Nasal Foreign Bodies
Often seen in the emergency department, nasal foreign bodies (NFBs) are most often a pediatric phenomenon. However, adults, particularly those with mental retardation or psychiatric illness, can also fall victim. NFBs can cause mucosal damage and, if they dislodge into the airway, can even prove fatal. [1, 2] See the image below.
See Foreign Bodies: Curious Findings, a Critical Images slideshow, to help identify various foreign objects and determine appropriate interventions and treatment options.
Foreign bodies can be classified as either inorganic or organic. Inorganic materials are typically plastic or metal. Common examples include beads and small parts from toys. These materials are often asymptomatic and may be discovered incidentally. Organic foreign bodies, including food, rubber, wood, and sponge, tend to be more irritating to the nasal mucosa and thus may produce earlier symptoms. Peas, beans, and nuts are among the more common organic NFBs. 
A study by Svider et al indicated that jewelry beads are the most common NFBs prompting emergency department visits in the United States, with paper products and toys being the next most common objects. The study, which gathered data from the Nationwide Electronic Injury Surveillance System, also found that in males more than females, NFBs included toys, building set pieces, pens/pencils, batteries, coins, and nails/screws, while in females, these objects more often included jewelry, paper products, and buttons. The median patient age was 3 years. 
The most common locations for NFBs to lodge are just anterior to the middle turbinate or below the inferior turbinate (see the illustration below). Unilateral foreign bodies affect the right side about twice as often as the left. This may be due to a preference of right-handed individuals to insert objects into their right naris.
Some studies have demonstrated a greater prevalence of NFBs in males than in females (ie, 58% males  ); however, this trend has not been universal. Among children, those aged 2-5 years have the highest incidence of NFBs. Children develop their pincer grip at about age 9 months; in theory, this is necessary for most cases of NFB insertion.
A study by Scholes and Jensen evaluating NFB presentation and management at an American tertiary children’s hospital found that a high rate of intervention involving otolaryngology specialists was required. According to the investigators, this suggested that emergency room providers need to be educated with regard to nasal anatomy and NFB removal methods. The study included 102 patients, 36 (35%) of whom were referred to the otolaryngology clinic, with 58.9% of these children managed in the operating room. Of the 66 (65%) patients who underwent NFB removal in the emergency room, 30 (45%) were treated by an otolaryngology resident or attending physician. 
Bleeding is the most common complication reported in patients with nasal foreign bodies (NFBs), although it is characteristically minimal and resolves with simple pressure.
The foreign body itself may cause irritation to the patient; however, morbidity is primarily caused by the resulting inflammation, mucosal damage, and extension into adjacent structures. Reported complications include the following:
Acute otitis media
Nasal septal perforation
Local inflammation from NFBs can result in pressure necrosis. This, in turn, can cause mucosal ulceration and erosion into blood vessels, producing epistaxis. The swelling can cause obstruction to sinus drainage and lead to a secondary sinusitis. Organic foreign bodies tend to swell and are usually more symptomatic than are inorganic foreign bodies.
A delay in the diagnosis of complications of NFBs, such as sinusitis and acute otitis media, can result in prolonged morbidity. This can be avoided by performing a thorough examination and by reexamining the nasal cavity after removal of the NFB. (See the images below.)
Firmly impacted and unrecognized foreign bodies can in time become coated with calcium, magnesium, phosphate, or carbonate and become a rhinolith. Rhinoliths are radio-opaque and typically are found on the floor of the nasal cavity. Rhinoliths can remain undetected for years and only upon growth produce symptoms that lead to their discovery. NFBs tend to go unrecognized for longer periods of time than do foreign bodies in the ear because they usually produce fewer symptoms and are more difficult to visualize.
Button batteries, magnets, and living foreign bodies can be particularly destructive. For example, small button batteries may, within hours to days, cause chemical burns, ulceration, and liquefaction necrosis, leading to septal perforation. [7, 8, 9] Posterior dislodgement is very rare, but can occur. A recent case described a near-fatal tracheal aspiration of an NFB during physical examination. 
Metallic button batteries are small and shiny and are found in many toys, making them strong candidates for NFB insertion. Once inserted into the nose, they cause destruction via low-voltage electrical currents, electrolysis-induced release of sodium hydroxide and chlorine gas, and even liquefactive necrosis if their alkaline contents leak out.
Complications from button batteries are relatively common, occurring in 6 of 11 cases reviewed in one series.  In addition, they can occur rapidly, as discussed by Gomes et al, who reported nasal cavity burns from a battery that was in a nose for only 12 hours.  Button batteries require prompt removal and a thorough inspection of the nasal cavity for complications. It is particularly important not to irrigate the nasal cavities in order to avoid spreading alkaline content that may have leaked out. (See the images below.) 
Small magnets have been used recreationally as imitation earrings, as well as therapeutically for splinting after septoplasty. In the literature, magnetic NFBs have been shown to cause pressure necrosis and even perforation of the nasal septal mucoperichondrium. Therefore, they require prompt removal. One report described using metallic forceps enhanced by the magnetic force of a pacemaker magnet as a rescue technique after failed removal using the forceps alone. 
Larvae and worms have been known to occasionally inhabit the nasal cavities of persons living in tropical and unhygienic environments. They can lead to the destruction of the nasal mucosa and subsequent necrosis of septal cartilage and turbinates. Some authors have even reported extension to the orbit and paranasal sinuses. Because of the invasive nature of these NFBs, treatment typically consists of instillation of an agent to kill the larvae or worm, followed by surgical debridement and antibiotic therapy. These cases should be managed in conjunction with a specialist.
In most cases, the insertion of the nasal foreign body (NFB) is witnessed, and the dilemma of diagnosis is eliminated. In one study, presentations over 48 hours after the time of insertion accounted for 14% of all cases.  In addition to obtaining a thorough history from the patient and his or her primary guardian(s), all caretakers who have recently spent time with the patient (eg, babysitters) must be interviewed. Once the diagnosis is missed, the foreign body may not be detected for days, weeks, or even years.
Among the delayed presentations, the most common clinical scenario is unilateral nasal discharge. Nevertheless, clinicians must entertain the diagnosis of NFB in all patients with nasal irritation, epistaxis, sneezing, snoring, sinusitis, stridor, wheezing, or fever. Some authors have even reported discovering NFBs as the etiology of more unusual patient presentations, such as irritability, halitosis (unpleasant breath odor), or generalized bromhidrosis (body malodor). To avoid complications and delayed treatment, clinicians must maintain a high index of suspicion for this diagnosis.
The patient may present asymptomatically after having been witnessed inserting the item. Alternatively, the patient may have unilateral nasal drainage, foul odor, sneezing, epistaxis, or pain. Patients often deny having placed the foreign body; if the diagnosis is considered, this history should not lower the practitioner’s suspicion.
The physical examination is the main diagnostic tool, and a cooperative patient is essential for success. Parents and staff may be needed to comfort and immobilize a child to allow for a thorough otorhinolaryngologic examination. Sedation is often helpful in the pediatric population.
Maximal visualization of the nasal cavity is obtained by wearing a headlamp. Some authors recommend positioning children younger than age 5 years in a supine lying position and older children in a sitting “sniffing” position to allow optimal visualization. A nasal speculum may also help to view the nasal cavity, although some authors report less patient anxiety and equally good visualization by using one’s thumb to pull the nose upward.
The object can be found in any area of the nasal cavity, though objects are most predictably below the inferior turbinate or immediately anterior to the middle turbinate.  Occasionally, evidence of local trauma may exist, with erythema, edema, bleeding, or a combination thereof. After prolonged exposure, an increase in these findings is likely to be observed, as well as the presence of nasal discharge and a foul odor.
In addition to adequate inspection of the nasal cavity, assessing for complications of the nasal foreign body is important. Visualize the tympanic membranes for signs of acute otitis media, assess for sinusitis, check for nuchal rigidity in the toxic child, and auscultate the chest and neck for wheezing or stridor, which may be a clue of foreign body aspiration.
Lastly, looking for additional foreign bodies, whether they are in the nose or other body cavities, is important. Differentials to consider in the diagnosis of NFB include the following:
Upper respiratory infection (URI)
Unilateral choanal atresia
The extent of the workup depends on the clinical scenario.  Most isolated nasal foreign bodies (NFBs) require no diagnostic testing. Aside from metallic or calcified objects, NFBs tend to be radiolucent. Computed tomography (CT) scanning or other advanced imaging modalities may be useful when the differential diagnosis includes, for example, tumor or sinusitis. 
If there is a question of ingestion or aspiration of a foreign body, the patient should be evaluated with chest/abdominal radiography.  An aspirated, radiolucent foreign body may be inferred by postobstructive air trapping, and an ingested foreign body will show up if it is radiopaque, as most ingested foreign bodies are.
Nasal foreign body removal may be attempted by an experienced clinician if the object can likely be extracted. If doubt exists about the reasonable probability of extraction, an otolaryngologist should be consulted. Repeated attempts at removal may result in increased trauma and potential movement of the item into a less favorable location. Mechanical removal of a foreign body should not be attempted if the item appears to be out of range for instrumentation.
Removal should not be performed without adequate sedation in an uncooperative patient whose head cannot be securely and safely stabilized. Ideally, nonmechanical techniques such as positive air pressure should instead be attempted in these patients.
It is important to carefully plan a nasal foreign body (NFB) removal procedure and to make sure that the necessary instruments are at hand, since multiple attempts to remove an NFB may cause it to become more deeply lodged. Emergency airway supplies should also be immediately accessible, in case removal attempts inadvertently cause aspiration of the foreign body. 
Equipment used in NFB removal includes the following:
Light source (headlamp)
Alligator or bayonet forceps
Balloon catheter (eg, Fogarty biliary catheter)
Suction apparatus (eg, Frazier catheter)
Local anesthesia is typically not necessary, as pain is most often not present nor inflicted upon patients during removal. However, pharmacologic vasoconstriction of the nasal mucosa can facilitate examination and removal of an NFB and use of these agents should be strongly considered. Anesthesia and mucosal vasoconstriction can be accomplished by applying several drops of 1% lidocaine (without epinephrine) and 0.5% phenylephrine to the affected nostril.  For the apprehensive patient, a nebulized solution of 1-2mL of 1:1000 epinephrine has been used successfully for mucosal vasoconstriction. Of note, the author of the nebulized epinephrine case report recommended its use only if the NFB is large enough that posterior movement is unlikely and if the practitioners are experts at securing airways.
If the head of an uncooperative patient cannot be stabilized, procedural sedation should be achieved prior to mechanical removal. One study reported a very high success rate (95%) and a low complication rate with the use of procedural sedation, even among patients who had undergone prior, unsuccessful removal attempts. 
Proper positioning is vital in achieving optimal visualization and stability of the head. Patients may be placed in the “sniffing position,” either supine or with slight elevation of the head. Uncooperative patients in whom procedural sedation cannot be used must be securely immobilized. Even in a cooperative patient, assistance should be obtained to stabilize the head.
Several removal techniques are available, and the choice of a particular method depends upon the type of nasal foreign body (NFB), the supplies available, and the clinician’s comfort with each removal method. For easily visualized, nonspherical, non-friable objects, most clinicians prefer direct instrumentation. If the object is poorly visualized or spherical or cannot be successfully removed by direct instrumentation, balloon-catheter removal is a preferred method. For large, occlusive NFBs, positive pressure techniques are commonly used. (See the video below.)
All attempts at removal can be complicated by mucosal damage and bleeding. In addition, all failed attempts can result in posterior displacement of the NFB.
This technique is ideal for easily visualized, nonspherical, nonfriable foreign bodies. Previously described instruments include hemostats, alligator forceps, and bayonet forceps (see the video below). Friable and spherical foreign bodies are particularly difficult to remove with this technique; friable objects may tear, and spherical objects may be difficult to grasp, resulting in posterior displacement.
Hooked probes (eg, a right-angle hook) can be used for objects that are easily visualized but difficult to grasp. The hook is placed behind the NFB and is then rotated so that the hook angle is behind the bulk of the object. The object is then pulled forward.  One author reported using a flexible endoscope to visualize the NFB and then using it as a hook to pull out the object.  This technique, referred to as the “hook-scope” technique, may be useful provided that the patient is extremely cooperative and the clinician is highly adept at flexible nasopharyngoscopy. A recent case report described the use of a smooth metallic wire grasped by a hemostat to create a snare, which was used to dissect adhesed tissue planes adjacent to the NFB and then pull the NFB anterior with the leading snare edge posterior to the foreign body. 
Interestingly, some authors have suggested using the combination of direct instrumentation to grasp an object while having a balloon catheter (see next paragraph) placed behind the object to prevent posterior displacement during removal attempts.
This approach is ideal for small, round objects that are not easily grasped by direct instrumentation. Authors have used Foley catheters (eg, 5-8 French) or Fogarty catheters (eg, No. 6 biliary or No. 4 vascular), and the Katz Extractor Oto-Rhino Foreign Body Remover (InHealth Technologies, Calif) is also an option.
The biliary Fogarty catheter has been preferred over the vascular Fogarty catheter by some authors because its balloon is firmer and theoretically less prone to rupture.
Regardless of catheter type, the technique is similar. First, the balloon is inspected, and the catheter is coated with 2% lidocaine jelly. Then, with the patient lying supine, it is inserted past the foreign body and inflated with air or water (2mL in small children and 3mL in larger children). After inflation, the catheter is withdrawn, pulling the foreign body with it. (See the illustration below.)
Large, occlusive foreign bodies are especially amenable to the positive-pressure technique. Several techniques have been developed to expel NFBs by force provided in the form of positive pressure. The least invasive form, “forced exhalation,” can be accomplished by occluding the unaffected nostril and asking the child to blow hard out of his or her nose. If this fails, the positive pressure can be applied by either the parent’s mouth (“parent’s kiss” [19, 20] ) or a bag-valve mask.
With either method, a tight seal is formed around the child’s mouth, while avoiding the nose. The unaffected nostril is then occluded, and a forceful puff of air is provided. When the bag-valve mask is used, the Sellick maneuver can be considered to prevent esophageal air insufflation. 
If these techniques do not completely remove the object, they may at least dislodge the object more anteriorly and allow for removal using the previously described techniques.
Another positive-pressure technique delivers air into the unaffected naris with the patient’s mouth closed. In this method, the patient is placed on his or her side (foreign-body-side down), and the delivery device (known as a Beamsley Blaster) provides high-flow oxygen (10-15L/min) into the unaffected naris. To set up the Beamsley Blaster, one end of oxygen tubing is connected to the oxygen source and the other end is connected to a male-male oxygen tube adaptor that is placed in the patient’s unaffected naris.
Self-limited, subcutaneous, periorbital emphysema has been reported as a complication of NFB removal via intranasal positive pressure.  Positive-pressure techniques also have the risk of causing barotrauma to the airway, lungs, or the tympanic membranes, and clinicians should avoid using large volumes of forced air. To the best of our knowledge, these latter complications have not been reported.
This technique is ideal for easily visualized, smooth or spherical foreign bodies. The catheter tip is placed against the object, and suction is applied at 100-140mm Hg (readily supplied by standard medical suction equipment). A strong seal is important for success of this technique, and authors have recommended using a Schunk neck suction catheter with its plastic umbrella tip or a Frazier suction catheter with a segment of pliable tubing connected to its tip for a strong seal with the foreign body.
This method is ideal for easily visualized smooth or spherical foreign bodies that are dry and nonfriable. A thin coat of cyanoacrylate adhesive is placed on the tip of a wooden or plastic applicator, which is then pressed against the foreign body for 60 seconds and removed. Without full cooperation of the patient, the nasal mucosa can be easily injured by misplaced glue.
Rarely, a foreign body may be so posterior that the above techniques will not work. In these cases, after consultation with a specialist, it may be necessary to induce further posterior displacement of the object into the oropharynx for removal. Of course, this requires general anesthesia, endotracheal intubation, and esophageal occlusion.
A case report demonstrated successful removal of a loose ball bearing from a nasal cavity using a household magnet.  The authors believe that a strong magnet may be especially useful to remove button batteries, which are associated with mucosal edema and significant bleeding with direct instrumentation, making visualization especially difficult.
This technique has been strongly criticized for carrying a significant risk of aspiration or choking. The authors do not recommend the use of this method; however, it will be reviewed so that clinicians can be aware of its existence. The irrigation technique is performed by forceful squeezing of a bulb syringe filled with 7mL of normal saline into the unaffected naris.
In general, nasal foreign bodies (NFBs) can be safely removed by emergency physicians. However, an otolaryngologic specialist should be promptly consulted for cases of failed removal or an NFB complicated by significant damage to adjacent structures.  A nonemergent referral to a specialist should be made when there is concern that a tumor or mass is present. Contact a specialist when a tumor or mass is suspected to avoid delayed diagnosis of a malignancy.
Consult a specialist when managing an NFB complicated by significant damage to the nasopharynx (eg, button battery content leakage).
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Jonathan I Fischer, MD Emergency Physician, Department of Emergency Medicine, Lankenau Medical Center
Disclosure: Nothing to disclose.
Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.
Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center
Disclosure: Nothing to disclose.
Robert J Cox, MD, FAAEM, FACEP Director and Chief of Emergency Services, Assistant Professor, Department of Emergency Medicine, Spalding Regional Medical Center
Robert J Cox, ME, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Assocation, Medical Association of Georgia, and National Association of EMS Physicians
Disclosure: Nothing to disclose.
Edmond A Hooker II, MD, DrPH, FAAEM Assistant Professor, Department of Emergency Medicine, University of Cincinnati College of Medicine
Edmond A Hooker II, MD, DrPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Public Health Association, Society for Academic Emergency Medicine, and Southern Medical Association
Disclosure: Nothing to disclose.
Prajoy P Kadkade, MD Assistant Professor, Department of Otolaryngology and Communicative Disorders, North Shore University Hospital-Long Island Jewish Hospital System, Albert Einstein College of Medicine
Prajoy P Kadkade, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and Medical Society of the State of New York
Disclosure: Nothing to disclose.
Arlen D Meyers, MD, MBA Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting
Erik D Schraga, MD Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
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Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
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Mary L Windle, PharmD, Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
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The authors and editors gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.
Medscape Drugs & Diseases thanks Brian Kip Reilly, MD, Assistant Professor of Otolaryngology and Pediatrics, Department of Otolaryngology, Children’s National Medical Center, George Washington University School of Medicine, for many of the images in this article.
Medscape Drugs & Diseases thanks Philip E Zapanta, MD, Assistant Professor of Surgery, Associate Director of Otolaryngology Residency Program, Division of Otolaryngology-Head and Neck Surgery, George Washington University Medical Center; Consulting Staff, Division of Otolaryngology-Head and Neck Surgery, Medical Faculty Associates, for the videos and one of the foreign-body images in this article.
Nasal Foreign Bodies
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