# Foreign Body Removal- Nose

## Overview

This module describes how to remove a foreign object from the nose.

## Indications

1. Confirmed or

   suspected foreign body
   suspected foreign body

   Strongly suspect in cases of unilateral malodorous discharge and/or epistaxis from a child's nose.

   in the nasal fossa

2. Button batteries
   Button batteries

   These objects can cause tissue necrosis and septal perforation within hours. Attempt removal only if feasible and if no help available within reasonable time; otherwise refer emergently to ENT for removal in theatre. Delayed referral may result in septal perforations or stenosis of the nasal vestibule.

   require urgent referral to ENT

## Contraindications

1. Risk of dislodgement of foreign body into the airway

2. Uncooperative, unsedated patient

3. Poor visibility of the foreign body or posterior displacement of the object

4. Several unsuccessful attempts at removal

5. Underlying or suspected tumour or mass

6. Presence of oedema, bony destruction, granulation tissue from chronic foreign body

## Patient information & consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“There is a foreign object stuck in the nose and I need to remove it, because it can cause infection, damage to the tissues in your nose, and bleeding.”

### What can my patient expect?

“Depending on what the object is I will either try to grab it or hook it out with an instrument. This will be uncomfortable and can even cause your nose to bleed a little bit, but it will not be painful.”

### What is my patient’s role?

“Describe exactly what the object is, as this will help me know how to remove it. Please try to remain very still during this procedure.”

## Preparation

You may use

0.5% phenylephrine

0.5% phenylephrine

Do not use in the case of a button battery as it may increase the leakage of acids.

(Neo-Synephrine) to reduce mucosal oedema.

### Documentation

1. Patient notes

### Equipment

The type of equipment will vary depending on the type of foreign body.

1. Alcohol-based hand rub

2. A light source: head light, torch or otoscope with a large speculum

3. Fine toothed forceps such as a crocodile or Tilley’s forceps

4. Suction catheter and blade or scissors

5. Lubricant jelly

## Site & Positioning

The site of foreign body impaction in the nose is between the inferior turbinate and the septum. The best way to remove hard objects is with a Jobson-Horn probe. Soft objects are best grasped using Tilley’s forceps or crocodile forceps.

For small children, let an assistant or parent hold the child. Wrap the child in a sheet and sit them upright, facing you on the parent’s lap with the child’s legs restrained by the parent’s crossed legs. The parent holds the child’s body with one arm, and the child’s forehead with the other. Rest the back of the child’s head against the parent’s body.

## Procedure

Follow medical asepsis with non-sterile gloves.

1. Perform hand hygiene and don gloves.

2. Examine the nasal passages to confirm a visible foreign body.

3. Suction away any secretions.

4. Blowing: ask the patient to blow their nose while closing the opposite nostril.

5. Ask the parent or caregiver to cover the child’s mouth with their lips and blow inside until they feel resistance caused by the closed glottis, then to blow again forcefully to expel the foreign body.

6. Grasping: grasp

   soft foreign objects
   soft foreign objects

   such as paper, sponge, food or cloth. Animate objects include worms and maggots. If the object is solid do not try and grasp it as it may slide deeper into the nasal cavity.

   with forceps and remove it.

7. Suctioning: gentle wall suction can be used to remove the object. Cut a large rubber catheter at right angles to the tip and lubricate the tip. Pinch the catheter closed until the tip is near the foreign body.

8. Other methods, such as using curved-tip probes or Foley’s catheters inserted past the object, risk trauma to the nose and displacing the object upwards towards the base of the skull, and are not recommended for inexperienced practitioners.

9. Re-examine the nose to confirm removal of all foreign bodies.

10. Dispose of medical waste safely.

11. Record completion of the procedure in patient notes.

## Troubleshooting

I am unable to remove the object

Re-examine the nose and, if the foreign body is still visible, try again. Try a third time before referral to a specialist.

The patient is too uncooperative and I want to sedate them.

Sedation is discouraged, as this reduces the gag and cough reflexes as airway protection.

I would like to try the suction technique, but I do not have wall suction.

You can use the bulb from a sphygmomanometer or the bulb from a pneumatic otoscope to provide suction.

## Risks

1. Nasal septal perforation

2. Button battery — delayed referral may lead to tissue necrosis

3. Aspiration of foreign body

4. Epistaxis

5. Nasovagal response/respiratory arrest

6. Healthcare worker exposure to infectious substances

## References

1. Baranowski K, Mahmoud S.Nasal foreign body. [Updated 2021 July 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459279/

2. Heim S, Maughan K. Foreign bodies in the ear, nose and throat. Am Fam Physician. 2007 Oct 15;76(8):1185-1189. Available from: https://www.aafp.org/afp/2007/1015/p1185.html

3. Prescott CAJ. Practical skills in ENT. In: Handbook of ENT: Diseases and Disorders of the Ear, Nose and Throat. 4th ed. Southern Africa: Oxford University Press; 2009: 193-195

4. Kenny P. How to remove a foerign body from the nose In: Mash B, Blitz-Lindeque J, eds. South African Family Practice Manual. 2nd ed. Pretoria: Van Schaik Publishers; 2010:140.

5. Reichman EF (Ed.). Chapter 169. nasal foreign body removal. In: Emergency Medicine Procedures, 2e. McGraw Hill; 2013. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683§ionid=45343817