WORKUP	Section 5 of 8
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No specific workup is indicated. X-rays or other imaging techniques may be helpful if considering a diagnosis of tumor or sinusitis. No blood tests are indicated.

	TREATMENT	Section 6 of 8
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• Most nasal foreign bodies can be removed easily and safely by emergency physicians. The need for urgent removal is infrequent, and usually adequate time is available to assemble the correct instruments and provide needed anesthesia and sedation. The physician should not attempt removal without appropriate instruments and good control of the patient. Parents are often apprehensive, and children are likely to be agitated and uncooperative. A failed attempt only makes subsequent attempts more difficult.

• Prior to any procedure, treat nasal mucosa with 0.5% phenylephrine (Neo-Synephrine) to decrease mucosal edema and aerosolized lidocaine for local anesthesia.

• Because nasal foreign bodies have different sizes, shapes, and locations within the nares, the emergency physician should be familiar with several removal techniques. The most commonly used techniques, described below, include mechanical dislodgement with a hooked probe or forceps, Fogarty or Foley balloon catheter, suction catheter tip, or stick and glue and bag-valve-mask or mouth-to-mouth positive pressure ventilation. Recently, use of a permanent magnet to remove metallic foreign bodies has been described.
  • Hooked probe or forceps: Several authors recommend using a hooked probe or forceps (bayonet or alligator) to remove the foreign object. If the object is small and close to the anterior naris, it can be grasped easily with forceps. However, objects that are large, solid, smooth, or rounded tend to be more difficult to grasp and often are pushed further into the naris with forceps.

  • Balloon catheters: A Fogarty or Foley balloon catheter may be useful for objects that cannot be grasped easily. The Fogarty catheter is preferred to the Foley because the Fogarty is stronger and stiffer and passes by the object more easily. With either device, check the balloon for patency, lubricate the catheter, and advance the deflated balloon past the object. Then inflate the balloon and withdraw the catheter, gently pulling out the foreign body. Complications may include bleeding.

  • Suction catheter: Position a suction catheter in the nares until the tip touches the object. Then turn the suction on to 100-140 mm Hg and retrieve the object while removing the catheter. The addition of a soft, pliable PE tube gives the Frazier suction tube a suction cup tip and allows better adherence to the foreign body's surface. Apply surgical lubricant to the PE tube's flange to further enhance its adherent properties. Although a solid seal is required for suction to be effective, smaller round foreign objects are removed easily with these maneuvers.

  • Cyanoacrylate glue: Apply cyanoacrylate glue to the end of a wooden or plastic applicator stick, then press it against the foreign body for approximately 1 minute to remove a nasal foreign body rapidly. Prevent accidental adhesion to the patient's nasal mucosa.

  • Positive pressure ventilation: Researchers have reported using positive pressure ventilation applied either with bag-valve-mask or mouth-to-mouth to expel nasal foreign bodies forcefully. A theoretical risk of barotrauma to the tympanic membranes or lower airways exists, although this has not been reported. This technique is most likely to be useful with large objects that occlude the entire nasal passage and limit ability to pass a catheter or probe. The unobstructed naris is occluded with a finger, and air is exhaled briskly into the mouth, producing positive pressure behind the object. This may reposition the object so that it can be grasped. In most cases, the object actually pops out. Success rates of 79% have been reported in a prospective study, and parents surveyed rated the procedure less traumatic than an injection and less traumatic than an oropharyngeal examination with a tongue depressor.

• For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center. Also, see eMedicine's patient education article Foreign Body, Nose.

	SPECIAL CONSIDERATIONS	Section 7 of 8
Author Information Introduction Clinical Differential Diagnosis Workup Treatment Special Considerations Bibliography

One special consideration is the patient with a small button battery foreign body. Moisture within the cavity creates the potential for current, hydroxide formation, and significant tissue damage. Irrigation and nasal wash should be avoided, and leakage of the battery can cause liquefactive necrosis and organ injury. Immediate removal is necessary.

	BIBLIOGRAPHY	Section 8 of 8
Author Information Introduction Clinical Differential Diagnosis Workup Treatment Special Considerations Bibliography

• Backlin SA: Positive-pressure technique for nasal foreign body removal in children. Ann Emerg Med 1995 Apr; 25(4): 554-5[Medline].
• Botma M, Bader R, Kubba H: 'A parent's kiss': evaluating an unusual method for removing nasal foreign bodies in children. J Laryngol Otol 2000 Aug; 114(8): 598-600[Medline].
• Chan TC, Ufberg J, Harrigan RA, Vilke GM: Nasal foreign body removal. J Emerg Med 2004 May; 26(4): 441-5[Medline].
• Douglas SA, Mirza S, Stafford FW: Magnetic removal of a nasal foreign body. Int J Pediatr Otorhinolaryngol 2002 Feb 1; 62(2): 165-7[Medline].
• Fox JR: Fogarty catheter removal of nasal foreign bodies. Ann Emerg Med 1980 Jan; 9(1): 37-8[Medline].
• Henry LN, Chamberlain JW: Removal of foreign bodies from esophagus and nose with the use of a Foley catheter. Surgery 1972 Jun; 71(6): 918-21[Medline].
• Kadish HA, Corneli HM: Removal of nasal foreign bodies in the pediatric population. Am J Emerg Med 1997 Jan; 15(1): 54-6[Medline].
• Kalan A, Tariq M: Foreign bodies in the nasal cavities: a comprehensive review of the aetiology, diagnostic pointers, and therapeutic measures. Postgrad Med J 2000 Aug; 76(898): 484-7[Medline].
• McMaster WC: Removal of foreign body from the nose. JAMA 1970 Sep 14; 213(11): 1905[Medline].
• Morris MS: New device for foreign body removal. Laryngoscope 1984 Jul; 94(7): 980[Medline].
• Navitsky RC, Beamsley A, McLaughlin S: Nasal positive-pressure technique for nasal foreign body removal in children. Am J Emerg Med 2002 Mar; 20(2): 103-4[Medline].
• Stool SE, McConnel CS Jr: Foreign bodies in pediatric otolaryngology. Some diagnostic and therapeutic pointers. Clin Pediatr (Phila) 1973 Feb; 12(2): 113-6[Medline].

Foreign Bodies, Nose excerpt