How to remove a foreign body from a child's nose?

Nasal Foreign Body Removal in Children

For a child with a nasal foreign body, attempt positive-pressure expulsion first (parent's kiss technique or bag-valve-mask), followed by direct mechanical extraction with appropriate instruments if this fails, but refer immediately to ENT for button batteries or magnets which require emergent removal. 1, 2

Initial Assessment and Risk Stratification

• Identify the type of object immediately - button batteries and magnets require emergent ENT referral as they can cause septal perforation or necrosis within hours 1, 2
• Most nasal foreign bodies occur in children aged 2-4 years and are typically plastic toys or beads 1
• Look for unilateral nasal discharge, foul odor, epistaxis, or nasal obstruction as presenting symptoms 1, 3
• Do not perform blind finger sweeps - this can push the object posteriorly into the airway, creating a life-threatening aspiration risk 4, 5

Removal Technique Algorithm

First-Line: Positive-Pressure Expulsion

This should be your initial approach for most nasal foreign bodies as it avoids instrumentation and restraints while maintaining high success rates 1, 6:

• Parent's kiss technique: Have the parent occlude the unaffected nostril, place their mouth over the child's mouth, and blow a short sharp puff of air 1, 6
• Bag-valve-mask technique: Occlude the unaffected nostril and deliver positive pressure via bag-valve-mask over the child's mouth 1
• This method is underutilized despite being effective and avoiding the trauma of instrumentation 6

Second-Line: Direct Mechanical Extraction

If positive-pressure fails, proceed to instrumental removal 1, 7:

• Use appropriate visualization - adequate lighting and nasal speculum are essential 7
• Instrument selection based on object characteristics 1:
  • Smooth, round objects: Use a right-angle hook or balloon-tipped catheter passed beyond the object, then pull forward
  • Irregular objects: Use alligator forceps or bayonet forceps for direct grasp
  • Soft objects: Consider suction catheter
• Avoid pushing the object posteriorly - this creates aspiration risk 1, 3

Third-Line: Saline Irrigation

• Nasal lavage with saline can wash out certain objects 1
• Use caution as this may also push objects posteriorly 1

Critical Contraindications and Emergencies

• Button batteries require removal within hours - they cause liquefactive necrosis and septal perforation rapidly 1, 2
• Magnets require emergent removal - risk of tissue necrosis and perforation 1
• If respiratory symptoms develop, this suggests posterior displacement into the airway and requires immediate intervention 4
• Multiple failed removal attempts increase complication risk including epistaxis and further impaction - refer to ENT after 1-2 failed attempts 2, 7

Common Pitfalls to Avoid

• Attempting removal without proper visualization leads to posterior displacement 7
• Using excessive force with instruments causes mucosal trauma and epistaxis 2
• Delaying removal of button batteries or magnets while attempting conservative measures 1, 2
• Not recognizing when to refer - if you cannot remove the object safely within 1-2 attempts, ENT consultation is warranted 7

Post-Removal Care

• Examine the nasal cavity for retained fragments, mucosal injury, or septal damage 1, 2
• For button battery or magnet cases, even after removal, examine for tissue necrosis and consider ENT follow-up 2
• Educate parents about prevention and signs of complications 2