Removal of a foreign body from the nose requires specific instruments and skills.
Topic Resources
Nasal foreign bodies are occasionally encountered in young children, people who are cognitively impaired, and people with psychiatric disorders. The most commonly affected population are children with a mean age of 3 years (1). Most nasal foreign bodies are inorganic, such as plastic beads, pebbles, toys, button batteries, or cotton wool, accounting for up to 80% of extracted objects. Organic foreign bodies including beans, seeds, nuts, or insects are less common (2).
Most foreign bodies are in the most anterior part of the anterior nasal vault, specifically anterior to the middle turbinate or within the inferior meatus (1). Foreign bodies are often lodged on the right side owing to right-handed predominance in the population. Because they are typically anteriorly situated, nasal foreign bodies are often easily seen using a nasal speculum.
Button batteries and magnets must be removed immediately because they may burn or perforate the nasal mucosa and/or septum (from leakage of corrosive battery contents, direct pressure, or electrical injury).
(See also Nasal Foreign Bodies.)
Indications for Removing a Nasal Foreign Body
Simple nasal foreign body (common; self-inserted objects, not including projectiles, impalements, or other complex situations)
Contraindications to Removing a Nasal Foreign Body
Absolute contraindications
Inability to see the foreign body or reach it with available instruments
Relative contraindications
Impacted foreign body associated with significant inflammation and/or edema
Foreign body that is small, transparent, and/or situated far posteriorly or superiorly
Failed attempts at removal
Consult an ear, nose, and throat (ENT) specialist (who may need to do nasal endoscopy) if there is doubt about the ability to remove the object or if repeated attempts at removal have been unsuccessful. Multiple attempts increase the risk of local injury and/or movement of the object deeper into the nose where it is more difficult to retrieve.
Complications of Removing a Nasal Foreign Body
Injury to nasal mucosa and resultant bleeding
Infection
Aspiration of the object, particularly in patients with cognitive impairment or those who are sedated
Equipment for Removing a Nasal Foreign Body
Chair with headrest or an ENT specialist's chair
Headlamp or directable light source with adjustable narrow beam
Gloves, mask, and gown
Topical anesthetic/vasoconstrictor mixture (eg, 4% cocaine, 1% tetracaine, or 4% lidocaine plus 0.5% oxymetazoline) Topical anesthetic/vasoconstrictor mixture (eg, 4% cocaine, 1% tetracaine, or 4% lidocaine plus 0.5% oxymetazoline)
Cotton swabs or pledgets to apply topical medications
Nasal speculum
Suction source and Frazier-tip suction in a variety of sizes with integrated finger control to regulate the strength of the suction
Bayonet or alligator forceps
Wire loop and hook curettes
Balloon-tipped catheter (5 to 8 French Fogarty catheter or Katz extractor)
Young children typically require restraint or sedation. Restraint can be achieved using sheets or a commercial immobilization board but may be emotionally traumatic. Unless the foreign body appears quite close to the nares and easy to remove very quickly, sedation (eg, using ketamine or another appropriate medication) is usually preferred.Young children typically require restraint or sedation. Restraint can be achieved using sheets or a commercial immobilization board but may be emotionally traumatic. Unless the foreign body appears quite close to the nares and easy to remove very quickly, sedation (eg, using ketamine or another appropriate medication) is usually preferred.
Additional Considerations for Removing a Nasal Foreign Body
Button batteries and magnets must be removed immediately. Batteries may cause chemical burns (from leakage of battery contents) or electrical injury of the nasal tissue, and magnets can cause pressure necrosis of nasal structures, including the septum. Button batteries can induce perforation in as little as 7 hours (3). Consider urgent ENT consultation in these cases.
Insects should be rendered immobile using anesthetic spray prior to extraction.
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Relevant Anatomy for Removing a Nasal Foreign Body
The lateral wall of the nose has 3 turbinates, which are long, narrow shelves of bone that protrude into the nasal cavity. These can be fragile and should not be mistaken for foreign bodies or tumors.
The nasal septum is often deviated and, if deviation is found on examination, extra care should be taken when introducing instruments to prevent trauma to the septum.
Positioning for Removing a Nasal Foreign Body
The patient should sit upright in the sniffing position with head extended, preferably in a specialized ENT chair. The patient's occiput should be supported to prevent sudden backward movement. The patient's nose should be level with the physician's eyes.
Step-by-Step Description of Nasal Foreign Body Removal
Have the patient gently blow the nose to remove mucus and perhaps the foreign body. If the nose is dripping, suction the nasal passageway carefully to remove mucus without pushing the foreign body further posterior.
Apply a topical anesthetic and vasoconstrictor to reduce sensitivity and mucosal swelling.
Wait 3 to 5 minutes to allow the anesthetic and vasoconstrictor to take effect. If there is still significant edema, apply a second treatment of topical vasoconstrictor.
Insert a nasal speculum with your index finger resting against the patient's nose or cheek and the handle parallel to the floor (so the blades open vertically).
Gently open the speculum and examine the nose using a bright headlamp or directed light source to allow for stabilization of the nasal speculum with one hand and manipulation of instruments or suction during the examination.
Use a Frazier-tip suction to remove any mucus obscuring the view.
For certain soft objects or hard objects with a graspable edge located anteriorly, grasp and remove the object using forceps (eg, alligator or bayonet forceps).
Remove harder or larger objects located anteriorly by placing a wire loop or hook curette behind the object and gently pulling.
Remove smooth, round objects using a suction catheter; place the suction tip against the object with the finger control open. Once the tip is in place, cover the finger control to activate suction, and then gently withdraw the object.
Remove objects not amenable to an anterior approach with a balloon-tipped catheter (eg, an 8 French urinary catheter). Insert the lubricated deflated balloon behind the object. Be careful not to push the object further into the nasal passage. Slowly inflate the balloon with air—approximately 2 mL in small children, 3 mL in older children, and 5 mL in adults. Slowly withdraw the balloon, pulling the object forward until resistance is met, then remove the object. Deflate the balloon and remove it from the nose.
Aftercare for Removing a Nasal Foreign Body
After removal of magnets or batteries, refer patients for otolaryngology evaluation due to the risk of nasal soft tissue damage from the foreign body.
Antibiotics are typically not indicated following removal of a foreign body.
Warnings and Common Errors When Removing a Nasal Foreign Body
Do not open the nasal speculum laterally or use in an unsupported manner. (Brace a finger of the hand holding the speculum on the patient's cheek or nose.)
Trying to grab round, smooth objects with forceps often makes them slip deeper.
Cease attempts at removal if they are unsuccessful. Making repeated attempts is a common cause of unnecessary trauma.
In general, removal by direct visualization and instrumentation is preferable to other techniques.
Tips and Tricks for Removing a Nasal Foreign Body
Elevating the patient's chair to eye level puts less strain on the clinician's back compared to bending down.
Examine the contralateral nasal cavity, oral cavity, and ear canals for additional foreign bodies.
Reexamine the nose after removal of a foreign body to prevent missing debris or another foreign body.
References
1. Abou-Elfadl M, Horra A, Abada RL, et al. Nasal foreign bodies: results of a study of 260 cases. Eur Ann Otorhinolaryngol Head Neck Dis. 2015;132(6):343-346. doi:10.1016/j.anorl.2015.08.006
2. Heim SW, Maughan KL. Foreign bodies in the ear, nose, and throat. Am Fam Physician. 2007;76(8):1185-1189.
3. Loh WS, Leong JL, Tan HK. Hazardous foreign bodies: complications and management of button batteries in nose. Ann Otol Rhinol Laryngol. 2003;112(4):379-383. doi:10.1177/000348940311200415