Foreign-Body Removal




Abstract


For the uninitiated, the thought of removing a foreign body from an uncooperative pediatric patient can be a panic-inducing moment. With appropriate anxiolysis, behavior management, and mastery of a few simple techniques, most pediatric foreign-body removal can be easily managed in the urgent care setting.




Keywords

aspiration, ear, fishhook, foreign body, ingestion, nose, pediatric, splinter, ticks, tetanus

 




Ear and Nasal Foreign Bodies



What makes foreign-body removal unique in the pediatric patient?


The provider must accommodate for the maturity level and behavior of the child and seek input from the parent on the child’s ability to tolerate a minor procedure. The provider must explain the procedure to both the parent and the child in language they can understand. Outpatient referral to an otolaryngologist may be warranted if likelihood of success is low based on initial evaluation of the patient.



What behavioral or immobilization techniques can assist in procedures on an uncooperative child?


The child may remain in the parent’s lap, while giving the parent straightforward instructions on how to assist with holding. An alternative method is laying the child down, swaddling the arms and legs with a bedsheet, with an assistant or parent gently immobilizing the trunk and head.



Should medications be used for ear or nasal foreign-body removal?


Lidocaine can be instilled into the ear to assist with anesthesia, or to drown bugs if present; however, it should be avoided if tympanic membrane perforation is suspected. Vasoconstrictors (e.g., oxymetazoline nasal spray) may reduce nasal mucosal swelling and improve success.



Is sedation appropriate for pediatric foreign-body removal?


Anxiolysis with intranasal midazolam (0.2–0.4 mg/kg) is the preferred strategy for minor pediatric procedures. A single dose of intranasal midazolam does not induce moderate sedation, and therefore does not require cardiorespiratory monitoring, though pulse oximetry may be used if institutional protocol dictates.



Is there a noninvasive method to remove a foreign body from the nose?


In the positive pressure, or “magic kiss,” technique, the opposing nostril is occluded and positive pressure is applied through the patient’s mouth, either by a parent creating a mouth-to-mouth seal and exhaling forcefully, or using a bag-valve mask.



When is irrigation indicated for foreign-body removal?


Irrigation is not indicated for nasal foreign-body removal. Irrigation with warm tap water or saline through the soft catheter of a butterfly cannula can flush a foreign body from the auditory canal. Irrigation should be avoided with organic matter that can swell or injure tympanic membrane, or in button batteries.



When can tissue adhesive (glue) be used to aid foreign-body removal?


Tissue adhesive, such as Dermabond, is useful for round, rigid, or smooth objects (e.g., beads) in the ear. The foreign body must be dry and easily visualized. A drop of tissue glue is placed on a thin dowel, such as a cotton swab stick, and applied to make contact with the foreign body. Wait several seconds for the glue to dry, then the object can be extracted. Take caution not to drip tissue adhesive into the ear canal or push the object deeper.



How can a Foley catheter be used to remove foreign bodies from the nose?


Apply lubricating jelly to a small Foley catheter bulb (e.g., 6–8 Fr), slide the catheter along the floor of the nare past the foreign body, then inflate the balloon and sweep the object out of the nose ( Fig. 48.1 ).




Fig. 48.1


A bead in a 2-year-old’s nose, removed with a 6-Fr Foley catheter ( top ). If the bead has a hollow hole, the Foley may be threaded through the hole prior to balloon inflation to aid in removal ( bottom ).



When are forceps appropriate for foreign-body removal?


Forceps are successful for easily visualized, graspable materials with a high level of material integrity and patient cooperation. The risks are canal and mucosal abrasions.



When is a nasal foreign body a medical emergency?


Button batteries in any cavity (e.g., ear, nose, esophagus) require immediate removal, due to the risk for liquefaction necrosis, secondary to the battery current discharged when adjacent to mucosal tissue. Two magnets across the nasal septum require emergent removal because they can create ischemic necrosis.



What are the indications for referral to otolaryngology for removal?


Indications for referral include need for sedation, development of granulation tissue, signs of trauma, nongraspable or nonvisualized foreign body, sharp objects, objects abutting the tympanic membrane, or unsuccessful extraction attempt.



When are antibiotics needed?


Antibiotic coverage is not routinely required after extraction of the acute foreign body, unless there are signs of concomitant infection, such as otitis externa or cellulitis.




Foreign-Body Ingestion or Aspiration



What is the typical profile of a foreign-body ingestion or aspiration in a child?


The typical profile of a foreign-body ingestion or aspiration is a toddler to preschool-age child, who was eating or playing with hot dogs, peanuts, seeds, raw carrots, popcorn, coins, toy parts, or balloons and has sudden onset of choking or respiratory distress.



What are the symptoms of foreign-body aspiration or ingestion?


Symptoms of a foreign body in the oropharynx or esophagus include throat pain, drooling, gagging, vomiting, or difficulty swallowing. Symptoms of a foreign body in the airway are coughing, choking, stridor, cyanosis, wheeze, or respiratory distress.



What are the x-ray findings of an aspirated foreign body?


Secondary signs of an aspirated foreign body may be found on inspiratory and expiratory chest x-rays (or bilateral decubitus views in the uncooperative child). The foreign body causes air trapping, leading to ipsilateral hyperinflation and mediastinal shift to the contralateral side, or segmental hyperlucency or atelectasis. Chest x-ray to identify a foreign body has sensitivity and specificity at 61% and 77%, respectively.



When is a foreign-body aspiration or ingestion considered an emergency?


Emergent endoscopic removal is indicated for any foreign-body aspiration, or an ingested object with high risk for perforation, obstruction, or toxicity ( Box 48.1 ). A single, high-powered magnet ingestion is managed expectantly with serial x-rays and removing all nearby magnet sources at home. Management of low-risk objects (e.g., coins) in the stomach includes weekly x-rays to ensure passage. Coins retained in the stomach at 4 weeks may warrant endoscopic removal.


Sep 15, 2018 | Posted by in EMERGENCY MEDICINE | Comments Off on Foreign-Body Removal

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