“You Put That Where?!?!” Removal of pediatric foreign bodies
By Hoi See Tsao, MD, and Alicia Genisca, MD
CASE
A 2-year-old previously healthy boy presented to the emergency department with a foreign body in his right nostril.
The patient was staying at his father’s house and the father became concerned about a foreign body when the patient suddenly began complaining of right nostril pain and dark brown nasal discharge. The father did not know what foreign body may have been inserted. On the patient’s return to his mother’s house the next day, he was found to also have right nostril swelling. His mother brought him to the emergency department for evaluation. The mother denied the patient having fever, coughing, gagging, vomiting, diarrhea, or abdominal pain.
Vital signs were within normal limits other than a heart rate of 193 beats per minute while crying. Physical examination was notable for a swollen right naris with brown mucus completely occluding the nostril.
The patient received intranasal midazolam, and a hard and metallic object was removed from the right naris with forceps (Figure 1 and 2).
Figure 1: Superior surface of foreign body (button battery) removed from right naris.
Figure 2: Inferior surface of foreign body (button battery) removed from right naris.
DIAGNOSIS
Nasal foreign body - button battery
DISCUSSION
Nasal foreign bodies make up 0.1% of pediatric emergency department visits. The most common age of presentation is 2 to 4-years-old. Most patients are asymptomatic. In asymptomatic patients, the foreign body may be found when children or caregivers report a history of nasal foreign body or when complications occur. In symptomatic children, the most common symptoms are pain and discomfort. Less commonly, foul-smelling nasal discharge, persistent rhinorrhea or epistaxis can also occur.[1,2]
Common nasal foreign bodies include food and toys.[1] The most common locations for nasal foreign bodies to be lodged are in the right naris and anterior of the middle turbinate.[3] Nasal foreign body removal strategies include positive pressure techniques (“Parent’s Kiss), use of a balloon catheter, direct instrumentation or use of cyanoacrylate glue at the end of a plastic swab. These techniques have been described in a prior Brown Emergency Medicine blog post: http://brownemblog.com/blog-1/2016/6/9/the-ole-bead-in-the-nose.
Success with nasal foreign body removal depends on the size, shape, and texture of the nasal foreign body, patient cooperation, the ability to visualize the foreign body, nasal trauma from insertion or prior attempts at foreign body removal, available equipment and tools, and provider experience. Topical vasoconstrictive agents, such as nasal oxymetazoline spray, should be considered to aid in foreign body visualization intranasally and to decrease epistaxis and swelling during and after the foreign body removal attempt.
Magnets or button batteries, such as in this case, can be attractive to children due to their small size and bright reflective appearance.3 Magnets or button batteries should be emergently removed due to the risk of necrosis and nasal septal perforation, with more severe cases requiring surgical debridement.[1,3] Complications include epistaxis (most common), foul odor, nasal discharge, nasal vestibulitis, sinusitis, mucosal irritation. Complication rates increase with prior removal attempts and prolonged foreign body exposure. It is also important to be mindful that any nasal foreign body can be dislodged into the airway and become an aspirated foreign body.[3]
Increased education of caretakers on age-appropriate foods and household items is important to prevent recurrence of foreign bodies in the nares or other parts of the body.[3]
CASE RESOLUTION
Upon identification of the foreign body as a button battery, an ear, nose and throat (ENT) specialist was consulted. Physical examination by ENT demonstrated gray debris along the lateral nasal wall and the caudal septum. Bimanual palpation of the caudal septum suggested the septum was intact without perforation. ENT performed rapid nasal endoscopy that showed a significant amount of char along the caudal septum that obscured the view further into the nasal cavity. No additional foreign bodies were visualized. Given that the button battery was in the right nasal cavity for a prolonged period of time, emergency department and ENT providers were concerned about the risk of development of septal perforation or synechiae.
The patient was discharged with ENT recommendations for nasal saline every 4 hours, mupirocin to the nostrils at bedtime to facilitate healing, and close ENT follow up.
During the ENT follow-up visit 2 days later, physical examination showed a diffusely grey, scabbed caudal septum and the right inferior turbinate was burned anteriorly. The right nasal cavity was debrided with cotton-tipped applicators. The caudal septum remained intact without perforation. Nasal saline and mupirocin were continued.
TAKE-AWAYS
-foreign bodies are a common pediatric emergency department complaint
-management varies, and depends on the tools, equipment, and personnel available, as well as patient factors
-magnets or button batteries can cause skin necrosis and emergent removal is indicated
Author: Hoi See Tsao, MD is a 3rd year Pediatric EM fellow at Brown University/Hasbro Children’s Hospital
Faculty Reviewer: Alicia Genisca, MD is an Attending Physician for Brown Pediatric Emergency Medicine
References:
1. Kiger JR, Brenkert TE, Losek JD. Nasal foreign body removal in children. Pediatric emergency care. 2008;24(11):785-792.
2. François M, Hamrioui R, Narcy P. Nasal foreign bodies in children. European archives of oto-rhino-laryngology. 1998;255(3):132-134.
3. Cetinkaya EA, Arslan İB, Cukurova İ. Nasal foreign bodies in children: Types, locations, complications and removal. International Journal of Pediatric Otorhinolaryngology. 2015;79(11):1881-1885.