What is the best next step in managing a patient with a battery lodged in their nostril, presenting with fever, tachycardia, tachypnea, erythematous mucosa, and purulent discharge?

Nasal Battery Foreign Body - Emergency Management

This patient requires immediate removal of the battery using forceps under direct visualization, making option E the correct answer. The clinical presentation of fever, tachycardia, tachypnea, erythematous mucosa with black purulent discharge indicates active tissue necrosis from the battery, which constitutes an ENT emergency requiring urgent intervention.

Why Immediate Forceps Removal is Critical

Button batteries in the nasal cavity cause liquefaction necrosis and severe local tissue destruction that can occur within as little as 3 hours 1. The black, purulent, blood-tinged discharge with erythematous mucosa in this patient indicates that tissue necrosis has already begun 2, 3.

• The battery releases electrical current, contains toxic substances, and exerts direct pressure on surrounding tissues, all contributing to rapid tissue damage 2
• Delayed diagnosis and removal leads to significant morbidity including nasal septal perforation, synechiae, nasal stenosis, and saddle nose deformity 1, 3, 4
• Immediate surgical removal is the treatment of first choice 2, 4

Why Other Options Are Incorrect

Option A (Direct Pressure to Kiesselbach Plexus)

This addresses epistaxis management, not foreign body removal. The bleeding here is secondary to battery-induced tissue necrosis, not primary epistaxis 1.

Option B (Topical Lidocaine)

Anesthesia alone does nothing to address the ongoing tissue destruction. Every minute the battery remains causes further necrosis 3, 4.

Option C (Consult Otolaryngology)

While ENT involvement may ultimately be needed for reconstruction, delaying removal to arrange consultation allows continued tissue destruction 4. The battery must be removed immediately by the first qualified provider.

Option D (Positive Pressure Technique)

This technique (having the patient blow their nose while occluding the unaffected nostril) is appropriate for inert foreign bodies in cooperative patients. However, it is contraindicated here because:

• The patient's systemic signs (fever, tachycardia, tachypnea) suggest significant tissue injury requiring direct visualization
• Positive pressure could fragment necrotic tissue or worsen the injury
• Direct visualization is essential to assess the extent of damage 1, 2

Post-Removal Management

After forceps removal under direct visualization (ideally with nasal endoscopy):

• Carefully irrigate the nasal cavity and debride necrotic tissue 2, 5
• Apply topical antibiotic ointment (such as erythromycin) to injured mucosa 5
• Initiate systemic antibiotics given the purulent discharge and systemic signs 5
• Assess for septal perforation, which may already be present 2, 4
• Close follow-up is mandatory to monitor for complications including adhesions, stenosis, and the need for future reconstructive surgery 2, 3, 5

Critical Pitfall to Avoid

Do not delay removal for any reason. Button batteries in the nose are an ENT emergency requiring removal within hours, not days 4. The presence of black discharge and systemic signs indicates this patient is already experiencing significant tissue necrosis that will worsen with every passing minute 3, 4.