Rosen & Barkin's 5-Minute Emergency Medicine Consult (281 page)

• Foreign body cannot be recovered in ED
  
• Removal under general anesthesia is required
  

• Ensure that there is no airway compromise
  
• Return if bleeding, infection (nasal discharge)
  
• If a button battery was removed, monitor for delayed sequelae as outpatient:
  
  • Ischemic mucosa
    
  • Turbinate or septal damage
    
  • Saddle-nose deformity
    

• Follow up with otolaryngologist if:
  
  • Removal unsuccessful in ED
    
  • Concern for nasal mucosa injury
    

• Return to the ED immediately if:
  
  • Coughing, wheezing, noisy, or difficult breathing
    
  • Vomiting, gagging, choking, drooling, neck or throat pain, or inability to swallow
    
• Parents should be instructed to seek medical care for the following:
  
  • Fever
    
  • Headache or facial pain
    
  • Persistent epistaxis
    
  • Persistent drainage of nasal fluid
    

• Consider nasal foreign bodies in children 2–6 yr presenting with what appears to be sinusitis
  
• Parents are best suited to perform positive-pressure removal to avoid frightening the child
  
  • Often successful, with little/no sedation
    
  • Can make other techniques more likely to succeed, even if it fails
    
• Mix equal parts Lidocaine 4% with oxymetazoline to deliver simultaneously
  

• Fundakowaski CE, Moon S, Torres L. The snare technique: A novel atraumatic method for the removal of difficult nasal foreign bodies.
  J Emerg Med.
  2013;44:104–106.
  
• Heim SW, Maughan KL. Foreign bodies in the ear, nose, and throat.
  Am Fam Physician
  . 2007;76:1185–1189.
  
• Kiger JR, Brenkert TE, Losek JD. Nasal foreign body removal in children.
  Pediatr Emerg Care
  . 2008;24:785–792.
  
• Purohit N, Ray S, Wilson T, et al. The ‘parent’s kiss’: An effective way to remove paediatric nasal foreign bodies.
  Ann R Coll Surg Engl
  . 2008;90:420–422.
  
• Soto F, Murphy A, Heaton H.Critical procedures in pediatric emergency medicine.
  Emerg Med Clin North Am
  . 2013;31:335–376.
  

CODES

932 Foreign body in nose

BASICS

• Self-insertion (autoeroticism):
  
  • Phallic substitutes inserted by patient or partner
    
  • Usually men aged 20–40 yr, with male to female ratio 20:1
    
• Ingested objects lodged in rectum:
  
  • Chicken bones
    
  • Fish bones
    
  • Toothpick
    
• Iatrogenic accidental:
  
  • Thermometer
    
  • Enema tips
    
  • Foreign bodies (FBs) used to aid in removal of feces
    
• Assault:
  
  • Knife or pipe forcibly inserted
    
  • Incidence of perforation is very high.
    
• Concealment:
  
  • Body packing, “mules” illegally transporting drugs
    

DIAGNOSIS

• Complaint of rectal FB
  
• Rectal fullness
  
• Rectal pain
  
• Perirectal abscess (with imbedded bones/toothpick)
  
• FB on rectal exam:
  
  • High-lying FBs are located proximal to rectosigmoid junction and are not palpable on rectal exam.
    
  • Low-lying FBs are usually located in rectal ampulla and are palpable on rectal exam.
    
• Some patients may not be forthcoming with history
  
• Can present with vague symptoms of abdominal pain or obstruction
  
• Can present as bowel perforation with full peritonitis
  
• Often late presentation hours or days after placement, following repeated failed attempts at removal
  
• Rectal Organ Injury Scale (proposed by American Association for the Surgery of Trauma):
  
  • Grade I—Hematoma: Contusion or hematoma without devascularization:
    
    • Most injuries due to rectal FB are Grade I
      
  • Grade II—Laceration 50% circumference
    
  • Grade III—Laceration >50% circumference
    
  • Grade IV—Full-thickness laceration with extension into perineum
    
  • Grade V—Devascularized segment
    

• Identify number, type, and duration of FBs and mechanism of insertion.
  
• Physical exam with emphasis on abdominal and rectal exam
  
  • Classified as high-riding vs. low-riding based on relationship to rectosigmoid junction
    
• Biplane radiographic films to confirm number and size of FBs
  
• Serious injury more common with assault
  

• CBC:
  
  • For bleeding or peritonitis
    
• Urinalysis:
  
  • For urethral/bladder injuries
    

• Plain radiograph:
  
  • Consider doing kidneys, ureters, and bladder (KUB) radiograph prior to rectal exam to rule out objects harmful to examiner.
    
  • Define and locate FB.
    
  • Assess for complications of retained FB including bowel perforation and obstruction.
    
  • May be used serially to follow descent of FB
    
• CT scan of abdomen/pelvis:
  
  • To exclude perforation or abscess formation
    

• Pseudo-FB:
  
  • Patients insist there is FB when radiograph, rectal exams, and proctoscopy results are normal.
    
• Perirectal abscess
  
• Hemorrhoid
  

TREATMENT

Cautions:

• Patient has usually tried to remove FB and failed.
  
• Further attempts at extraction will not work and could cause perforation.
  

• Perforation with peritonitis and sepsis:
  
  • 0.9% NS IV fluid 500 mL bolus
    
  • Broad-spectrum antibiotics (anaerobic and gram-negative aerobes):
    
    • Cefoxitin, cefotetan, ticarcillin–clavulanate, ampicillin–sulbactam, imipenem, meropenem, ertapenem,
      or
      
    • Metronidazole/clindamycin _+ aminoglycoside/3rd-generation cephalosporin/fluoroquinolone/aztreonam
      
  • Urgent surgical consult
    
• Advanced trauma life support (ATLS) with evidence of other trauma
  

• Appropriate sedation and analgesia is important to overcome spasm, rectal edema.
  
• Avoid enemas or suppositories.
  
• Low-lying small rectal FBs that are not fragile or sharp are candidates for ED removal:
  
  • Firmly hold bimanually or with forceps
    
  • Remove with gentle but firm continuous traction to overcome anal sphincter.
    
  • Colonic mucosa tightly adherent to distal end of FB creates vacuum and impedes withdrawal of object:
    
    • Passage of Foley catheter beyond object with insufflation of air breaks vacuum and permits retrieval.
      
  • Awake and cooperative patients can facilitate transanal extraction with valsalva.
    
  • May use instruments to assist with extraction: Obstetrical forceps, tenaculum, ring forceps, vacuum extractor
    
  • 60% of rectal FBs may be removed transanally in the ED under proper sedation.
    
  • Following extraction, anorectum must be thoroughly evaluated to rule out occult injury.
    
• High-lying rectal FBs:
  
  • Not immediately accessible through rectum
    
  • Usually require surgical or GI consult
    
  • Attempt may be made to position object into low-lying position with gentle abdominal pressure
    
  • Avoid blind transanal removal
    
  • Direct visualization with lubricated operating anoscope (after blockage of sphincter and pudendal nerve with local anesthesia)
    
  • Admission and observation for spontaneous descent (with serial radiographs)
    
  • Laparotomy may be necessary as last resort if other methods fail, or if patient has evidence of perforation.
    
• Consider surgical or GI consult for other complicated rectal FBs:
  
  • Larger objects
    
  • Objects that have remained >24 hr with resulting edema
    
  • Objects with sharp edges
    
  • Proctoscopy/sigmoidoscopy after extraction to examine colonic mucosa
    
• Body packers:
  
  • Ruptured packets of concealed illicit drugs can cause systemic toxicity, bowel necrosis, and death.
    
  • Sharp instruments should not be used for retrieval, and other instruments should be used with extreme caution.