Foreign body - Nasal

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full PCH Emergency Department disclaimer.

Aim 

To guide staff with the assessment and management of nasal foreign body.

Background

• Foreign body insertion in the nose in paediatrics is a common presentation to the ED.
• It is more common in children less than 7 years or those with intellectual impairment.
• Most patients present on the day of insertion but occasionally this may be delayed for days / weeks and can present as an offensive nasal discharge or may be discovered incidentally on routine examination.

Key points

Types of foreign body:

• A large variety of objects have been implicated. These include beads, plastic toys, vegetation and food.
• The most serious retained FB is the button battery that can cause mucosal damage and necrosis (see Foreign body - ingested).

Children with nasal foreign bodies tend to be younger than other ENT foreign bodies. 

Assessment

History

• Local pain
• Nasal discharge (may be unilateral and/or offensive)
• Epistaxis
• Admission by child
• Rhinitis
• Mouth breathing
• Sensation of swelling. 

Examination

• Foreign body is usually seen on direct vision

Investigations

• Usually none indicated

Management

• Accurate identification of foreign body is essential prior to removal to guide removal technique.
• Ensure good lighting preferably with headlight.
• A cooperative or clinically held (internal WA Health only) patient is necessary and this may require sedation techniques. See Oral Conscious Sedation - PCH Clinical Practice Manual (internal WA Health only).
• Nasal Lidocaine (lignocaine) 5% phenylephrine 0.5% - Co-phenylcaine Forte® may be used to reduce swelling and may help in the expulsion of the foreign body.
  • 1 squirt, 2 - 4 years old, 
  • 2 squirts, >4 years old 

Removal options

• Forced air using air viva into mouth and occlusion of opposite nostril. Or the ‘Parent’s Kiss’ for FBs that totally occlude the nostril.

• Suction – may be used but requires a smooth spherical object provide a good seal.
• Forceps – can grasp some objects but often will slip on rounded objects and push the object further in.
• Hook – insert along medial wall of nostril with hook pointing cranially and then pass hook behind the object and rotate hook laterally to bring hook behind object and withdraw object.
• ENT referral for fibre optic endoscopy.

Timing of removal

Button batteries in the nasal cavity and magnets across the nasal septum warrant urgent removal.

Otherwise, removal can be an urgent elective procedure on discussion with the ENT registrar. There are no reports of bronchial FB spontaneously arising from nasal FB in the literature.

Complications of removal

• Trauma
• Bleeding
• Aspiration.

Bibliography

1. Isaacson GC, Aderonke O (2014) Diagnosis and Management of Intranasal Foreign Bodies. UpToDate 
   
   

Endorsed by:	Co-Director, Surgical Services	Date:	Aug 2021
		Review date:	Aug 2024

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