14.5 Foreign bodies and caustic ingestion

Nasal foreign bodies

Introduction

Nasal foreign bodies are a relatively common presentation to a paediatric emergency department (ED), although there is little published literature on the subject. They are not life threatening, but can cause significant morbidity.

History

Nasal foreign bodies predominantly present in children from 2 to 5 years of age. Children with nasal foreign bodies are usually brought in within 24 hours of insertion/impaction. Delayed presentation is mostly with unilateral purulent nasal discharge, which is usually offensive. Other possible symptoms include foul breath, nasal pain, sneezing, snoring and mouth breathing.

Examination

The type of foreign body is extremely variable, although it is most commonly a plastic toy or bead. The foreign body is usually readily visible.

Investigations

Investigations are not usually required. Imaging is usually indicated for other possible causes such as tumour.

Except for button batteries (see also Chapter 7.6), removal of the foreign body is not urgent. Most foreign bodies can be successfully removed in the ED with adequate preparation and planning. Prior to the attempted removal, use of a topical anaesthetic nasal spray, such as lidocaine + phenylephrine, is recommended. Sedation and/or appropriate restraint of the child may be required. A good light source and an assistant to hold the child’s head still are essential.

The appropriate procedure for removal will depend upon the foreign body size, shape, consistency and location in the nares. These include:

• Right-angle hooked probes can be passed alongside and past larger objects, rotated and then drawn back gradually, removing the object.

• Forceps (alligator or bayonet) are useful for smaller objects near the anterior nares.

• Positive pressure ventilation using bag–valve–mask is effective, particularly for larger objects that occlude the nasal cavity. An alternative to a bag–valve–mask is for the parent to blow into the child’s mouth with their own. Air is ‘bagged’ or blown rapidly through the mouth while the unaffected nostril is occluded with a finger. The high pressure generated in the upper airway expels the foreign body from the nose. There is an unreported theoretical risk of barotrauma.

• Suction catheters can be used. Generally a soft, pliable end is required, and this can be made up using soft tubing, although commercially available kits are now available.

• A balloon catheter can be used if passed beyond the foreign body, inflated and drawn back.

• Application of cyanoacrylate glue via a wooden swab stick or similar is described, but requires patience and a very steady hand. It may adhere to the mucosa.

General anaesthesia and removal by ear, nose and throat (ENT) staff is required for the failed removal and the unco-operative child.