Immediate Management of Naphthalene Ball Lodged in Child's Nostril
Remove the naphthalene ball immediately using direct mechanical extraction under controlled conditions, as naphthalene carries significant risk of systemic toxicity through mucosal absorption and requires urgent removal to prevent hemolysis, methemoglobinemia, and renal failure. 1, 2
Removal Technique Selection
Perform removal under general anesthesia with sevoflurane induction and endotracheal intubation to prevent aspiration if the foreign body dislodges posteriorly. 3
Anesthetic Approach
- Use slow inhalational induction with sevoflurane maintaining spontaneous breathing 3
- Intubate the trachea without neuromuscular blocking agents to preserve airway reflexes 3
- Alternatively, use rapid sequence induction with cricoid pressure if aspiration risk is high 3
- The foreign body can migrate into the trachea during crying or with reduction of muscle tone, making airway protection critical 3
Mechanical Extraction Methods
Direct mechanical extraction can be accomplished with: 1
- Forceps - grasp visible objects
- Hooks - retrieve smooth round objects like balls
- Balloon-tipped catheters - pass beyond object, inflate balloon, withdraw
Alternative Techniques (if anesthesia unavailable)
- Positive-pressure expulsion via parent's mouth or Ambu bag 1
- Nasal saline irrigation 1
- Catheter-based or oxygen source pressure 1
Critical Naphthalene-Specific Concerns
Naphthalene requires emergent removal similar to button batteries and magnets due to risk of rapid systemic absorption and severe toxicity. 1, 2
Toxicity Timeline
- Naphthalene toxicity occurs abruptly after exposure 2
- Mucosal contact allows absorption leading to systemic effects 2, 4
- Toxicity is more severe in patients with G6PD deficiency 2
Post-Removal Monitoring
Monitor for signs of systemic naphthalene toxicity: 2
- Acute hemolysis - check hemoglobin, haptoglobin, LDH
- Methemoglobinemia - measure methemoglobin levels
- Hemoglobinuria - observe urine color, check urinalysis
- Renal dysfunction - monitor creatinine and urine output
Treatment of Naphthalene Toxicity (if absorbed)
Methemoglobinemia Management
- Methylene blue 1-2 mg/kg IV for methemoglobin levels >20-30% 2
- Contraindicated in severe G6PD deficiency 2
- Alternative: ascorbic acid and N-acetylcysteine 5
Hemolysis Management
- Supportive care with hydration 5, 2
- Consider plasmapheresis for severe refractory hemolysis 5
- Hemodialysis may be needed for acute renal failure 5
Common Pitfalls to Avoid
- Never attempt removal in an uncooperative child without anesthesia - crying increases aspiration risk 3
- Do not delay removal - naphthalene is not an inert foreign body and requires urgent extraction 1, 2
- Avoid blind instrumentation - can push object posteriorly causing aspiration 1
- Do not discharge immediately - observe for 2-4 hours post-removal for signs of systemic toxicity 2