves that are notoriously difficult to anesthetize. Topical anesthesia has only a partial effect, and four quadrant injections for local anesthesia are difficult and painful. The nose, notorious for bleeding from the slightest trauma, can also hide foreign bodies behind and under the turbinates.
Thankfully, a number of adjuncts can make removing a foreign body from the nose or ears go more smoothly, including:
- Child life specialists
- Atomized intranasal midazolam
- Papoose boards or burrito sheets
- Atomized intranasal lidocaine
- Topical tetracaine to the external auditory canal
- Oxymetazoline hydrochloride nasal spray
- Ketamine procedural sedation
- Nasal speculums
Insects, most often cockroaches, are occasionally still moving. Besides being unnerving to the patient, insects desperately clawing during the extraction process can be uncomfortable, but several substances are reportedly excellent at humanely euthanizing cockroaches: microscope oil, 2% to 4% lidocaine, viscous lidocaine, mineral oil, EMLA cream, and ethanol.
A number of interventions are often recommended following extraction. First, always check the orifice for additional foreign bodies. Many clinicians will use topical antibiotic drops for the external ear canals or a topical antibiotic ointment for the nostrils. Their reasoning is that trauma to the mucosa or skin is not uncommon after orifice instrumentation. Systemic antibiotics may be necessary to treat sinusitis from a chronically retained nasal foreign body. Pain control with ibuprofen or acetaminophen is also helpful. Post-procedure epistaxis can be treated with an oxymetazoline nasal spray. The emergency department visit may also be an appropriate time for counseling the parents on child safety.
Watch a video of using a suction catheter to remove a bead stuck in child's nose.
Two medical students help Dr. Mellick experiment using suction to remove a hearing aid from the ear in this video.
EPs first tried a bulb syringe, direct removal, and bag-valve-mask to remove a nasal foreign body, but sometimes you just have to call for ENT consult, as shown in this video.