Nasal foreign body: Removal of an open safety pin from the left nostril.

Abstract

We describe the case of a woman who presented with an open safety pin lodged in her left nostril. An attempt to remove the pin with the patient under local anesthesia was not successful. Removal was eventually accomplished in the operating room with the patient under general anesthesia.

Introduction

Many cases of nasal foreign bodies have been reported in the otolaryngologic literature. [1-8] They occur more often in the pediatric population than in adults. In adults, foreign bodies can usually be removed in an outpatient setting, with or without local anesthesia. This report describes the removal of an open safety pin that became lodged in the nostril. This case serves as an example of the occasional need for general anesthesia during a technically difficult removal of a nasal foreign body in an adult.

Case report

A 43-year-old woman who was employed at the Medical College of Virginia of Virginia Commonwealth University came to the emergency department with a complaint of pain related to a pin lodged in her left nostril. She explained that earlier that evening, she had scratched an itch in her nose with a closed safety pin. The pin had opened during the process and was now stuck, causing severe discomfort. There was no epistaxis.

On examination, the patient was tearful and in moderate distress. Anterior rhinoscopy with a headlight and nasal speculum revealed that the "keeper" of the safety pin (figure 1) was lodged in the anterior floor of the nose, and the point of the pin was embedded in the mucosa high in the ethmoid region. Posteroanterior and lateral skull films confirmed that the safety pin had opened, and that the keeper and point were oriented anteriorly and the spring was positioned posteriorly on the nasal floor (figure 2).

After the administration of midazolam intravenously and local anesthesia with a 4% cocaine solution on a cotton pledget, removal was attempted with a straight hemostat. The attempt was not successful because of patient discomfort and the degree of technical difficulty. The decision was made to remove the foreign body under general anesthesia.

The patient was taken to the operating room. Endoscopic equipment and various foreign body extractors were available in the event that the pin could not be simply removed under direct vision. The patient's nose was decongested with phenylephrine 0.25% on a cotton pledget. Endoscopic rhinoscopy revealed that the point of the pin had entered the mucosa at the root of the middle turbinate.

Three methods of removal were entertained. The first was to grasp the point shaft and dislodge it from the nasal mucosa by advancing it posteriorly; closing the spring would then allow for safe removal through the nostril. The second option was to cut the point shaft close to the spring and remove the foreign body in two pieces. The third option was to grasp the spring and push the safety pin into the nasopharynx; an oral approach would then be used to deliver the foreign body. This third option is analogous to a method that has been described for the removal of an open safety pin in the esophagus, a method that minimizes mucosal trauma by creating a trailing point. [1,2]

The first method was successfully employed. The point shaft was grasped with a hemostat, dislodged posteriorly, and pushed craniad. Next, the keeper shaft was controlled with a second hemostat. The safety pin was closed and removed through the nostril with no damage to the surrounding mucosa. Nasal endoscopy confirmed that there was no significant bleeding or granulation tissue. Followup fiberoptic examination 1 week later revealed no evidence of mucosal damage.

Discussion

The removal of an open safety pin in the nose presents several technical issues for which there are few guidelines. There is one report that describes the removal of an open intranasal safety pin that had eroded through the soft palate, where the keeper shaft was first cut. [3] The safety pin was then removed in two pieces, one orally and one nasally.

There are several methods of removing esophageal safety pins described in the otolaryngologic literature, including sheathing, straightening, and closing. [2] In our case, we administered general anesthesia to optimize visualization and to permit bimanual manipulation to control an anteriorly oriented safety pin keeper and point.

From the Department of Otolaryngology-Head and Neck Surgery, Medical College of Virginia of Virginia Commonwealth University, Richmond.

Reprint requests: Lawton H. Salley, Jr., MD, Department of Otolaryngology-Head and Neck Surgery, Medical College of Virginia of Virginia Commonwealth University, Richmond, VA 23298.

References

(1.) Stool SE, Manning SC. Foreign bodies of the pharynx and esophagus. In: Bluestone CD, Stool SE, eds. Pediatric Otolaryngology. Philadelphia: W.B. Saunders, 1990:1009-18.

(2.) Marsh BR. The problem of the open safety pin. Ann Otol Rhinol Laryngol 1975;84:624-6.

(3.) Utrata J. Erosion of the soft palate by a foreign body of the nose. Ear Nose Throat J 1977;56:403-4.

(4.) Babu KN. An unusual foreign body in the nose. J Laryngol Otol 1981;95:961-2.

(5.) Forrest AW. A large foreign body in the nose. J Laryngol Otol 1987;101:1280-2.

(6.) Malhotra C, Arora MM, Mehra YN. An unusual foreign body in the nose. J Laryngol Otol 1970;84:539-40.

(7.) Shapiro RS. Foreign bodies of the nose. In: Bluestone CD, Stool S, eds. Pediatric Otolaryngology. Philadelphia: W.B. Saunders, 1990:752-9.

(8.) Tong MC, Ying SY, van Hasselt CA. Nasal foreign bodies in children. Int J Pcdiatr Otorhinolaryngol 1996;35:207-11.