Rosen & Barkin's 5-Minute Emergency Medicine Consult (280 page)

CODES

935.1 Foreign body in esophagus

BASICS

• Object impacted in the nasal cavity
  
• Most common site of foreign body insertion in children
  
• Type of foreign body limited only by nostril size
  
• Population at risk:
  
  • Children between 2–6 yr most common
    
  • Mental retardation
    
  • Psychiatric illness
    
• Causes of worsening impaction and difficulties with removal:
  
  • Organic material may expand if moistened
    
  • Mucosal swelling over time
    
• Complications:
  
  • Sinusitis is the most common complication
    
  • Foreign bodies may migrate into the sinuses
    
  • Septal perforation
    
  • Bronchial aspiration
    
  • High risk of complications with button batteries:
    
    • Ischemic mucosa
      
    • Turbinate or septal damage
      
    • Saddle-nose deformity
      

• Food
  
• Beans
  
• Seeds
  
• Beads
  
• Rocks
  
• Paper
  
• Pieces of toys
  
• Sponge pieces
  
• Vegetable matter
  
• Insects and live worms
  
• Button batteries:
  
  • High risk of complications compared with other foreign bodies (tissue necrosis, septal perforation, saddle nose); require rapid removal
    
• Magnets:
  
  • Used to mimic nasal piercing
    
  • Often imbedded in nasal tissue, leading to difficult removal
    
  • May cause intestinal perforation if swallowed, especially newer high-powered neodymium magnets
    
• Glass fragments
  

DIAGNOSIS

• Most nasal foreign bodies are asymptomatic.
  
• Unilateral nasal obstruction
  
• Nasal pain
  
• Difficulties with nasal breathing
  
• Nasal discharge:
  
  • Acute or chronic
    
  • Unilateral
    
  • Foul smelling
    
  • Halitosis
    
• Sinus discomfort
  
• Persistent epistaxis
  
• Local inflammation
  
• Septal perforation
  
• Ingestion or aspiration of foreign body
  

• Child witnessed putting object into nose
  
• Foreign body noticed by parent or caretaker
  
• Many children are reluctant to admit to placing a foreign body for fear of adult disapproval
  
• Delayed presentation:
  
  • When placement of the object is unwitnessed, the child may present weeks after with nasal discharge and bleeding
    
  • Often misdiagnosed at this stage as sinusitis
    

Visualization of the foreign body in the nostril: Always check both nostrils

• Fiberoptic visualization if foreign body cannot be visualized on rhinoscopy
  
• Sinus films if present for extended period:
  
  • Symptom persistence despite removal of the foreign body and antibiotics
    
• May need chest or abdomen films for aspiration/ingestion
  

• Sinusitis
  
• Swollen inferior turbinate:
  
  • May be mistaken for a pink bead
    
• Rhinitis
  
• Nasal polyp
  
• Benign tumors:
  
  • Hemangioma most common
    
• Malignant tumors:
  
  • Lymphoma
    
  • Rhabdomyosarcoma
    
  • Nasopharyngeal carcinoma
    
  • Esthesioneuroblastoma (also known as an olfactory neuroblastoma)
    
• Congenital masses:
  
  • Dermoid
    
  • Encephalocele
    
  • Glioma
    
  • Teratoma
    
• Retropharyngeal abscess
  
• Traumatic dislocation of nasal bones or septum
  
• Nasal deformity:
  
  • Usually associated with cleft palate
    
• Nasopharyngeal stenosis
  
• Rhinitis medicamentosa:
  
  • Rebound nasal mucosal edema caused by extended use of topical decongestants
    

TREATMENT

• Cautions:
  
  • Transport in sitting position:
    
    • To avoid posterior displacement and possible aspiration of foreign body
      
• Avoid interventions that upset the child.
  
  • Forceful negative inspiration from crying may lead to aspiration
    

• Topical vasoconstrictors:
  
  • Presence of mucosal edema, or bleeding secondary to removal attempts
    
  • Nebulized epinephrine
    
  • Cocaine: 4%
    
  • Oxymetazoline: 0.05%
    
  • Phenylephrine: 0.125–0.5%
    
• Positive pressure for children:
  
  • Occlude contralateral nostril
    
  • Upright sitting position if possible
    
  • Positive pressure applied to mouth only (best done by parents)
    
  • Deliver brisk puff as child begins to inhale
    
  • Parent may tell the child he or she will be given a “big kiss.”
    
  • Placement of 4 × 4 gauze pads on caregiver’s cheek
    
  • Foreign body dislodges onto cheek of the provider or into room
    
  • Repeated as necessary
    
  • Can use straw in older children to create pressure without mouth to mouth
    
  • Alternatively, deliver puff with a bag-mask over the mouth and O
    ₂
    at 10–15 L/min.
    
  • Alternatively, into contralateral nostril male–male adapter on oxygen tubing, deliver wall oxygen at 10–15 L/min.
    
    • Risk of barotrauma with sustained, unmodulated positive pressure
      
• Hooked probe, alligator forceps:
  
  • Anterior foreign bodies that are easily grasped
    
  • Headlamp, nasal speculum facilitate use
    
  • Risk of further posterior displacement
    
• Suction catheter:
  
  • Best for round, smooth objects
    
  • Optimal retrieval with suction catheter
    
  • Suction tip placed against the object
    
  • Suction turned up to 100–140 mm Hg
    
  • Catheter and object withdrawn
    
• Cyanoacrylate tissue glue:
  
  • Film of glue applied to cut end of hollow plastic swab handle
    
  • Apply against object for 60 sec, and then withdraw
    
  • Caution with nontissue cyanoacrylate glues; tissue irritation
    
• Balloon catheters:
  
  • Used primarily when instrumentation fails
    
  • 5F or 6F Foley or Fogarty balloon catheter lubricated with 2% lidocaine jelly
    
  • Advance catheter past object
    
  • Following inflation with 2–3 mL of air, gently withdraw catheter
    
• Magnet for removal of metal foreign body described; limited experience
  
• Snare technique:
  
  • 24G wire made into a loop with a hemostat
    
  • Useful when size of object known
    
  • Thin wire can slip through swollen tissue, behind object, allowing it to be pulled free
    

• Cocaine: 4% solution, 2 drops affected nares
  
• Lidocaine: 4% solution, 2 drops affected nares
  
• Oxymetazoline: 0.05%, 2–3 drops/sprays affected nares
  
• Phenylephrine: 0.125–0.5%, 2–3 sprays affected nares
  
• Procedural sedation may be necessary
  

FOLLOW-UP

Referral for ambulatory surgical removal: