INTRODUCTION — Intranasal foreign bodies (FBs) occur most commonly in young children and consist of a variety of inorganic and organic objects. In most instances, the patient is asymptomatic. The majority of intranasal FBs are removed at initial presentation and do not require referral to an otolaryngologist. Button batteries and paired disc magnets can cause serious damage to nasal structures and merit urgent removal.
The diagnosis and management of intranasal FBs is presented here. FBs of the outer ear, airway, and digestive tract are discussed separately:
EPIDEMIOLOGY — More foreign bodies (FBs) are retrieved from the nose than from all other aero-digestive tract sites combined . Intranasal FBs typically present in toddlers and preschoolers and less often in older children, adolescents, and adults with intellectual or behavioral disabilities [2,3]. FBs are more frequently located on the right side due to the predominance of right-handed children [2,4]. A wide variety of foreign bodies find their way into the nose including inorganic items, such as pearls and beads, pins, nails, screws, paper, stones, rubber, small toys, crayons, and chalk and food items, such as beans, carrots, seeds, meat, apples, candy, and chewing gum [1,4-8].
Three types of FBs deserve special mention because of their potential for damage to nasal structures:
●Button batteries – Button batteries are found in many devices including toys, hearing aids, and household electronics. Once in the nose, they cause destruction because of strong electrical currents (rather than leakage of battery contents). Electrolysis at the negative battery pole generates hydroxide ions that cause alkaline tissue necrosis (picture 1) [9-11]. If the negative pole is directed toward the nasal septum, this can result in septal perforation in under four hours .
●Paired disc magnets – High-powered, 1 cm diameter, round disc magnets are used to attach some types of jewelry (eg, metal earrings and nose rings) and are popular in adolescents and young adults [13-15]. Instances have been described in which the magnets, one in each nostril, attach to each other high in the nasal septum and cannot be manually removed. Prolonged attachment can cause perforation from chronic compression of the nasal septum [16,17]. Unlike disc batteries, this tissue damage occurs over a period of weeks .
●Superabsorbent polymers – Water-expanding polymer beads are used in consumer products, such as diapers, and in children's toys . When hydrated, they can expand 30 to 60 times their size. In the nose, the expanded balls can lodge and cause tissue pressure necrosis over a period of days .
CLINICAL ANATOMY — Nasal foreign bodies (FBs) are most commonly located on the floor of the nasal passage just under the inferior turbinate or superiorly in the nasal cavity just in front of the middle turbinate (figure 1) .
CLINICAL MANIFESTATIONS — Nasal foreign bodies (FBs) are rare in normal healthy older children and adults. Relative frequencies of clinical findings in younger children and intellectually disabled patients with nasal FBs are as follows [2,4,7]:
●History of nasal FB insertion without symptoms (71 to 88 percent)
●Mucopurulent nasal discharge (17 to 24 percent)
●Foul odor (9 percent)
●Epistaxis (3 to 6 percent)
●Nasal obstruction (1 to 3 percent)
●Mouth breathing (2 percent)
Most FBs are inorganic (eg, pearls, beads, or small toys) and relatively asymptomatic. These more often come to attention because of parental concern although up to 25 percent of nasal foreign bodies are unsuspected by the caregiver .
Unilateral purulent and foul-smelling nasal discharge in a young child strongly suggests the presence of a porous nasal FB such as paper or foam rubber or organic matter (eg, carrot, meat, or other food material) (picture 2) . These objects produce local inflammatory reactions or become secondarily infected also leading to sneezing, epistaxis, nasal obstruction, foul-smelling nasal discharge, and facial pain from sinusitis.
Button battery FBs may also produce a purulent nasal discharge and epistaxis [23,24]. In patients with associated tissue necrosis, the discharge may have a black color . Facial swelling with pain and fever may also occur and be mistaken for periorbital cellulitis or sinusitis [25-27].
The clinician should carefully examine both nostrils and ears in patients with a nasal FB to ensure that no other objects are present.
DIAGNOSIS — Visualization of the foreign body (FB) establishes the diagnosis. In most children, this can be accomplished with the use of a headlight or otoscope after suctioning of purulent secretions (picture 3); however, some FBs that are located high in the nasal vault or posterior nasal cavity may elude detection with an otoscope or headlight. Thin or transparent FBs are also sometimes hard to find. In these patients, rigid or flexible fiberoptic endoscopy may be necessary to identify the FB .
Most nasal FBs are radiolucent. Thus, plain radiographs are not routinely needed or helpful when the FB is clearly visualized on physical examination and the presence of a button battery or magnet is excluded .
However, plain radiographs can establish the presence of button batteries or magnets within the nasal cavity when suspected. These studies are suggested when the type of FB is not obvious on physical examination or is associated with significant epistaxis, black nasal discharge, pain, or facial swelling [13,30]. Unsuspected FBs (either radio-opaque or encrusted in calcium salts) may also present as incidental findings on sinus radiographs or computed tomography performed for symptoms of clinical sinusitis or periorbital cellulitis (image 1) [26,31].
DIFFERENTIAL DIAGNOSIS — In most patients, visualization of a nasal foreign body (FB) during physical examination or the presence of foul-smelling unilateral discharge makes the distinction of nasal FB from other entities associated with bilateral nasal discharge, such as sinusitis, upper respiratory tract infection, or allergic rhinitis straight forward. Occasionally, a child with bilateral nasal discharge may have placed FBs in both nasal cavities without the caregiver’s knowledge . Thus, all patients with nasal discharge warrant careful examination of the nasal cavity to exclude a foreign body before other treatments (eg, antibiotics for sinusitis or allergy medications for allergic rhinitis) are prescribed. (See "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis", section on 'Clinical features' and "The common cold in children: Clinical features and diagnosis", section on 'Nasal manifestations' and "Allergic rhinitis: Clinical manifestations, epidemiology, and diagnosis", section on 'Clinical manifestations'.)
FOREIGN BODY REMOVAL
Timing — Button batteries in the nasal cavity and magnets that are attached across the nasal septum (picture 4) warrant urgent removal [9,18]. Otherwise, nasal foreign body (FB) extraction is an elective procedure. Concern for migration of an inert nasal FB through the nasopharynx followed by aspiration into the trachea is not warranted in a normal healthy patient with intact airway reflexes. The estimated risk for this complication is less than 6 in 10,000 cases. In addition, there are no reports of bronchial FBs spontaneously arising from nasal FBs in the literature .
However, aspiration of a nasal FB has occurred during attempts at removal and the risk is likely increased when extraction is attempted by inexperienced clinicians or under circumstances in which appropriate instruments or personnel to ensure adequate restraint are lacking [33,34].
High-risk foreign bodies
Button batteries — Electrolysis at the negative battery pole generates hydroxide ions that cause alkaline tissue necrosis (picture 1) . If the negative pole is directed toward the nasal septum, this can result in septal perforation in under four hours . Thus, intranasal button batteries require rapid removal. Impacted intranasal button batteries require urgent consultation with a pediatric otolaryngologist for removal.
Disc magnets — When two round disc magnets used to attach some types of jewelry (eg, metal earrings and nose rings) are placed in each nostril, they may attach to each other high in the nasal septum (picture 4) [13,14,16,17]. In most instances, these can be removed by grasping one magnetic with a mosquito hemostat and pulling it away from the other magnet.
Occasionally, because of the strength of the magnets, removal using forceps may not work because the magnetic attraction to the instruments may not exceed the force of attraction between the intranasal magnets [14,17]. This problem can be overcome as follows:
●Magnetize two instruments (eg, two Lucae or Gruenwald nasal dressing forceps) using two separate magnets (eg, cardiac pacemaker magnets)  and apply them simultaneously to the intranasal magnets or utilize a rare-earth magnet clamped in a hemostat.
Superabsorbent polymer beads — These beads can lodge in the nose and cause tissue necrosis over a period of days . Otolaryngology consultation is warranted because patients may require endoscopic removal in the operating room due to tissue edema and the friable nature of the expanded beads.
Indications for subspecialty consultation or referral — For most patients with nasal FBs, referral to an otolaryngologist is not necessary. As an example, in one case series of 60 children, 98 percent of nasal FBs were successfully removed by pediatric emergency clinicians . Thus, medical specialty is less important than experience, availability of proper equipment and restraint, and knowledge of which FBs are likely to require special skills for extraction.
Otolaryngology referral is warranted for the following FBs :
●Posterior FBs (ie, not readily visualized by anterior rhinoscopy)
●Impacted FBs associated with marked inflammation, especially button batteries, magnets, or superabsorbent beads, which warrant urgent removal
●Penetrating or hooked FBs
●Any FB that cannot be removed at initial attempt due to poor cooperation, bleeding, or limited instrumentation
Procedure — Most nasal FBs can be removed using positive pressure techniques or direct instrumentation in the primary care office or emergency department. The procedure that is used is determined by the nature and location of the FB. Although success has been reported with nasal irrigation of the nasal passage not containing the foreign body, we do not advocate this technique given the theoretical potential for aspiration [37,38].
Positive pressure techniques — Based upon small case series and expert opinion, we suggest that patients with soft or smooth nasal FBs that totally occlude the anterior nasal cavity undergo removal using positive pressure techniques rather than instrumentation [35,39-42]. Having the patient blow his or her nose while occluding the nostril opposite of the FB (picture 6) is the easiest method and is frequently successful . However, this technique is only applicable to cooperative patients who are generally older than three years of age.
Oral positive pressure by the parent or caregiver while occluding the unaffected nostril has been described in case reports and small case series of children with nasal FBs [39-43]. In a systematic review of 152 children undergoing the technique, successful foreign body removal occurred in 60 percent with no reported complications .
Visibility and time since insertion may be important factors in determining successful removal. As an example, mouth-to-mouth blowing by the parent or caregiver ("parent’s kiss") successfully removed 15 of 19 nasal FBs with no complications . In this study, which was not included in the systematic review mentioned above, all FBs were visible with anterior rhinoscopy, and the median time since insertion was four hours (range one hour to two weeks). The children were allowed to sit or stand, depending upon their preference. The unaffected side of the nose was occluded, and the parents were instructed to firmly seal their mouth over the child's mouth and give a short, sharp puff of air into the child's mouth.
Children typically tolerate this procedure well without restraint. If the parent or caregiver is unwilling or unable to perform this procedure, then the approach can be approximated using a bag-valve-mask, although patient cooperation is unlikely, and restraint will probably be necessary.
If removal by positive pressure techniques is unsuccessful or unable to be performed, the clinician may proceed to instrumentation as described below. (See 'Instrumentation' below.)
Nasal positive pressure is another method that has been described in small case series with evidence of barotrauma reported in one patient [44,45]. However, in our opinion, the potential for excess application of pressure to the nasopharynx is high, and we do not advocate this approach.
Instrumentation — Based upon case series and expert opinion, we suggest that patients with nonocclusive foreign bodies in the anterior portion of the nose undergo removal by instrumentation rather than positive pressure techniques. Instrumentation permits intranasal FB removal under direct visualization and examination of the nasal cavity after extraction. Adequate restraint, appropriate illumination, and proper equipment are essential to success [34,35,40].
Instrumentation can be painful and may warrant topical anesthesia (eg, a solution of one part oxymetazoline with one part 4 percent lidocaine) with proper attention to maximum weight-based dosing. Nasal drops should not be used on patients with lodged button batteries .
In young children and other uncooperative patients, procedural sedation may be needed for successful FB removal. If procedural sedation is performed, special caution is advised given the proximity of the nasal FB to the airway when using medications that can blunt airway and respiratory reflexes . (See "Procedural sedation in children: Approach" and "Procedural sedation in children: Selection of medications".)
When safe removal of a nasal FB is doubtful based upon the setting or patient factors, removal in the operating room under general anesthesia with airway protection is advised.
Equipment — The following equipment should be available:
●Sheet for wrapping or an immobilization device (picture 7)
●Topical anesthesia and vasoconstrictor nose drops (eg, one part, 4 percent lidocaine without epinephrine, mixed with one part oxymetazoline nasal spray, maximum dose 1 mg/kg [0.1 mL/kg of 2 percent lidocaine solution]) (picture 8)
●Otoscope with an operating head (allows instrumentation under direct visualization)
●Headlight or lamps (picture 8)
●Right angle hook, wire loop or curette (picture 8)
●Lucae or Gruenwald nasal dressing forceps (picture 8)
●Alligator or Hartmann forceps (picture 8)
●Schuknecht foreign body remover (picture 9)
●Suction apparatus, including catheters of various sizes
●5 to 8 French Fogarty, Foley, or Katz catheter
Techniques — Steps for removing an intranasal FB include the following [21,22,35,40]:
●Approximately five minutes prior to the procedure, instill topical anesthetic and a topical vasoconstrictor into the nose (eg, one part, 4 percent lidocaine without epinephrine mixed with one part oxymetazoline nasal spray, maximum dose 1 mg/kg [0.1 mL/kg]).
●If the patient is cooperative and the FB is readily seen in the anterior nasal cavity, use the nondominant hand to push the tip of the nose up with the patient sitting upright (picture 10).
●For deeper FBs, insert a nasal speculum as shown in the figure (figure 2).
●Remove the FB using specific instruments, depending upon the type of FB, as follows:
•Extract non-occlusive compressible objects such as foam rubber or ones with rough surfaces with alligator, Lucae, or Gruenwald nasal dressing forceps (figure 3).
•Avoid using forceps for smooth objects that cannot be easily grasped. Unsuccessful attempts at removal will push the object deeper into the nasal cavity (figure 4).
•Remove smooth objects or others that cannot be easily grasped using a blunt right-angle hook (bead, stones or other small objects) (figure 5). Remove smooth, round, solid objects (eg, a marble or bead) with balloon catheters (Fogarty of Foley) or Katz extractors.
When using Foley or Fogarty catheters (5 to 8 French), lubricate the catheter with 2 percent lidocaine jelly, or if anesthetic drops have already been applied, water soluble lubricating jelly and advance the uninflated catheter or extractor past the object. Inflate the balloon with 2 to 3 mL of air, and withdraw the catheter and the FB (figure 6).
When using a Katz extractor, insert the extractor to past the object, inflate with 1 mL of air using the attached syringe, and then remove the extractor and the foreign body from the canal with balloon inflated.
•Alternatively, use a metal suction catheter with a plastic umbrella at the tip (Schuknecht catheter) to remove smooth, round, solid objects (picture 9). Place the plastic umbrella against the FB. Turn on the suction to 100 to 140 mmHg, and remove the FB .
•Cyanoacrylate glue also may be used to remove a FB from the nose. Apply a thin coat of cyanoacrylate glue to the cut end of a hollow plastic swab. Press the swab against the FB for 60 seconds and then remove the swab with the attached FB . The patient must remain still until the glue dries. Because of the time necessary, this technique is most appropriate for cooperative older children, adolescents, and adults.
COMPLICATIONS — Complications may occur as a result of the nature of the foreign body (FB) such assize, shape and content; length of time the FB has been lodged; or as a result of removal attempts. The most serious complications can occur with intranasal button batteries; septal perforation with saddle nose deformity, nasal meatal stenosis, inferior turbinate necrosis, and collapse of the alar cartilage have all been described [23,26,49,50].
Instrumentation of the nose may cause trauma to the nasal cavity with brief epistaxis that is typically controlled with direct pressure . (See "Management of epistaxis in children", section on 'Direct pressure'.)
Chronic FBs of the nose may occlude the inferior or middle meatus and predispose the patient to infection, primarily sinusitis. Findings of sinusitis include fever for three or more consecutive days with ill appearance, and purulent nasal discharge or daytime cough and nasal discharge for 10 or more days. The treatment of sinusitis is discussed separately. (See "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis", section on 'Clinical features' and "Acute bacterial rhinosinusitis in children: Microbiology and management".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Removing objects stuck up the nose (The Basics)")
ADDITIONAL RESOURCES — The reference provides a video that demonstrates techniques for intranasal foreign body removal .
SUMMARY AND RECOMMENDATIONS
●Intranasal foreign bodies (FBs) most commonly occur in young children and are most commonly located on the floor of the nasal passage just under the inferior turbinate or superiorly in the nasal cavity just in front of the middle turbinate (figure 1). (See 'Epidemiology' above and 'Clinical anatomy' above.)
●Most FBs are inorganic (eg, pearls, beads, or small toys) and relatively asymptomatic. Unilateral purulent and foul-smelling nasal discharge in a young child strongly suggests the presence of a porous nasal FB such as paper or foam rubber or organic matter (eg, carrot, meat, or other food material) (picture 2). (See 'Clinical manifestations' above.)
●Intranasal button batteries are associated with purulent nasal discharge that is sometimes black in color, epistaxis, and facial pain with swelling and have significant potential for damage to nasal structures. (See 'Clinical manifestations' above.)
●Visualization of the FB establishes the diagnosis. The clinician should carefully examine both nostrils and ears in patients with a nasal FB to ensure that no other objects are present. Plain radiographs can establish the presence of button batteries or magnets within the nasal cavity when suspected but are not necessary for the diagnosis of other types of intranasal FBs. (See 'Diagnosis' above.)
●Button batteries in the nasal cavity and magnets that are attached across the nasal septum warrant urgent removal. Otherwise, nasal FB extraction is an elective procedure. (See 'Timing' above.)
●For most patients with intranasal FBs, referral to an otolaryngologist is not necessary. Potential indications for referral to a specialist include posterior, impacted, or penetrating FBs and those that cannot be removed at the initial attempt due to poor cooperation, bleeding, or limited instrumentation. When safe removal of a nasal FB is doubtful based upon the setting or patient factors, removal in the operating room under general anesthesia with airway protection is advised. (See 'Indications for subspecialty consultation or referral' above and 'Instrumentation' above.)
●We suggest that patients with soft or smooth nasal FBs that totally occlude the anterior nasal cavity undergo removal using positive pressure techniques rather than instrumentation (Grade 2C). These techniques are described in the topic. (See 'Positive pressure techniques' above.)
●We suggest that patients with nonocclusive foreign bodies in the anterior portion of the nose undergo removal by instrumentation rather than positive pressure techniques (Grade 2C). Instrumentation can be painful and warrants topical anesthesia and, in some patients, procedural sedation. Proper restraint is essential to success. The choice of instrument depends upon the type of foreign body as discussed in the topic. (See 'Instrumentation' above and 'Techniques' above.)
●Successful removal of magnets that are adherent across the nasal septum may be accomplished using a mosquito hemostat to grasp and pull the magnets apart. A pocket magnet pickup or magnetized instruments may be used in difficult cases (picture 5). (See 'Disc magnets' above.)
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