Nasal foreign bodies are commonly seen in children, particularly those between 1 and 4 years of age. Young children are naturally curious and spend a great deal of time investigating themselves and the world around them. This involves handling, tasting, and smelling whatever they get their hands on. The Emergency Physician is faced with a foreign body in the nose when these investigations go too far. Adult patients with mental disabilities or psychiatric illness can present with a nasal foreign body. The most common foreign bodies found are beads, food (e.g., corn, nuts, peas, and popcorn), paper, rocks, and toy parts.1,2 Nasal foreign bodies result from attempts to clean the nasal cavity or to control bleeding with cotton swabs, paper, or sponge material.3
Children may present with a known nasal foreign body. Other presentations may be subtle. This includes an odor, halitosis, persistent unilateral nasal discharge, or recurrent epistaxis. Foreign bodies can be found incidentally during a routine examination or on radiographs in the asymptomatic child.1,4-6
The task of the Emergency Physician is fourfold.7,8 Suspect the presence of a nasal foreign body. Perform a thorough physical examination, including a search for the foreign body. Visualize the foreign body. Remove the foreign body efficiently and with minimal trauma.
ANATOMY AND PATHOPHYSIOLOGY
The nasal cavity consists of two passages on either side of the nasal septum. The superior, middle, and inferior bony turbinates project medially into each passage and are covered by a mucous membrane overlying a venous plexus. Foreign bodies can be located anywhere in the nose. Most foreign bodies are found on the floor under the inferior turbinate or anterior to the middle turbinate.9 The cartilaginous septum is covered by a thin mucosa and receives its blood supply from the overlying mucoperichondrium. Sensory nerves of the nasal cavity are branches of the greater palatine nerve and sphenopalatine ganglion.10 These nerves are easily numbed with topical anesthetics. The nasal cavity is separated from the orbit by the thin lamina papyracea and from the anterior cranial fossa by the cribriform plate of the ethmoid bone. See Chapter 203 on nasal fracture reduction and Chapter 205 on epistaxis for a more detailed review of nasal cavity anatomy.
A foreign body in the nasal cavity sets off an inflammatory response and the venous plexus becomes congested. Swelling may eventually obscure the foreign body from view. The longer the foreign body remains in the nasal cavity, the more likely the patient is to develop pressure necrosis, granulation tissue, infection, and a purulent discharge. The foreign body can erode into the surrounding tissues over time if it is not removed. A unilateral malodorous discharge and/or epistaxis from a child’s nose is a sign of a foreign body.