Direct Instrumentation or Manual Removal
The most straightforward and common method is to remove the anteriorly located nasal foreign body under direct vision. Instrument removal should not be attempted if the foreign body is located posteriorly. The instruments most often used include alligator forceps, bayonet forceps, straight forceps, or mosquito forceps. Hooked probes, such as right angles or curved hooks, ear curettes, wire loops, or mastoid hooks can also be utilized. In the absence of these, a paper clip can be fashioned into a hook. A novel device is the Lighted Forceps for Foreign Body Removal (Bionix Medical Technologies, Toledo, OH). It is a single patient use and disposable device that contains a light source and acts like a forceps (Figure 169-3).
The Lighted Forceps for foreign body removal. (Photo courtesy of Bionix Medical Technologies, Toledo, OH.)
The EasiEar Disposable Comfort Curette (Splash Medical Devices LLC, Atlanta, GA) is an improvement to the standard disposable plastic curette (Figure 169-4). It is a stainless steel, single patient use, and disposable curette. The rounded wire head is smooth. It lacks the jagged and sharp plastic edges that are often found on molded plastic curettes. The EasiEar has no abrasive edges, seams, or surfaces to potentially abrade the nasal mucosa. This design may prevent abrasions, lacerations, and procedure-related bleeding. The spring wire shaft provides some flexibility and enhanced maneuverability when compared to molded plastic curettes, making the foreign body removal process easier. The angled head and flexible shaft allow it to be manipulated within the nasal cavity to remove a foreign body.
The EasiEar Metal Curette (Splash Medical Devices LLC, Atlanta, GA).
These instruments enable the Emergency Physician to grasp the foreign body directly or pull it out from behind. Anterior located foreign bodies are often easily removed with instrumentation. Forceps are better suited for soft and irregularly shaped foreign bodies (Figure 169-5).5,14 Curettes and hooks are more effective for hard and spherical foreign bodies.5,14 Relative contraindications to instrumentation include posterior located foreign bodies, friable foreign bodies, and smooth or round foreign bodies. Potential complications include posterior displacement of the foreign body leading to nasal obstruction or even aspiration, mucosal abrasions and lacerations, and epistaxis.
Using forceps to remove a thumb tack lodged in the nostril.
Insert the nasal speculum to hold the nostril open. Adjust the headlight or head mirror to illuminate the nasal cavity. It cannot be overemphasized how crucial adequate light and visibility are to successfully remove the foreign body. Remove any mucus or blood with the Frazier suction catheter. Grasp an irregularly shaped foreign body with a type of forceps. Forceps may cause a round or smooth foreign body to slip farther posteriorly when the jaws close. In these cases, pass a curette, wire loop, or mastoid hook behind the foreign body and pull it out (Figure 169-6).9 If the foreign body is a bead and the opening is facing outward, the jaws of a small alligator forceps can be passed through the opening (Figure 169-7). Open the jaws when they are beyond the lumen of the bead and pull the bead from the nasal cavity.
Removing a round, smooth foreign body from the nasal cavity. The curette, mastoid hook, or wire loop is passed through the nares and behind the foreign body. The hook is used to pull the foreign body out.
An alligator forceps is used to remove a bead or other foreign body with a hollow center.
Balloon Catheter Extraction
Some Emergency Physicians prefer to use a catheter with a balloon to pull foreign bodies from the nasal cavity. This technique has a reported success rate of 90%, and is used most successfully for foreign bodies that are round, smooth, and cannot be grasped readily.15 A balloon catheter does not work if the foreign body fully obstructs the nasal passage. Authors describe using a variety of catheters. This includes a #4 to 8 Fogarty vascular catheter, a #6 Fogarty biliary catheter, and a 5 to 6 French Foley balloon catheter.3,9,16 Suction is relatively contraindicated if the foreign body is shaped so that the suction device cannot form a seal or if the foreign body is friable.
Inflate the balloon to ensure it has no leaks. Deflate the balloon. Lubricate the catheter. Insert the catheter until the balloon is beyond the foreign body. The catheter may be placed either above or below the foreign body.9 Inflate the balloon with 2 to 3 mL of air. Gently pull the catheter. The balloon will push the foreign body out of the nostril. A balloon catheter can also be used to stabilize a foreign body from behind while it is removed with a forceps.
The disadvantage to this method is that it is more traumatic and epistaxis is more common.2 If the catheter is not passed under direct vision or if it is too large to pass around the foreign body, the Emergency Physician risks pushing the foreign body posteriorly and impacting it, obstructing the nasal passage, or dislodging it into the airway.
The Katz Extractor Oto-Rhino Foreign Body Remover (InHealth Technologies, Carpinteria, CA) is a device designed to extract foreign bodies from the nasal and auditory passages (Figure 169-8). It is a disposable single-use device consisting of a balloon-tipped catheter attached to a syringe. Always test the device before using it. Push the plunger to inflate the balloon and inspect it for any air leaks. Release the plunger to deflate the balloon.
The Katz Extractor. The balloon at the tip inflates and deflates by pushing and releasing the plunger, respectively. (Photo courtesy of InHealth Technologies, Carpinteria, CA.)
Grasp the device with the dominant hand (Figure 169-9). Gently insert the catheter along the wall of the nasal activity until the balloon is just past the foreign body (Figure 169-9A). Inflate the balloon by depressing the plunger on the syringe (Figure 169-9B). Withdraw the catheter and foreign body from the nasal cavity while maintaining the balloon in the inflated state (Figure 169-9C). If the foreign body has a central hole (e.g., candy or bead), insert the catheter through the hole, rather than behind it, and inflate the balloon.
The Katz Extractor removing a nasal foreign body. A. The device is inserted until the balloon is just past the foreign body. B. The balloon is inflated. C. The Katz Extractor is removed with the balloon inflated and the foreign body is removed.
The Hognose (IQDr. Incorporated, Manitou Springs, CO) is a disposable, latex free, and single-use device that attaches to a standard otoscope (Figure 169-10). It comes in three sizes (3, 4, and 5 mm), each with a color-coded tip. The size represents the cup size at the tip of the device. The tip is soft, self-molding, and looks like the nose of a hog. It has an insufflation port and suction tubing attached to its side. The adapter on the suction tubing attaches to standard wall suction tubing.
The Hognose otoscope tip attached to an otoscope. (Photo courtesy of IQDr. Incorporated, Manitou Springs, CO.)
Attach the Hognose to the otoscope similar to attaching a disposable speculum to an otoscope. Turn on the otoscope light source. Attach the hognose tubing to suction tubing and a suction source. Turn the suction source on to low or medium. Grasp the otoscope with the dominant hand. Insert the Hognose into the nasal cavity while visualizing the foreign body through the otoscope head. When the tip of the Hognose is just next to the foreign body, place an index finger over the insufflation port to engage the suction at the device tip. Gently advance the otoscope until the tip of the Hognose is against and attached to the foreign body. If you suddenly see black through the otoscope, the soft tip has collapsed on itself. Remove the finger over the insufflation port and reapproach the object. While maintaining suction, withdraw the Hognose with the foreign body attached.
The Gatornose (IQDr. Incorporated, Manitou Springs, CO) is a disposable, latex free, and single-use device that attaches to a standard otoscope (Figure 169-11). It twists onto an otoscope like a speculum. It comes with three different jaw types that attach to the body of the device. These jaws are small flat jaws, large flat jaws, and open loop jaws. A trigger on the body of the device controls jaw opening and closing.
The Gatornose otoscope tip attached to an otoscope. Note the three types of jaws that are available to snap onto the base of the device. (Photo courtesy of IQDr. Incorporated, Manitou Springs, CO.)
Attach the Gatornose to the otoscope similar to attaching a disposable speculum to an otoscope. Turn on the otoscope light source. Grasp the otoscope with your dominant hand. Insert the ring finger into the trigger. Pull the trigger to close the Gatornose jaws. Gently insert the Gatornose jaws just into the nasal cavity. Push the trigger to open the Gatornose jaws and be able to view through the otoscope. Gently advance the otoscope while visualizing the foreign body through the otoscope head. Position the jaws above and below or anterior and posterior to the foreign body. Pull the trigger to close the jaws onto the foreign body. Withdraw the otoscope with the foreign body in the jaws of the Gatornose.
Frazier suction catheters are most useful with small or round foreign bodies. Otherwise, this technique will be unsuccessful or will push the object farther into the nasal cavity. This technique is best reserved for large, round foreign bodies where suction can be maintained between the device and the foreign body. Complications include trauma to the surrounding tissues and epistaxis.17
Attach the Frazier suction catheter to the suction tubing. Turn on the suction source to at least 100 mmHg. Gently insert the catheter into the nasal cavity. Place a thumb over the hole in the catheter handle to direct the suction through the tip of the catheter. Gently advance the suction catheter until the tip is in contact with the foreign body. Withdraw the Frazier suction catheter and foreign body from the nasal cavity.
For impacted smooth, spherical objects, suction with plastic intravenous tubing can be used.18,19 Cut a short length of plastic intravenous tubing and attach one end to the suction source. Fashion the other end into a small flange shape using a heat source and any metal object with a rounded end, such as the tip of a hemostat or larger clamp. Heat the jaws of the hemostat and insert them into the plastic tubing just enough to create a flange. Turn on the suction source. Place a hemostat onto the tubing to temporarily clamp the suction tubing. Gently advance the flange tip into the nasal cavity until it contacts the foreign body, taking care not to push it inward. Remove the hemostat from the tubing to activate the suction. Gently but quickly remove the tubing and attached foreign body from the nasal cavity.
This technique is best utilized for foreign bodies that are large, posteriorly located, or occlude the nasal passage. It involves the generation of positive pressure in the nasopharynx behind the foreign body to force it out of the nostril. There are several ways to generate positive pressure within the nasal cavity. One is to simply ask the patient to occlude the unaffected nostril, take a deep breath through their mouth, close their mouth, and then forcefully exhale the air out through the nostril with the foreign body while keeping their mouth closed. This technique is most successful in older children and adults who are cooperative and can coordinate the movements. The advantage to this technique, if it is successful, is that no instruments are placed into the nose. The disadvantage is that the foreign body becomes a flying body. Eye protection is advised.
Other variants of this technique have been developed. The “big kiss,” also known as the “parent's kiss” or “mouth-to-mouth” technique, involves asking the parent to blow into the child's mouth.20 This is similar to rescue breaths during cardiopulmonary resuscitation (CPR). Explain the procedure to the child and the parent. Instruct the parent to open the child's mouth with one hand and stabilize the chin while occluding the unaffected nostril with a finger from their other hand. Instruct the parent to open their mouth, take a big breath, and then place their mouth over the child's open mouth. The child's mouth must be completely covered by their parents and a good seal formed. Instruct the parent to deliver a sudden and forceful breath into the child's mouth. This entire sequence of events should only take 3 to 4 seconds to complete.
This maneuver causes the child's glottis to close. If enough pressure is generated, the foreign body will be expelled from the affected nostril. This technique may be less traumatic to the child and involves no instrumentation or restraint.20 High success rates have been reported.21 However, this technique may be difficult for some parents to perform. A modified version of this technique involves using a drinking straw or small tube between the child's mouth and parent's mouths. The parent then gives a big puff of air through the straw while the child tries to make a tight seal between their mouth and the straw. This technique can also be performed by the Emergency Physician without placing their mouth on the child's mouth.
A bag-valve-mask device (i.e., the Ambu-bag) can also be used to blow the foreign body out the nostril.22 Choose a face mask that is small enough so that it only covers the patient's open mouth. Cover the patient's mouth tightly with the mask. Close the unobstructed nostril with a finger (Figure 169-12). Squeeze the bag to force air into the mouth, lungs, and out the nose.22 A variant of this method uses an anesthesia bag connected to high-flow oxygen (10 to 15 L/min). Cover the mouth with the mask, close the thumb hole, and allow the bag to expand and gradually increase the airway pressure. If this does not expel the foreign body, compress the bag.3
Bag-valve-mask method of removal. The child is restrained and the contralateral nostril is occluded. Bag-valve-mask is applied on the mouth to create a seal and a few breaths are delivered until foreign body is expelled.
The “Beamsley Blaster” technique makes use of the positive pressure generated from the application of high flow (10 to 15 L/min) oxygen from tubing attached to an oxygen wall outlet.23 The other end of the tubing is attached to a male-male adapter, which is then inserted into the unaffected nostril. The set-up generates enough pressure in the posterior nasopharynx to dislodge the foreign body from the nostril. The patient's mouth must be closed during the procedure to create a seal. Although there were no complications noted in the initial study, a subsequent case of barotrauma (subcutaneous orbital emphysema) was recently reported.24
If an SMR cabinet or other blower with a nasal tip is available, place the nasal tip in the unobstructed nasal cavity. This method is contraindicated if there are foreign bodies in both nasal passages. It is important to be sure that the nasal tip is placed in the open nasal cavity or the foreign body could be blown into the trachea or esophagus. Blow short puffs of air during the child's cries. The soft palate will close when the child is vocalizing and direct both the air and the foreign body out the other nostril.2
Cyanoacrylate Glue—Assisted Removal
Cyanoacrylate glue can be used to extract spherical and other solid foreign bodies that are visible.25 However, this technique can be fraught with complication. There is a chance of gluing the foreign body to the nasal mucosa as well as creating a glue foreign body. The foreign body can be further impacted if pushed posteriorly or fall into the oropharynx and aspirated.
Obtain a long, thin object (e.g., straightened paper clip or the stick end of a cotton-tipped applicator). Moisten the tip of the paper clip or applicator stick with a very tiny amount of cyanoacrylate glue. A larger amount can drop off into the nasal cavity. Insert the paper clip or applicator stick before the glue dries and until it just touches the foreign body. Maintain this position for 30 to 60 seconds to allow bonding of the glue to the foreign body. Do not allow the drop of glue to fall from the stick, as it will bond to the nasal mucosa. Do not touch the tip of the wooden applicator stick to the nasal mucosa, as it will bond to the mucosa. Remove the paper clip or applicator stick with the foreign body attached. The main disadvantages of this technique are potential bonding of the nasal mucosa and the time it takes for the glue to bond to the foreign body.