Nasal Foreign Body Removal: A Common But Challenging Emergency In Children

Introduction:

Foreign bodies in the nasal cavity are commonly seen in children within the age group of two to five years. The intellectual impairment or cognitive impairment in children results in repeated episodes of inserting multiple foreign bodies into the nasal cavity. The consequences of nasal foreign bodies range from local irritation at the insertion site to severe complications, including death. Trying to remove the stuck foreign body from the nose has the best chance of success. But if the first attempt is unsuccessful, refer to an ENT (ear, nose, and throat) specialist for the removal of the foreign body.

What Are The Common Foreign Bodies Inserted Accidentally Inside The Nose?

Children can accidentally insert common foreign bodies like food, cotton, paper, pebbles, beads, seeds, beans, nuts, insects, button batteries, and small toy parts into the nose. Most of the nasal foreign bodies are found inside the anterior nasal cavity that connects the nasal floor and the inferior turbinate.

This is a real incident. A 4-year-old child whose parents are tailors was brought to a community health care center with a shirt button inserted accidentally into the left nasal cavity while playing at home. The father tried to remove it by himself, tried to squeeze the nose, and then brought him to the hospital. The child was in pain and started to cry, and his nose started to bleed. To confirm if the button went into the stomach, an x-ray of the face was taken. The child had a fever due to the infection in the nose. The child still had the button in the nose, to be removed under anesthesia and then was admitted to treat the infection.

There have been over 50 peer-reviewed articles on the epidemiology and management techniques for foreign bodies impacted within the nasal cavities in the last 10 years. The latest articles have been about novel techniques for removing nasal foreign bodies (NFB). Based on the structured clinical observations with multidisciplinary teams, it was found that this problem is frequently encountered, leading to faulty removal with surgical consequences.

• Children between 2-6 years are considered the most vulnerable victims of impacted foreign objects in their nasal cavities.

• It is probably because of their curiosity to play with tiny objects and explore the nasal cavity by inserting things inside in unsupervised surroundings, which is much the case in low to middle-income families with both working parents.

• Many times an allergic process in the nose creates a sense of itching, and children often use objects easily available to them to insert into the nasal cavities as an attempt to relieve their distress.

• Though such impactions are seen in older populations, they are believed to be due to mental retardation or morbid psychiatric illnesses.

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Who Typically Removes These Nasal Foreign Bodies?

ENT (ear, nose, and throat) surgeons usually do nasal foreign body removal procedures. However, many cases are attempted by pediatricians and general practitioners also.

What Are The Indications For Nasal Foreign Body Removal?

The indications for nasal body removal include:

• Simple nasal foreign body.

• Common, self-inserted objects including cotton, paper, pebbles, beads, seeds, beans, nuts, insects, and button batteries.

What Are The Contraindications For Nasal Foreign Body Removal?

The nasal foreign body removal is contraindicated in the following conditions:

• If unable to see the foreign body or reach it with available instruments.

• If the impacted foreign body is accompanied by a significant inflammation or edema.

• A foreign body that is very tiny, transparent, or stuck far posteriorly or superiorly.

• Suppose the foreign body could not be removed even after several attempts. In that case, multiple attempts can increase the risk of injury or movement of the object deeper into the nose, which is more challenging to remove.

Consult an ENT specialist to get the stuck foreign body removed or if unable to remove the object even after repeated attempts.

Is It Safe To Sedate To Remove A Foreign Body In The Nose?

Irrigation and the use of glue are not usually suggested. Due to the increased risk of aspiration, sedation is not recommended while removing the foreign object from the nasal cavity.

What Equipment Are Used To Remove Nasal Foreign Body?

• Chair with headrest or an ENT specialist's chair.

• Light source and head mirror or headlamp with an adjustable narrow beam.

• Gloves, mask, and gown.

• Topical anesthetic or vasoconstrictor mixture like 1% Tetracaine, 4% Cocaine, or 4% Lidocaine plus 0.5% Oxymetazoline.

• Cotton swabs or pledgets to apply topical drugs.

• Nasal speculum.

• Suction source and Frazier-tip and other suction-tip, suction catheters of various sizes.

• Wire loop and hook curettes.

• Bayonet or alligator forceps.

• Balloon-tipped catheter.

What Are the Techniques Involved In The Removal Of The Nasal Foreign Body?

• The removal techniques have been a topic of debate since the existence of humanity, and many articles have discussed the pros and cons of various techniques.

• Until today there seems to be no standardized tool or method to remove these impacted foreign bodies from the nasal cavities.

• Though some may claim the foreign body hook is the most accepted solution, it is not designed exclusively for the nasal cavity. It is an effective tool if the child is stabilized well while performing the removal. It is not very easy to use and is used only by a few ENT surgeons.

• Some prefer using the eustachian tube catheter, which was initially created to catheterize the eustachian tube, an opening behind the nasal cavity connecting the middle ear. Again, only a few ENT surgeons prefer this method, and it is heavily skill-dependent.

What Is The Incidence of NFB Removal Cases?

It is important to note that an average of 25 cases per month are pointed out in all types of hospitals ranging from private clinical to general tertiary hospitals. A pattern noted frequently were fewer patients in urban private hospitals/clinics (10 -12 cases per month) whereas higher cases in rural government hospitals and clinics (up to 40 cases per month).

What Are The Complications Associated with Nasal Body Removal?

• Injury to the nasal mucosa and resultant bleeding.

• Aspiration of the object, especially in sedated patients.

Why Are There So Many Cases of Nasal Foreign Body (Based on Extensive Publications) Insertion?

There are many theories to address this question. Some believe that the reason behind this is the financial status of the families. With the low-income families turning to middle-income families with an increase in the number of working parents, there may be a decline in parental supervision given to children.

Where Does the Problem Lie?

Based on the discussion, it may be concluded that the ENT surgeons are comfortable removing these nasal foreign objects successfully. Very few cases nowadays actually need removal under general anesthesia (<5%). The problem seems to be present with the age group of the victims. The need for a simplified and standardized NFB removal tool for this segment of patients will probably help solve this problem more effectively.