Ear, Nose & Throat
Question 177 of 180
A 2 year old girl is brought to the Emergency Department by her concerned parents. They describe 3 days of purulent, foul smelling discharge from the right nostril. What is the most likely diagnosis?
Answer:
Presentations of nasal foreign body (NFB):- Unilateral purulent rhinorrhoea (most common presentation)
- Asymptomatic presentation after witnessed insertion of NFB
- Other symptoms:
- Epistaxis
- Pain
- Irritation
- Chronic sinusitis
- Unilateral nare obstruction
- New-onset snoring
- Sneezing
- Wheezing
- Stridor
- Unilateral facial swelling
Foreign Body in Nose
Ear, Nose & Throat
Last Updated: 12th February 2021
Nasal foreign bodies (NFBs) are a common complaint in the emergency department, especially among children, as well as adults with mental disabilities. Although NFBs rarely pose a true emergency, certain ones, such as batteries and magnets, can cause extensive, permanent damage and require emergency removal. Consideration of the most effective retrieval technique is essential, since a dislodged NFB can be displaced into the airway, resulting in aspiration or fatal airway obstruction.
Location and type of NFB
- Type
- Foreign bodies can be classified as either inorganic or organic.
- Inorganic materials are typically plastic or metal e.g. beads and small parts from toys. These materials are often asymptomatic and may be discovered incidentally.
- Organic foreign bodies may include food, rubber, wood, and sponges and tend to be more irritating to the nasal mucosa; thus, they may produce earlier symptoms.
- Location
- The most common locations for NFBs to lodge are just anterior to the middle turbinate or below the inferior turbinate.
- Because most people are right-handed, most NFBs are right sided.
Presentation
- Unilateral purulent rhinorrhoea (most common presentation)
- Asymptomatic presentation after witnessed insertion of NFB
- Other symptoms:
- Epistaxis
- Pain
- Irritation
- Chronic sinusitis
- Unilateral nare obstruction
- New-onset snoring
- Sneezing
- Wheezing
- Stridor
- Unilateral facial swelling
Imaging
- If an NFB is easily visualised on physical examination, imaging may not be necessary.
- However, if NFB placement was unwitnessed and the type of NFB is unknown, plain radiography should be ordered to rule out the presence of a button battery. Aside from metallic or calcified objects, NFBs tend to be radiolucent.
- A radiograph should also be obtained if possible ingestion or aspiration is a concern.
Indications for ENT referral
- Dislodgement of a foreign body into the airway
- Several unsuccessful attempts at removal
- Button battery foreign body
- Non-cooperative child who needs sedation
- Difficulty in visualising the NFB
- Potential tumor or mass
Methods of extraction
- Non-invasive techniques:
- Forced expiration: Instruct patient to blow hard out of nose whilst occluding the unaffected nostril.
- 'Mother's kiss': Position the child lying down and ask parent to blow into child’s mouth while occluding the unaffected nostril.
- If these techniques do not completely remove the object, they may at least dislodge it more anteriorly and allow for removal via direct instrumentation.
- Direct instrumentation
- This technique is ideal for non-spherical, non-friable foreign bodies. It should be attempted only with objects that are well visualised and within reach of available instruments. Recommended instruments include hemostats, alligator forceps, and bayonet forceps.
- Hooked probes
- Hooked probes (e.g. right-angle hooks) can be used to retrieve objects that are easily visualised but difficult to grasp. The hook is placed behind the NFB and is then rotated so that the hook angle is behind the bulk of the object. The object is then pulled forward.
- Balloon catheters
- This approach is ideal for small, round objects that are not easily grasped by direct instrumentation. With the patient lying supine, the balloon is inserted past the foreign body and inflated with air or water. After inflation, the catheter is withdrawn, expelling the foreign body from the nose.
- Suction
- This technique is ideal for easily visualised, smooth or spherical foreign bodies. The catheter tip is placed against the object, and a suction force of 100-140 mm Hg is used.
- Glue
- This method is ideal for easily visualised smooth or spherical foreign bodies that are dry and non-friable. A thin coat of cyanoacrylate adhesive is placed on the tip of a wooden or plastic applicator, which is then pressed against the foreign body for 60 seconds and removed.
Complications
-
- Foreign body aspiration +/- airway obstruction
- Epistaxis
- Septal perforation
- Infection
- Epiglottitis
- Sinusitis
- Acute otitis media
- Periorbital cellulitis
- Meningitis
- Tetanus
- Button battery complications
- Complications from a button battery NFB include mucosal damage, direct pressure necrosis, electrolysis, caustic exposures, and possible heavy metal toxicity.
- Magnetic NFBs
- Magnetic NFBs have been shown to cause pressure necrosis and even perforation of the nasal septal mucoperichondrium.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
