Foreign body in the nose – Emergency management in children

Purpose

This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) in Queensland with a suspected or confirmed foreign body in the nose.

This guideline has been developed by senior ED clinicians and Paediatricians across Queensland, with input from ENT specialists, Queensland Children’s Hospital, Brisbane. It has been endorsed for use across Queensland by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.

Introduction

Nasal foreign bodies are more common in the following children:

• aged two to five years
• intellectual impairment (may have multiple foreign bodies and repeated episodes)

Common foreign bodies include food, paper and small toy parts. Most nasal foreign bodies are found in the anterior nasal cavity between the floor of the nose and inferior turbinate.¹ High rates (92-98%) of successful removal in ED have been reported.

Assessment

When to suspect a foreign body in the nose

Most children with a nasal foreign body are asymptomatic. A history of insertion may be reported by the child or the caregiver. Delayed presentations are usually triggered by parents noticing blood stained purulent discharge or a bad smell.

Regardless of a history of insertion, consider a nasal foreign body in children presenting with any of the following symptoms:

• nasal occlusion
• epistaxis
• malodourous, purulent or blood-stained nasal discharge (usually unilateral but may be bilateral if multiple foreign bodies or in case of septal perforation)
• facial swelling and/or facial pain

Investigations

X-rays are not routinely recommended as the objects inserted are rarely radiopaque but must be considered if there is a possibility of a button battery or paired magnets which cannot be directly visualised.

Contact Retrieval Services Queensland (RSQ) to arrange urgent transfer of a child with a suspected button battery and no X-ray facilities are onsite.

Management

Refer to flowchart [PDF 211.2 KB] for a summary of the emergency management for a child with a nasal foreign body.

Urgent ENT referral (onsite or via RSQ) is required for the following children:

• button battery in nose
• history of insertion and bleeding or airway issues

Refer to ENT as per local practices in the following circumstances:

• multiple unsuccessful attempts at removal prior to ED presentation
• foreign body is posterior and not easily visualised
• paired magnets or magnet and metallic object across nasal septum
• chronic or impacted foreign bodies with marked inflammation
• penetrating or hooked foreign bodies

Preparation for foreign body removal

• engage two staff members to assist (in addition to carer)
• provide developmentally appropriate information and encouragement and use demonstration or role play to prepare the child for the procedure
• position the child appropriately (upright or lying down)
  • upright positioning encourages a sense of control thereby minimising distress
  • ideal upright positioning is on the carer’s lap with his/her head supported by staff member
  • may be easier to secure younger children lying down
  • refer to CHQ Nursing Standard 62111: Clinical Holding – Holding and Supporting Children [PDF] (QH only)
• use auditory and visual distraction techniques and promote child’s coping skills
• prior to mechanical extraction, consider applying topical local analgesia such as Co-Phenylcaine Forte (5% Lignocaine, 0.5% Phenylephrine) at appropriate doses using flexible nozzle extension (maximum single dose of 3mg/kg Lignocaine) 10 minutes prior to removal (not routinely recommended prior to removal by positive pressure techniques)
• use a head lamp (+/- magnification) to optimise visualisation and allow the use of two hands
• consider using a nasal speculum to maximise visualisation (place in a cephalo-caudal orientation to avoid the nasal septum)

Blind attempts at removal are not recommended due to risk of posterior dislodgement and aspiration.

Methods of removal

Recommended methods of removal include positive pressure or mechanical extraction. Positive pressure methods aim to push the foreign object anteriorly either completely out of nasal passage or into a visible range where it can be grasped by other instruments. These methods carry a theoretical risk of barotrauma including periorbital subcutaneous emphysema. Irrigation and use of glue are not routinely recommended.

Sedation is not recommended as may increase the risk of aspiration.

The risk of aspiration in foreign bodies that are unable to be removed is estimated to be 1 in 1,500 patients.² Referral for elective removal is therefore acceptable with appropriate safety-net advice for the family.

Positive pressure removal methods for nasal foreign body

Mechanical extraction removal methods for nasal foreign body

Refer to ENT as per local practice if first attempt at removal of foreign body (via any method) is unsuccessful.

Post-removal care

• inspect nasal orifice to exclude co-existing foreign body and trauma
• examine other nasal and aural orifices for additional foreign bodies

Escalation and advice outside of ED

Clinicians can contact the services below to escalate the care of a paediatric patient as per local practices. Button battery cases require urgent transfer if removal onsite is not possible. Other nasal foreign bodies requiring specialist referral are usually managed as an outpatient.

Button battery insertions

Other insertions

Disposition

A child may be discharged following successful removal of the foreign body.

On discharge, provide accident prevention advice to caregiver/s including:

• safe storage of small objects including marbles, coins, button batteries and balloons to ensure out of reach of infants and young children
• ensuring toys for play are appropriate for developmental age

Follow-up

• advise caregiver/s to seek medical attention if child experiences any signs or symptoms of complications such as fever, purulent nasal discharge, epistaxis, facial pain and/or swelling
• referral to ENT as per local practice any child with significant complications following foreign body removal