The nose is the most common site of aerodigestive tract foreign bodies in children. Most children present with a history of witnessed or suspected foreign-body insertion and are symptom free. However, one-quarter are discovered incidentally, with no preceding history by the caregiver. Common symptoms include mucopurulent discharge, foul odor, epistaxis, pain, and nasal obstruction. Objects most often include inorganic material (beads or small toys) and food. Unilateral foul-smelling discharge suggests organic or porous material (paper, sponge, foam rubber) or the long-standing presence of a foreign body leading to a localized inflammatory reaction.
Nasal Foreign Body. Purulent drainage from the left nostril due to a candy wrapper which had been in place for 2 weeks. (Photo contributor: Larry B. Mellick, MD, MS, FAAP, FACEP.)
Nasal Foreign Body. A round circular bead (insert) is embedded in the right nostril. (Photo contributor: Lawrence B. Stack, MD.)
Button Battery. A button battery is seen in the right nasal passage, surrounded by necrotic tissue. (Photo contributor: Craig Folsom, MD.)
Foreign bodies are typically lodged anteriorly on the floor of the nasal passage under the inferior turbinate or superiorly in front of the middle turbinate. Diagnosis is through direct visualization, although high foreign bodies may preclude visual diagnosis even with a head lamp or otoscope. Most are radiolucent, and unless you suspect a concomitant airway or GI foreign body, plain films are unnecessary. Button batteries and paired magnets can be especially dangerous due to the risk of local tissue compromise and should be removed promptly. Otherwise, removal can be an elective procedure. Techniques for removal include the use of positive pressure through the mouth with simultaneous occlusion of the unaffected nares (“mother’s kiss maneuver”) and removal with alligator forceps, a day hook (right-angle hook), or via a balloon catheter device threaded past the foreign body with subsequent balloon inflation and device retraction (Katz extractor). Children should be adequately prepared and properly immobilized. The value of an adept holder cannot be underestimated. The differential diagnosis includes allergic rhinitis, upper respiratory infection, acute sinusitis, cerebrospinal fluid leak, and nasopharyngeal polyp or mass.
Management and Disposition
Most foreign bodies can be successfully removed in the emergency department. After removal, always inspect for trauma and the presence of additional foreign bodies. Otolaryngology consultation or referral is warranted for poorly visualized posterior foreign bodies, chronic or impacted objects with significant inflammation, button batteries, penetrating or hooked foreign bodies, or any foreign body that cannot be removed due to poor cooperation or limited resources. After successful removal, patients can be safely discharged with instructions to return with any persistent, unilateral nasal discharge, ...