Summary
Foreign bodies (FBs) are typically inserted in the nose by young children or adults with developmental or psychiatric disorders. Inanimate objects such as jewelry, food, toys, and pebbles are most commonly found, while animate objects such as insects are less common. Patients may initially be asymptomatic, presenting with only a history of a witnessed FB insertion. Patients with an unwitnessed FB insertion typically present late with symptoms of unilateral nasal obstruction, purulent discharge, and epistaxis. Foreign bodies in the nose are usually diagnosed clinically with anterior rhinoscopy. All nasal FBs require removal and a variety of techniques can be used (e.g., positive pressure, instrumentation). Sedation and specialist consultation may be required for complex cases. Complications include infection and foreign body aspiration.
Epidemiology
- Occurs most commonly in children; peak age 1–5 years [1][2]
- Can occur in adults with developmental and/or psychiatric disorders [3]
Epidemiological data refers to the US, unless otherwise specified.
Etiology
-
Inanimate objects (most common) [4]
- Jewelry (e.g., beads, pearls)
- Small toys
- Food (e.g., beans, nuts, corn kernels, grapes)
- Pebbles
- Others: paper, magnets, button batteries
- Animate objects (less common): E.g., insect or larvae infestation can occur in tropical climates. [3]
Clinical features
Patients may present with few or no symptoms if they are brought in by a caregiver shortly after a witnessed FB insertion.
- Classic clinical features
-
Onset
- Often delayed, as patients can be initially asymptomatic
- Early onset is more likely with animate FBs.
- Clinical features of complications
Consider nasal FBs in nonverbal patients with unexplained upper respiratory symptoms, as the insertion may not have been observed by their caregiver. [5]
Diagnostics
- Anterior rhinoscopy: direct inspection of both nasal cavities using otoscope or nasal speculum
- Flexible fiberoptic nasolaryngoscopy: if FB not visualized on anterior rhinoscopy
-
Imaging (e.g., x-ray, CT)
- Not routinely indicated if foreign body visualized
- Consider to rule out differential diagnoses (e.g., nasal cavity carcinoma)
Evaluate for foreign bodies in the ear and foreign body aspiration in at-risk patients.
Evaluate for nasal FB in patients with unilateral nasal symptoms to avoid a misdiagnosis of rhinitis or sinusitis. [5]
Differential diagnoses
See “Differential diagnosis of nasal congestion.”
The differential diagnoses listed here are not exhaustive.
Treatment
General principles [3][6][7]
-
Removal is indicated for all confirmed nasal FBs.
- Consult ENT for: [6]
- FBs with a high risk of tissue necrosis: e.g., button batteries, multiple magnets
- Low likelihood of successful removal: e.g., poor visualization, limited patient cooperation
- High risk of traumatic removal: e.g., sharp or penetrating FBs, impacted FBs with surrounding inflammation, infection, or granulation tissue [5]
- Multiple unsuccessful attempts [7]
- Suspected neoplasm [3][5]
- For all other cases, attempt removal in a primary care setting. [8]
- Consult ENT for: [6]
- Noninvasive techniques (e.g., positive pressure techniques) are preferred when possible.
- Troubleshooting techniques (e.g., topical anesthetic, procedural sedation) may aid in FB removal.
- Operative removal under general anesthesia is considered a last resort.
Bedside removal techniques [3][6][7]
The preferred removal technique is based on the FB (e.g., size, location) and patient characteristics (e.g., age, expected degree of cooperation) with a preference for noninvasive techniques (e.g., positive pressure techniques).
Positive pressure techniques
- Self-administered: Ask the patient to occlude the unaffected nostril and then blow their nose.
- “Parent's kiss” technique: Ask a parent or guardian to occlude the patient's unaffected nostril and provide mouth-to-mouth positive pressure.
- Bag-mask ventilation (BMV) technique: Occlude the patient's affected nostril and apply positive pressure using a well-sealed BMV device over the mouth.
Instrumentation techniques
-
Forceps
- Alligator or nasal packing forceps are used to grasp and retrieve the FB.
- Suitable for soft FBs that can be grasped without disintegrating
-
Angled blunt probe or curette
- A probe is passed behind the FB, rotated to hook the object, and then withdrawn.
- Suitable for solid FBs and cooperative patients
-
Balloon-tipped catheter
- A catheter is passed behind the FB, the end balloon is inflated (e.g., 1 mL), and the catheter is then withdrawn.
- Suitable for solid FBs
-
Suction-based technique
- A catheter connected to low wall suction is applied directly to the object.
- Suitable for FBs that are loose, made up of organic matter, or smooth and round
-
Glue-based technique
- Cyanoacrylate glue is applied to the end of a swab, attached to the object for ≥ 60 seconds, then withdrawn.
- Suitable for loose solid FBs and cooperative patients
Instrument-assisted and glue-based techniques can cause injury in uncooperative patients.
Avoid irrigation and probing that could lead to foreign body aspiration. Keep airway management equipment nearby during removal.
Troubleshooting [3][6][7]
The following may facilitate a successful removal and can be considered on a case-by-case basis:
- Proper patient positioning: E.g., place young children in their parent's laps, with their arms, legs, and head secured to minimize movement.
- Reassurance and distraction, e.g., using child life specialists
- Topical decongestants (e.g., oxymetazoline)
- Topical anesthesia and lubrication
- Procedural sedation (e.g., with ketamine) [9]
Anticipate epistaxis after removal and be ready to treat with direct pressure. [6]
Complications
- Nasal septal perforation
- Foreign body aspiration
- Infection: e.g., rhinitis, sinusitis, meningitis (rare) [10]
Paired magnets and button batteries can lead to tissue necrosis and nasal septal perforation. [6]
We list the most important complications. The selection is not exhaustive.
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