PEPO-454; No.

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pediatria polska xxx (2016) xxx–xxx

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Case report/Kazuistyka

An unusual complication of nasal foreign body in

a pediatric patient: A case report

Santosh Kumar Swain 1,*, Mahesh Chandra Sahu 2

1
Department of Otorhinolaryngology, Institute of Medical Sciences and SUM Hospital, Siksha “O” Anusandhan
University, Odisha, India
2
Directorate of Medical Research, Institute of Medical Sciences and SUM Hospital, Siksha “O” Anusandhan University,
Odisha, India

article info abstract

Article history: Foreign body (FB) of nasal cavity is a common clinical incidence in Pediatric Otorhinola-
Received: 11.08.2016 ryngology. Inferior meatus is a rare location for FB lodgment inside the nasal cavity. In
Accepted: 23.08.2016 case of nasal FB, patients usually present with nasal obstruction, foul smell discharge
Available online: xxx and epistaxis. FB at the inferior meatus blocking the nasolacrimal outflow is an extre-
mely rare complication of nasal FB leading to dacryocystitis. X-ray skull will help to rule
Keywords: out the radio-opaque FB in the nasal cavity. Diagnostic nasal endoscopy will help for
 Inferior meatus accurate diagnosis of nasal FB. Early diagnosis and safe removal of FB from nasal cavity
 Foreign body help to reduce complications. We present an unusual case of nasal FB in a 10-year-old
 Chronic dacryocystitis boy presented with chronic dacryocystitis. Chronic dacryocystitis is an extremely rare
presentation due to FB of nasal cavity.
© 2016 Polish Pediatric Society. Published by Elsevier Sp. z o.o. All rights reserved.

with pressure necrosis. This leads to ulceration with granu-

Introduction
Foreign body (FB) in nasal cavity is a common incidence
seen in outpatient department of Pediatric Otorhinolaryngo-
logy [1]. FB in nasal cavity may complicate with epistaxis
and bronchoaspiration. Sometimes nasal FB shows no
symptoms for weeks or months. Metallic FBs as comparison
to vegetable ones are inert and minimally reacting [2]. Inert
FB at nasal cavity may not cause any damage to the
surrounding structures if kept for long time without distur-
bance. They sometimes present with local inflammation
lation formation. The edema surrounding the FB may cause
obstruction of nasolacrimal duct opening at the inferior
meatus leading dacryocystitis. But dacryocystitis is an
extremely rare incidence seen with FB of nasal cavity. FB at
inferior meatus of nasal cavity blocking nasolacrimal duct
outflow resulting in chronic dacryocystitis is our first case at
our tertiary care teaching hospital. Dacryocystitis is the
inflammation of the lacrimal sac. The most common cause
for dacryocystitis is the blockage of the nasolacrimal duct
leading to inflammation of the sac. It can be acute, chronic
or congenital. Longstanding or recurrent infection of the

* Corresponding author at: Department of Otorhinolaryngology, IMS&SUM Hospital, Kalinga Nagar, Bhubaneswar 3, Odisha, India.
Tel.: +91 9556524887.
E-mail address: santoshvoltaire@yahoo.co.in (S.K. Swain).
http://dx.doi.org/10.1016/j.pepo.2016.08.017
0031-3939/© 2016 Polish Pediatric Society. Published by Elsevier Sp. z o.o. All rights reserved.

Please cite this article in press as: Swain SK, Sahu MC. An unusual complication of nasal foreign body in a pediatric patient: A case report.
Pediatr Pol. (2016), http://dx.doi.org/10.1016/j.pepo.2016.08.017
PEPO-454; No. of Pages 3
2 pediatria polska xxx (2016) xxx–xxx
lacrimal sac is called as chronic dacryocystitis. The basic
etiology of dacryocystitis is the blockage of nasolacrimal
duct which is an integral part of the lacrimal system helping
drainage of the tear into the nasal cavity. The infection in
lacrimal sac may occur due to spread of infection from
mucosal lining of the nose and sinuses. In majority cases,
the cause of inflammation appears to be primarily of the
lacrimal system. FB in the nasal cavity causing dacryocys-
titis is an extremely rare one and hardly described in
medical literature. After confirmation of FB at the nasal
cavity, it should be removed immediately. The methods for
removal of FB depend on its position inside the nasal cavity,
type of FB and the cooperation of the patient [3]. Here we
are presenting an interesting and rare case of chronic
dacryocystitis due to long standing FB at inferior meatus of
nasal cavity obstructing the nasolcarimal duct outflow.
Case report
A 10-year-old boy presented to the outpatient department of
Otorhinolaryngology with complaints of unilateral watering
from left eye since six months. He was diagnosed as left
side chronic dacryocystitis. Anterior rhinoscopy showed left
inferior turbinate hypertrophy. On pressing over the lacrimal
sac, there was regurgitation of mucopurulent discharge from
both puncta. He was taking treatment from ophthalmologist
since 6 months. After repeated session of syringing, he
showed little improvement. He had no complaints of epis-
taxis, rhinorrhea and nasal obstruction. Diagnostic nasal
endoscopy revealed a gritty sensation foreign body inside
the middle third of inferior meatus (Fig. 1). X-ray of skull
showed a radio-opaque foreign body in the left nasal cavity
(Fig. 2). Patient was posted for endoscopic removal of FB
from inferior meatus under general anesthesia (GA). After
removal of foreign body which was a small metallic button,
child relieved from epiphora. He was kept on regular follow-
up for six months. There was no evidence of recurrence.
Fig. 1 – Endoscopic picture showing metallic foreign body at
the inferior meatus
Please cite this article in press as: Swain SK, Sahu MC. An unusual complication of nasal foreign body in a pediatric patient: A case report.
Pediatr Pol. (2016), http://dx.doi.org/10.1016/j.pepo.2016.08.017
Fig. 2 – Skull X-ray of child showing foreign body at the left
side of nasal cavity
Discussion
Nasolacrimal duct is an integral part of the lacrimal system
and responsible for transport of tear from the ocular surface
to the inferior meatus. Patent lacrimal sac and nasolacrimal
duct are essential for the proper flow of tear to the nasal
cavity. Chronic dacryocystitis is the inflammation of the
lacrimal sac. The highest risk factor for development of
dacryocystitis is the obstruction of nasolacrimal duct. Nasal
pathologies have a crucial role in developing dacryocystitis.
Common nasal abnormalities like deviated nasal septum,
inferior turbinate hypertrophy and rhinitis are associated
with same side of lacrimal sac infection. FB of nasal cavity
as in our case is an extremely rare incidence causing
nasolacrimal duct outflow obstruction, leading to chronic
dacryocystitis. FB at nasal cavity is a common clinical entity
in pediatric age group. Unilateral purulent nasal discharge
with foul odor in a child is highly suggestive of a FB in the
nose, until proven to the contrary. The presence of FB at the
nasal cavity may not be a life threatening situation but may
cause morbidity. FB in nasal cavity usually presents with
nasal bleeding and nasal obstruction. History of FB insertion
is an important for Otorhinolaryngologist and pediatrician
and it should not be overlooked. FB body in the nasal cavity
may be inorganic or organic often seen in children. Inorga-
nic FB of nasal cavity is usually plastic [4] such as buttons,
beads or stones, paper or small part of toys. In our case
there was small metallic button FB present at the inferior
meatus of nasal cavity. They are usually asymptomatic and
discovered incidentally whereas organic FB produces early
symptoms as they are more irritants to nasal mucosa.
Organic FB tends to swell rapidly and usually symptomatic
than nonorganic ones. In our case the FB was small metallic
button sitting at the middle third of inferior meatus without
any reaction to surrounding mucosa. The causes for FB
insertion into nasal cavity among children have been
attributed to the curiosity or playful attitude toward the FBs.
In adults, FB in nasal cavity is rarely seen, except in
psychiatric disorders. The FB can be found in any area of
the nasal cavity, although they are more predictable below
the inferior turbinate, due to inferior turbinate extension or
just anterior to the middle turbinate. Nasal FB is confirmed
by direct examination of nasal cavity [5]. Complications of
PEPO-454; No. of Pages 3
pediatria polska xxx (2016) xxx–xxx
nasal FB occur due to FB itself or due to repeated attempt
during its removal. The diagnosis is usually made on the
basis of patient’s history i.e. recurrent infections of the
lacrimal sac and intermittent or permanent epiphora. Diag-
nostic techniques include catheterization and irrigation of
the lacrimal duct. In few selected cases, Jone’s dye test and
dacryocystogram are used for confirmation of nasolacrimal
obstruction [6]. Sometimes the diagnosis of nasal FBs is not
easy and conclusive due to the obscure nature of FB, so it is
not visible by simple anterior rhinoscopy. When in doubt,
the nasal FBs are seen by rigid or flexible nasal endoscopy
[7]. Chronic dacryocystitis is seen in 2–3% cases of nasolacri-
mal duct obstruction [8]. Common causes of nasolacrimal
obstruction are idiopathic (59.2%), congenital (29.6%), iatro-
genic (4.5%) and secondary to radiotherapy (3.7%) [9]. FB in
the nasal cavity causing dacryocystitis is an extremely rare
incidence. It is hardly found to be reported in literature.
During FB removal, repeated attempt results in potential
movement of the object into a less favorable location. There
are number of factors associated with successful outcome
for FB removal. These factors are duration of FB stay in the
nasal cavity, characteristic of FB (size, shape and texture),
patient co-operation during FB removal, trauma due to
previous attempt, visibility of FB and surrounding structu-
res, available equipments and skill of attempting person [1].
The treatment is removal of intranasal FB without doing
surgery like DCR.
Conclusion
Exogenous FBs in the nasal cavity are not uncommon
particularly in children. Children that are not getting proper
individual attention at an early age are more prone to insert
FB inside the nasal cavity. FB of the nasal cavity particularly
at inferior meatus blocks the nasolacrimal opening and
leads to dacryocystitis. All patients of chronic of acute
dacryocystitis should undergo detail examination of nasal
cavity to rule out any pathology causing nasolacrimal duct
obstruction. The chronic dacryocystitis can be relieved by
treating the intranasal pathology without the need of
surgery like dacryocystorhinostomy (DCR). To prevent com-
plications of nasal foreign bodies, timely referral and remo-
val of foreign body is essential.
Authors’ contributions/Wkład autorów
SKS – study design, data collection and interpretation,
statistical analysis, acceptance of final manuscript version.
MCS – data interpretation, acceptance of final manuscript
version, literature search.
Please cite this article in press as: Swain SK, Sahu MC. An unusual complication of nasal foreign body in a pediatric patient: A case report.
Pediatr Pol. (2016), http://dx.doi.org/10.1016/j.pepo.2016.08.017
3
Conflict of interest/Konflikt interesu
None declared.
Financial support/Finansowanie
None declared.
Ethics/Etyka
The work described in this article have been carried out in
accordance with The Code of Ethics of the World Medical
Association (Declaration of Helsinki) for experiments invol-
ving humans; EU Directive 2010/63/EU for animal experi-
ments; Uniform Requirements for manuscripts submitted to
Biomedical journals.
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