What is the recommended treatment for a nasal foreign body?

Management of Nasal Foreign Bodies

The recommended treatment for a nasal foreign body is prompt removal using an appropriate technique based on the type of foreign body, its location, and patient cooperation, with skilled healthcare providers using visualization tools such as nasal endoscopy to guide the procedure and prevent complications. 1

Initial Assessment

• Nasal foreign bodies are common, especially in children with a mean age of 3 years 2
• Common presenting symptoms include unilateral epistaxis (bleeding), rhinorrhea (discharge), and foul smell 1, 3
• Some patients may be asymptomatic, with the foreign body discovered incidentally or reported by a family member 2
• Delay in diagnosis can result in significant morbidity including nasal infection, sinusitis, and nasal septal perforations or synechiae 1

Types of Foreign Bodies

• Non-organic synthetic beads (18.8%) and vegetable matter (17.7%) are the most common types 2
• Button batteries require emergent removal as they can cause tissue necrosis and septal perforation in as little as 3 hours 1, 4
• Magnets also require urgent removal due to risk of septal perforation 4
• Seeds, rubber items, and batteries are frequently encountered 3

Removal Techniques

Direct Visualization and Manual Extraction

• For visible foreign bodies, manual extraction is appropriate 1
• Skilled healthcare providers should use appropriate tools:
  • Forceps, micro-hooks, or suction devices for direct mechanical extraction 2, 5
  • Magill forceps for appropriately skilled healthcare providers 1

Visualization Techniques

• Nasal endoscopy should be performed to identify the site of the foreign body and guide management 1
• Endoscopy allows for complete examination to exclude foreign bodies not seen with anterior rhinoscopy 1
• With nasal endoscopy, the location of the object can be identified in 87-93% of cases 1

Other Removal Techniques

• Positive-pressure expulsion techniques:
  • Orally applied pressure via parent's mouth or Ambu bag
  • Nasally applied pressure via catheter or oxygen source 4
• Saline irrigation to wash out the object 4
• Balloon-tipped catheters can be used for certain foreign bodies 4

Anesthesia Considerations

• Local anesthesia can be used in cooperative patients (41.86% of cases) 3
• General anesthesia is often required for uncooperative children (53.49% of cases) to avoid complications 3
• For general anesthesia, consider:
  • Slow induction with sevoflurane under spontaneous breathing without neuromuscular blocking agents
  • Rapid sequence induction with cricoid pressure in cases with risk of aspiration 6

Special Considerations

• Avoid blind finger sweeps as they can cause harm and lack clear benefit 1
• Against routine use of suction-based airway clearance devices due to limited evidence 1
• If the patient is unconscious with airway obstruction, chest thrusts should be used 1
• For difficult cases or when there is concern for unrecognized pathology, refer to a specialist who can perform nasal endoscopy 1

Potential Complications

• Infection (most common complication) 2
• Epistaxis (bleeding) during or after removal 2, 4
• Nasal septal perforation (especially with button batteries or magnets) 2, 4
• Posterior dislodgement and aspiration into the airway 4
• Trauma caused by the object itself or by removal attempts 4
• Choanal stenosis as a long-term complication 4

Follow-up Care

• After successful removal, the nasal cavity should be examined for any residual foreign material 1
• Appropriate interventions may include topical vasoconstrictors, nasal cautery, or moisturizing/lubricating agents if there is bleeding from the identified site 1
• Patient education about prevention is important, especially for parents of young children 2