Case Report

NASAL FOREIGN BODY

Presentator : dr. Heribertus Diwyacitra Aribawa

Moderator : Dr.dr. Sagung Rai Indrasari, M.Kes, Sp.THT-KL(K),FICS

Otorhinolaryngology and Head Neck Surgery Departements

Medical Faculty of Gadjah Mada University / DR. Sardjito Hospital
Yogyakarta
2016

INTRODUCTION

Research Hospital during the 8-year period

of study, 1870 (0,3%) children had 1875

Nasal Foreign Bodies are quite common

among pediatric patients. The patients may
present asymptomatically after having been
witnessed inserting the item. The presence
of a Foreign Body in the nose may not be
life-threatening but it may cause morbidity.
Complications may arise from the Foreign
Body itself or from attempted removal. The
method of removal usually depends on
the type of Foreign Body, its position,
and cooperation of the patient. Although
more frequently seen in the pediatric setting,
they can also affect adults, especially those
with mental retardation or psychiatric
illness. Children's interests in exploring their
bodies make them more prone to lodging
foreign bodies in their nasal cavities. In
addition, they may also insert foreign bodies

NFBs. There were 989 (52.9%) boys

and 881 (47.1%) girls. The youngest
child treated was 19 months old, and the
oldest was 11.5 years old (mean age, 3
years 4 months; median age, 3 years). Five
boys required treatment for NFB in both
the right and left nasal cavities. As to the
types of foreign body, of the 1875 cases, in
33.4% (626 cases), the most common types
of FB removed were hard spherical objects
such as beads, bead like toy fragments,
dried vegetables, fruit seeds, nuts, etc. The
second most commonly found FBs in the
nasal cavities were irregular soft objects
(sponge, paper, leaf fragments, etc.) in
20.9% (390 cases). Of all objects, 1186
(63.2%) were inorganic, and 689 (36.7%)
organic. 2

to relieve preexisting nasal mucosal

irritation or epistaxis. As benign as an Nasal

If the foreign body is a battery or is

Foreign Body may seem, it harbors the

impacted, however, special precautions

potential for morbidity and even mortality if

have to be taken. In addition, if the child

the object is dislodged into the airway 1

is uncooperative, general anesthesia is

usually required to prevent complications.

Over the 8-year period, there were

Batteries are the type of foreign body most

adequate data in the charts for analysis.

commonly associated with early

Among 623,000 children seen at ENT

complications despite improvements in

Services of Antalya Ataturk State

product safety. Due to their small size,

Hospital and Izmir Tepecik Training

batteries can easily be inserted into

various orices such as nose, ear or

nickel, cadmium, and lithium. Liberation of

mouth.

these substances causes various types of

Some foreign bodies are inert and may

remain in the nose for years without mucosal
changes. However, most inanimate objects
initiate congestion and swelling of the nasal
mucosa, with the possibility of pressure
necrosis producing ulceration, mucosal

lesions depending on the localisation, with

an intense local tissue reaction and
liquefaction necrosis. As a result they can
cause septal perforations, synechiae,
constriction, and stenosis of the nasal cavity.
Maggots and screw worms in the nose

erosion, and epistaxis. The retained

initate varying degrees of inflammatory

secretion, the decomposed foreign body,

reaction from a mild localised infection to

and the accompanying ulceration can result

maximum destruction of the nasal bones

in foul fetor. These changes further impact

(both cartilaginous and bony) with

the foreign body because of surrounding

formation of deep, stinking suppurating

oedema, granulations, and discharge. This is

caverns. The larvae hatch in these caverns

particularly seen with vegetable foreign

and a new cycle is repeated.4

bodies which not only absorb water from

the tissues and swell but also evoke a very
brisk inflammatory reaction. Occasionally,
the inflammatory reaction is sufficient to
produce toxaemia. A foreign body can act as
a nucleus for concretion if it is firmly
impacted or is buried in granulation tissue by
receiving a coating of calz and thus becomes
a rhinolith. Occasionally this process may
occur around an area of inspissated
mucopus, or even a blood clot. Rhinoliths
usually form near the floor of the nose and
are radio-opaque. Button batteries may
result in severe destruction of the nasal
septum. These are composed of various
types of heavy metals: mercury, zinc, silver,

Foreign bodies are either animate or inanimate. Inanimate foreign bodiesThe list
of objects that have been reportedly
removed from the nose is endless. The most
commonly identified inanimate foreign
bodies include rubber erasers, paper wads,
pebbles, beads, marbles, beans, safety
pins, washers, nuts, sponges, and chalk.
Other authors have reported plasticine,
pieces of wood, a door handle, metal
hooks and eyes, pieces of cloth, bullets,
thimbles, shrapnel, umbrella springs, iron
bolts, corks, and coins. Endogenous
materials like bone and pieces of cartilage
have been left behind in the nasal cavity

after surgical intranasal manipulations.

is cosmopolitan in distribution. In temperate

Trauma to structures adjacent to the nose

regions it is generally associated with low

such as orbits, paranasal sinuses, and

standards of personal hygiene.5

palate can force bone spicules and

cartilage fragments into the nose.
Supernumerary teeth have erupted in the
floor of the nose, presented like osteoma,
and caused nasal obstruction.
Animate foreign bodiesMyiasis of the

At the very outset diagnosis could prove

difficult. To the unsuspecting, a unilateral
suppu- rative or mucopurulent fetid nasal
discharge may suggest a number of
possibilities other than a foreign body. On
the other hand, the presence of a foreign

nose is common in warm tropical climates of

body may be suspected but to prove its

South Western United States and the Far

presence may be a trying task A high index

East including India, the frequency of

of suspicion is necessary so that further

infestation being primarily related to the

diagnostic manoeuvres can be tried before

poor hygiene of the inhabitants. The most

a label of no foreign body is stamped on

common of all infestations is the fly maggot.

the case. Nasal foreign bodies may come to

The ordinary maggot represents the larval

be lodged in any part of the nasal fossa,

stage of this blow fly. It thrives in dead

but the commonest location is just anterior

tissue only and does not destroy living

to the middle turbinate or below the

material. Larvae of other flies like those of

inferior turbinate. The rarest location was

aestrous, hypoderma, and dermatobia also

when a transnasal foreign body had

invade the nasal cavities. Wohlfahrtia

penetrated the anterior skull base through

magnifica may also infest the nose. These

the cribriform plate and passed between the

infestations occur more commonly in

frontal lobes. 6

patients suffering from ozaena and nasal

syphilis. Ascaris lumbricoides is a species of
nematode or round intestinal worms and will
find lodgement in the nose when regurgitated
or coughed up. It is the most common
intestinal helminth of man and frequently
reaches epidemic proportions. Although it
flourishes best in warm, tropical climates, it

Complications were seen (12%),

epistaxis being the most common (3.5%),
followed by foul odor nasal discharge and
nasal vestibulitis (3.4%), and mucosal
irritation (1.6%). Early complications
(before 72 h) were due to the Nasal
Foreign Body itself (52%) or prior removal

attempts (48%). After prolonged exposure,

Rhinoliths are initially symptomless and

an increase in complications was seen due

later cause nasal obstruction only if they

to the Nasal Foreign Body itself (88%).

become enlarged. Examination of the

Prolonged exposure signicantly increased

nasal cavity shows a greyish irregular

the complication rate due to the Nasal

Foreign Body itself. Evidence of local
trauma from earlier removal attempts may be
present, with erythema, edema, bleeding, or
a combination. However, Nasal Foreign
Bodys located in part of the airway
both as a symptom or complication of
nasal obstruction were seen very rarely
(1%). In total, 11 foreign bodies were rmly
impacted and unidentiable (beads, nut
fragments, sponge fragments) in time
becoming rhinoliths. Button batteries
deserve particular attention due to the
severity of the injuries they cause. We found
10 cases of necrosis of the nasal mucosa and
two cases of septal perforation due to button

mass, usually along the floor of the nose

that feels bony, hard and gritty on probing.
Radiography usually confirms the diagnosis
and reveals the extent of the rhinolith. A
loose foreign object in the postnasal space
can accidentally be aspirated or pushed
back in an attempt at removal and may
result in acute respiratory obstruction.
Foreign bodies in the nose have been
implicated as carriers of the causative
organisms of diphtheria and other infectious
diseases. It therefore appears that foreign
bodies in the nose can create a real problem
and should not be taken lightly.8
Sedation is usually not recommended in

batteries. Three patients in this study

most nasal foreign body cases because

underwent surgical debridement. The most

of the ease of removal, short length of

life-threatening complication was an

the procedure, and, most importantly, the

intracranial penetrating injury associated

need for the patient to have a good gag

with a cerebrospinal uid stula. It is

and cough reflex to prevent aspirating the

possible that any occurrence of an aspirated

object if it were to be pushed posterior

nasal cavity-Foreign Body, thus becoming a

into the oral pharynx. If the patient is

potential bronchial Foreign Body.7

anxious, intranasal versed may be used, but

strict adherence to sedation guidelines
should be followed.

Local Anesthetic and

of the patient, we use a 5 or 6 Fr. Foley

Vasoconstrictor

balloon catheter to remove many foreign

The patients could be premedicated with

several drops of both 1% lidocaine without
epinephrine, and 0.5% phenylephrie
instilled into the nostril to provide local
anesthesia and decrease mu- cosal swelling,
unless there are contraindications to these
medications (allergies, chronic medical
problems).
Specific Techniques for Removal
Graspable Instrument
As in ear foreign bodies, alligator

bodies. The patient should be premedicated

with lidocaine without epinephrine and
phenylephrine. The patient is placed in the
supine position. After a check that the
balloon inflates properly, it is lubricated
with 2% lidocaine jelly and advanced past
the object. The balloon is inflated with 2 or
3 milliliters of air and the catheter
withdrawn gently, pulling out the foreign
body. The balloons inflation may need to
be varied depending on the size of the
nasal foreign body and the size of the
patients nares. This procedure works well

forceps are excellent at removing soft,

for foreign bodies that are in the posterior

graspable foreign bodies, especially if they

nasal pharynx, or nasal foreign bodies

are located in the anterior nares. The

that are round, smooth, and nongraspable.

disadvantage of this method is that some

The Foley catheter may also be used when

foreign bodies (bread, paper) may pull

direct visualization of the foreign body is

apart leaving portions still in the nose. The

difficult. The Foley catheter technique

possibility also exists of pushing the foreign

does not work if the nasal foreign body is

body further posterior. Many parents report

so big that it occludes the nasal passage and

that they pushed the foreign body in farther

the catheter cannot be passed posterior to it.

while tr ying to remove it at home.

Cur ved Hook

Folley cathether
A curved or right-angle hook is excellent for
This is one of the most common

removal of non-graspable objects (beads,

methods used for nasal foreign bodies, and

pop-corn kernels), especially in the anterior

in our study was used almost as commonly

nares. The hook is first passed behind the

as alligator forceps. Depending on the size

object and the tip rotated to rest just behind

the foreign body. The hook is gradually

for round or cylindrical foreign bodies that

removed withdrawing the foreign body out

are occluding the nasal passage.

the nose. In the case of beads with holes

in them, the hook can be placed within the
hole and gently removed

When the bag-mask technique is used, the

patient is placed in a supine position and
restrained if needed. The contralateral nares

Suction (Schuknect Foreign Body Catheter)

As previously discussed in the ear foreign body section, a Schuknect suction
catheter is a metal suction catheter with a
plastic umbrella at the tip. The plastic
umbrella is placed against the object and
the suction applied. The object is removed
from the nose as the catheter is removed.
This technique works best for round, smooth
objects in the anterior nares. The suction
catheter does not work as well for posterior
nasal foreign bodies or foreign bodies that
are tightly lodged.
Nasal Positive-Pressure Technique (Bag-

is occluded with external pressure. An

anesthesia bag connected to high-flow
oxygen at 1015 liters per minute, with a
mask that covers only the mouth, is
allowed to expand with the thumbhole covered. If this pressure is not sufficient, the
bag may be compressed, expelling the
foreign body or at least moving the foreign body to a more anterior position
allowing for it to be grabbed by forceps.
Although there is a theoretical potential for
barotraumas to the tympanic membrane or
lower air way, a review of the literature
reveals no adverse side effects of this
procedure.

mask, Male-male Tube Adapter, Parents

Kiss)

The male-male tube adapter technique

works in the same way as the bag-mask

There have been multiple reports in the

technique except a male-male tube adapter

literature of using positive pressure to

hooked up to wall oxygen is place in the

remove a nasal foreign body. They all have

contralateral nares instead of a mask

the same concept, which is positive

covering the patient s mouth. Navitsky et

pressure being applied to the patients

al reported 9 patients who had a nasal

contralateral nostril or mouth. The pressure

foreign body successfully removed with this

will force the nasal foreign body out of the

technique.

affected nostril. This technique works best

A parents kiss technique works the

same way as the above mentioned
techniques. A parent is instructed to make a
firm seal with their mouth over the childs
open mouth, and then give a short, sharp
puff of air into the childs mouth. The
contralateral side of the nose is occluded
with a thumb. The nasal foreign body is
usually expelled or at least moved anterior
allowing for easier forceps removal. Botma
et al reported 15 of 19 patients who had a
nasal foreign body removed successfully
with this technique. There were no
complications in any of the patients, and all
parents thought the technique was acceptable
Nasal Wash
Lichenstein et al described 3 patients in
whom the nasal wash technique was used
successfully. They recommend filling a bulb
syringe with approximately 7 milliliters of
sterile normal saline and placing it in the
contralateral nostril. The bulb syringe is
forcibly squeezed and the object is
propelled out by the flow of saline back
through the nasal passage. This method
has many disadvantages. Forcibly irrigating
saline through the nose is uncomfortable
and carries a significant risk of aspiration.
This method of nasal foreign body removal
is not recommended, since there are many

less irritating and dangerous methods

available for removal.9
Most people have no long-term
consequences from having an object in their
nose. The prognosis may be affected by any
of the complications, however. The most
serious complication - choking - is rare but
can be life-threatening. For this reason,
trying to remove the object at home is not
recommended if such attempts may push the
object farther into the nose. 2
CASE REPORT
A 4 years old girl came to the
emergency department of Sardjito Hospital
with a chief complaint the insertion of bead
in the right nose. An hour before her mother
saw her playing with her toys and she didnt
realize that her daughter used her beads as
her toys. When she looked the beads spread
out on the floor and her daughter came to her
say that the bead was inserted inside her
nose her mother tried to pull it out. But after
some tries and failed she decided to go to
hospital. Obstruction of the right nose (+),
serous discharge (+), epistaksis (-), odorant
rhinorea (-). The patient had no fever. Ear
and throat complaints were denied
On physical examination found that the
general condition was good, compos mentis,

weight 9 kg, pulse 100x/ minute, respiratory

consistent findings in patients with a nasal

rate 23x/minute, temperature 36,7 Celcius

foreign body. Occasionally it can be

degree. On rhinoscopy anterior right nose

there was a bead foreign body in the upper
of inferior turbinate, hyperemic inferior
turbinate (+), mucous discharge (+), active
epistaksis (-), septum nasi intact and there

bloodstained. The ensuing unilateral

vestibulitis, specific of the paediatric age
group, is diagnostic sign.10 We have to
make sure the signs and symptomps of the

was no deviation. Left nose there was no

nasal foreign body, then the type of the

epistaksis, slight serous discharge (+), no

foreign body with the routine ENT

hyperemic turbinate, septum intact and

examination. So that we can determine the

deviation (-), The examination of

equipment and technique we need to remove

oropharyng and ear within normal limits.

the foreign body.11

Based on the anamnesis and physical

examination the patient was diagnosed with
nasal foreign body in the right nose.
Evacuation was done with curved hook and
it succeeded. The patient was given

In fact some foreign bodies have

reportedly been present in the nasal cavity
for years without symptoms. However
rarely, pain and headache have been

ibuprofen syrup to reduce the pain and as an

experienced on the involved side with

antiinflamation. Control to the ENT clinic

intermittent epistaxis and sneezing reported

was not necessary unless there was a sequel

by others. Cases describing bromhidrosis

complaint. The parents of the patient was

(foul body odour) associated with nasal

educated not to use a small object as her toys

foreign bodies in children have also been

and the patient had been told not to insert the

published. Several unilateral lesions found in

toy inside her nose, ear and mouth.

both children and adults may produce

DISCUSSION
Nasal foreign bodies are generally

obstruction of the involved side. Such

lesions would include both benign and
malignant tumours of the nasal cavity,

painless, that is why sometimes it is found in a

unilateral sinusitis, unilateral choanal

long period. A unilateral mucopurulent nasal

atresia, unilateral nasal polyps, septal

discharge with foul odour is the most

haematoma, and infections like syphilis and

diphtheria.1

In this patient, there was no mucopurulent

Rhinoscopy anterior for this patient

discharge and foul body odour, there was

visualized that there was a foreign body in

no fever because it was found in a very

the anterior of meatus nasi media so it could

early period. We didnt check for

be sured that she had a nasal foreign body

leucocytosis because it was not necessary

enough. The consistent finding about nasal
foreign body in this patient was a unilateral
vestibulitis with mucous discharge in
pediatric age group and there was seen a
foreign body in nasal cavity.
Any patient who presents with a unilateral
nasal discharge should raise the suspicion of
a nasal foreign body and in children this
must be regarded the case until proved
otherwise. The physical examination of the
nose involving anterior rhinoscopy and use
of either a fibreoptic nasopharyngoscope or
a 0 degree rigid endoscope will often

that need to be evacuated. Nasoendoscopy

was not needed since the foreign body could
be visualized clearly with rhinoscopy
anterior. She didnt need to be under general
anesthesia because she was quite cooperative
during the evacuation and the foreign body
was not difficult enough to evacuate
A cooperative patient is needed to detect
and remove a nasal foreign body
successfully. The patient is usually
examined in the upright sitting position
carried out for routine otorhinological
examination. A child may be best
examined by tilting the head back slightly

reveal the foreign object. However on

so that the floor of the nose is visible to the

occasions mucosal oedema or granulations

examiner. For this an adult may need to

tend to hide it. In such cases the nose should

restrain a child and hold the head steady.

be sprayed with a vasoconstrictor agent to

shrink the mucosa before reexamination.
Many times the foreign body becomes
apparent with this manoeuvre. In younger or

Most inanimate foreign bodies, if

visualized well, can be removed easily
through the anterior nares with the use of

very apprehensive children it may be

cupped forceps, haemostats, curved hooks,

necessary for the search to be carried out

old metallic eustachian tube catheters, and

under a general anaesthetic or sedation.2

suction. This can be done either with no

anaesthetic or after spraying with a local
topically acting anaesthetic solution such as

4% lignocaine (lidocaine). Removal of a

instructed to take a deep breath through the

rounded object may be an arduous task

mouth and then forcibly exhale through the

because of difficulty in grasping foreign

nose. The attending doctor should occlude

bodies of this shape. A curved hook is best

the uninvolved nostril during this procedure.

suited for this job. The hook is first passed

behind the object, the tip rotated to rest just
behind it and then the foreign body is
gradually drawn forwards and out through
the nose.
However, it cannot be too strongly
empha-sised that unskilled attempts to
remove the foreign body in accident and

If the patient is not able to cooperative with

this manoeuvre, forced mouth-to-mouth
ventilation can be administered to the
patient by the doctor, again occluding the
uninvolved side. Both the success rate and
the incidence of complications associated
with the above mentioned procedures are
not well reported in the literature
In rare cases, the only successful method

emergency departments by a person without

of removing a nasal foreign body is to

appropriate training may result in disaster.

push the object posteriorly into the

The foreign body may be displaced

pharynx. In these cases a general

backwards and may even reach the

anaesthetic is required and endotracheal

nasopharynx with a risk of inhalation. In a

intubation performed to protect the airway.5

crying child the foreign body whi le

For this patient, we didnt use

being removed from the nos e can

vasoconstictor to reduce the mucosal edema

fal l into the mou th with calamitous

and topical anesthetic because the foreign

effects. Marked epistaxis may occur or a

body had been clearly visualized and she

docile child may become terrified and

was calm enough during examination. The

require a general anaesthetic, which might

curved hook was used to be the first method

otherwise have been avoided.1

for a plastic solid object like bead in this

In cases in which removal of a foreign

body is particularly difficult, several
alternative procedures have been described.
If the patient can cooperate, they can be

patient. The hook was placed passing the

object and it was pulled slowly and gently.
There were no blood and laceration during
the evacuation so we didnt need to use
tampon to stop bleeding. For the

inflammation, ibuprofen syrup was given 3

the nose. The Journal of Emergency

times a day (dose @100 mg)

Medicine, 2016. Vol. 50, No. 3, pp.

SUMMARY

485487
5. A Kalan, M Tariq. Foreign bodies in
the nasal cavities: a comprehensive

Reported a 4 years old female patient

review of the aetiology, diagnostic

diagnosed with nasal foreign body in her

pointers, and therapeutic measures.

right nose. It had been removed completely

using curved hook and there was no
complication

Postgrad Med J 2000 76: 484-487

6. Howard Kadish, MD. Ear and Nose
Foreign Bodies.. Department of
Pediatrics, Division of Pediatric

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