Endoscopic view of a foreign body in the nasal cavity that initially resembled a polypoid mass. (Rhinoscopic Clinic).

A healthy 4-year-old boy was examined in the emergency room of Yale-New Haven Hospital for a chief complaint of left nasal obstruction caused by an unidentified foreign body. Several attempts to remove the foreign body, including a Foley catheter technique, failed. The foreign body could not be visualized, and a small amount of bleeding was encountered. The patient was referred to the otolaryngology service for treatment.

Nasal examination was not possible because the patient would not cooperate. Therefore, he was taken to the operating room and placed under general anesthesia. A telescopic examination there detected a glistening object that resembled a polypoid mass in the mid-to-superior portion of the left nasal cavity between the septum and the inferior turbinate, which was inflamed and swollen (figure, A). Suction was applied to remove the thick mucus that had covered the foreign body. Upon closer inspection with a blunt nasal probe, the foreign body was identified as a spherical, solid mass (figure, B). An attempt to remove the object with grasping forceps only tended to push it posteriorly. A curved, right-angle hook (Lusk double-ended maxillary sinus ostium seeker) was placed behind the foreign body and pulled forward (figure, C). The foreign body was identified as a multifaceted plastic jewelry bead (figure, D). Following removal, both nasal cavities were thoroughly examined, and no other foreign body was found. The p atient experienced no complications and did well.

Nasal foreign body impaction is common in the pediatric population. It usually occurs in children between 2 and 5 years of age and during play. (1) Most of these foreign bodies are toys and other small objects, such as pieces of paper, rubber erasers, pebbles, beads, marbles, beans, safety pins, washers, nuts, pieces of sponge and chalk, etc. (1,2) It should be noted that button batteries in the nose produce a liquefaction necrosis that can progress to septal perforation and lateral nasal wall necrosis. (3) The early removal of a button battery is strongly recommended.

Nasal impactions are often witnessed by an adult or reported by the child. In either case, the patient often is brought to the emergency department within 48 hours. The most common sign is a persistent, unilateral, foul-smelling rhinorrhea. The patient may also experience nasal obstruction, epistaxis, pain, sneezing, or snoring. (1, 2) Radiographic evaluation is generally not necessary. However, if the foreign body is found late, sinus x-rays may show unilateral nasal obstruction with ipsilateral maxillary sinusitis. When a metallic foreign body is suspected, x-rays are very helpful in determining its exact location.

Most cases of nasal foreign bodies are diagnosed and treated in the emergency department. During the examination, children must be held and a topical decongestant and anesthetic should be administered. A cursory examination of an uncooperative patient will often miss an intranasal foreign body. When a child will not cooperate, general anesthesia must be considered.

Several techniques for removing nasal foreign bodies have been described. The nasal cavity can be visualized directly or endoscopically. Removal is often first attempted by nasal lavage or positive pressure. (4) If this is unsuccessful, the object may be removed with a nasal grasping forceps, a curved right-angle hook, suction, or a Foley balloon catheter. (2) Recently, innovative strategies with magnets (5) and the "parent; s kiss" (6) have been employed in some cases. During the parent's kiss, the parent's mouth forms a seal over the child's mouth. The parent then blows a short, sharp puff of air into the child's mouth, and the force of the pressure dislodges the foreign body. A round solid object, as in this case, is best removed with a curved, right-angle hook.

References

(1.) Francois M, Hamrioui R, Narcy P. Nasal foreign bodies in children. Eur Arch Otorhinolaryngol 1998;255:132-4.

(2.) Kalan A, Tariq M. Foreign bodies in the nasal cavities: A comprehensive review of the aetiology, diagnostic pointers, and therapeutic measures. Postgrad Med J 2000;76:484-7.

(3.) Dane S, Smally AJ, Peredy TR. A truly emergent problem: Button battery in the nose. Acad Emerg Med 2000;7:204-6.

(4.) Navitsky RC, Beamsley A, McLaughlin S. Nasal positive-pressure technique for nasal foreign body removal in children. Am J Emerg Med 2002;20:103-4.

(5.) Douglas SA, Mirza S, Stafford FW. Magnetic removal of a nasal foreign body. Int J Pediatr Otorhinolaryngol 2002;62:165-7.

(6.) Botma M, Bader R, Kubba H. "A parent's kiss": Evaluating an unusual method for removing nasal foreign bodies in children. J Laryngol Otol 2000;114:598-600.

From the Section of Otolaryngology, Hospital of St. Raphael, New Haven, Conn. (Dr. Yanagisawa); and the Section of Otolaryngology, Yale-New Haven Hospital, and the Section of Otolaryngology, Yale University School of Medicine, New Haven (Dr. Yanagisawa and Dr. Lesnik).