Nasal foreign bodies: Results of a study of 260 cases

Pleasecitethisarticleinpressas: Abou-ElfadlM,etal.Nasalforeignbodies:Resultsofastudyof260cases.EuropeanAnnalsof Otorhinolaryngology,HeadandNeckdiseases(2015),http://dx.doi.org/10.1016/j.anorl.2015.08.006

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Original article

Nasal foreign bodies: Results of a study of 260 cases

M. Abou-Elfadl

, A. Horra , R.-L. Abada , M. Mahtar , M. Roubal , F. Kadiri

Serviced’ORLetdechirurgiecervico-faciale,hôpital20-Août,CHUIbnRochd,6,rueLahssenElaarjoun,Casablanca,Morocco

a r t i c l e i n f o

Keywords:

Nasalforeignbody Child

Vegetable Nasalobstruction Purulentrhinorrhea Buttoncell Perforation

a b s t r a c t

Aims:Insertionofaforeignbodyinthenasalcavityisaverycommonincidentinchildren.Itiseasily diagnosed,butthetypeofforeignbodyvariesandextractioncansometimesbedifficult,withriskof complications.ThepresentstudyreportsnasalforeignbodiesseeninemergencyinourENTdepartment, withanupdateonthestateofknowledge.

Materialsandmethods:AprospectivestudybetweenMayandAugust2011includedallpatientsadmitted totheENTemergencyunitfornasalforeignbody.Datacomprisedage,gender,circumstancesofdiscovery, symptoms,typeofforeignbody,extractionmethodandcomplications.

Results:Twohundredandsixtycasesofnasalforeignbodywereincluded,representing4.3%ofallconsul- tationsintheunit.Meanagewas3years(range:1–16years);thesexratiowas1.4(malepredominance).

Theincidentwasreportedbyafamilymemberortheactualchildin76.9%ofcases(n=199),ordiscovered followingnasalsymptomsin23.1%(n=61).Themaintypesofforeignbodywerenon-organicsynthetic beadsin18.8%ofcasesandvegetableformsin17.7%.Extractionwaseasy,usingforceps,micro-hooks orsuction,in91.53%ofcases.Complicationscomprisedinfection(n=48),epistaxis(n=18)andnasal septumperforation(n=1).

Conclusion:Nasalforeignbodiesareafrequentaccidentinmedicalpractice,especiallyinyoungchildren.

Theyaregenerallyharmless,butmayincurcomplicationsifoverlookedorwhenabuttoncellisinvolved, whencetheimportanceoftimelyextraction.Thebesttreatment,however,remainsprevention.

©2015ElsevierMassonSAS.Allrightsreserved.

1. Introduction

Nasalforeignbodiesarefrequentlyencountered,especiallyin children.Thecircumstancesareusuallyaccidental,withaforeign bodytrappedorincarceratedinoneorbothnasalcavitiesbythe anterior(vestibular)ormorerarelyposterior(choanal)route[1].

Positivediagnosisisofteneasy,butmaybedelayedbythecon- text,typeofforeignbodyornon-specificityofthesymptomatology.

Earlydiagnosiscanavoidpotentiallyseriouscomplicationsrelated tothenatureoftheforeignbodyitselfortochronicizationofthe resultantirritation,witharealriskofsuperinfection.

Thepresentstudyreportsepidemiological,clinicalandthera- peuticaspectsofnasalforeignbodiesinaseriesof26cases.

2. Materialsandmethods

AprospectivestudyperformedbetweenMayandAugust2011 intheENTemergencyunitofthe20-AoûtHospitalinCasablanca

∗ Correspondingauthor.

E-mailaddress:drabouelfadlm@hotmail.fr(M.Abou-Elfadl).

(Morocco) included 260 nasal foreign body patients, admitted throughoutthedayandnightandreceivingimmediatetreatment.

Studyvariablescomprisedage,gender,particularcontext,cir- cumstancesofdiscovery,symptoms,typeofforeignbody,means ofextractionandanycomplications.

3. Results

Sixthousandandforty-fivepatientsconsultedintheENTemer- gencyunitduringthe4-monthstudyperiod,including780cases ofENTforeignbody,locatedinthenasalfossae(260),ear(313)or esophagus(207).Nasalforeignbodiesaccountedor4.3%ofcon- sultationsandfor33.3%ofENTforeignbodies.Table1presentsthe distributionofENTforeignbodiesfortheperiodMay–August2011.

Medianagewas3years(range:12monthsto16years;mean:

3years).Fig.1showsdistributionbyagegroup.

Thesexratiowas1.4:58.8%maleand41.2%female.

Theincidentwasreportedbyafamilymemberortheactual childin76.9%ofcases(n=199),andordiscoveredfollowingnasal symptomsin23.1%(n=61).

Most of the children (74.6%, n=194) were asymptomaticat admission. In the other cases, symptoms comprised purulent http://dx.doi.org/10.1016/j.anorl.2015.08.006

1879-7296/©2015ElsevierMassonSAS.Allrightsreserved.

Pleasecitethisarticleinpressas:Abou-Elfadl M,etal.Nasalforeignbodies:Resultsofastudyof260cases.EuropeanAnnalsof Otorhinolaryngology,HeadandNeckdiseases(2015),http://dx.doi.org/10.1016/j.anorl.2015.08.006

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Table1

DistributionofforeignbodiesintheENTregion(May–August2011).

Typeofforeignbody Number Percentageoftotalnumberofforeignbodies Percentageoftotalnumberofconsultations

Nasalcavities 260 33.33 4.3

Ear 313 40.12 5.17

Esophagus 207 26.58 3.42

Total 780 100 100(6045)

0 10 20 30 40 50 60 70

<1 yr 1-2 yrs 2-3 yrs 3-4yrs 4-5 yrs 5-6 yrs 6-7 yrs 7-8 yrs 8-16 yrs Boys Girls

Fig.1.Numberofcasesaccordingtoageandgender.

rhinorrheaassociatedwithunpleasantnasalodorin18.46%ofcases (n=48)andepistaxisin6.9%(n=18).

Therewas1caseofDown’ssyndrome,ina16-year-oldchild, butnocasesofmentalretardation.

Examinationlocatestheforeignbody,whichcanbeidentifiedby pushingthetipofthenosebackwithafinger;otherwise,effective anteriorrhinoscopycanbeperformedusinganotoscope.

Theforeignbodyisusuallyfoundintheantero-inferiorpartof thecavity,trappedbytheinferiorturbinate.Morerarely,itmay befoundmoreposteriorlyorsuperiorly,pushedbackbyprevious attemptsatextraction.

In5cases,foreignbodiesofthesametypewerefoundinboth nasalcavities;therewas1caseofnasalandauricularforeignbodies.

Thepresentseriespredominantlyinvolvednon-organicforeign bodies(beadsin18.8%ofcases)andvegetabletypes.Buttoncells, whichareespeciallytoxic,wereimplicatedin0.76%ofcases.

Table2showsdistributionbytype.

NasopharyngealX-raywasperformedin5casesinvolvingfetid purulentrhinorrheainwhichtheincidentofintroductionofthe

Table2

Distributionaccordingtotypeofforeignbody.

Typeofforeignbody Number Percentage

Bead 49 18.8

Vegetable 46 17.7

Plastic 37 14.2

Sponge 36 13.8

Chalk 26 10

Paper 22 8.4

Cotton-wool 21 8.07

Metal 14 5.38

Stone 7 2.7

Buttoncell 2 0.76

foreign body wasunknown and anterior rhinoscopy was non- contributive.

ExtractionwasperformedintheENTemergencyunit.Thechild wasimmobilizedononeoftheparents’knees.Theforeignbodywas visualizedandthelocation,formandpresentationwereanalyzed, andextractionwasachievedusingmicro-instruments(forcepsor micro-hook)oraspirationin91.53%ofcases(n=238).The2cases ofbuttoncellswereextractedbymicroforceps.

Sedationandextractionusinga0^◦opticwasnecessaryin8.46%

ofcases(n=22),including1caseinvolvingabuttoncell.

Outcomewasfavorableinmostcases.In18cases(6.9%),there wasslightepistaxis,withspontaneousresolutionnotrequiringany packing.Therewas1caseofasymptomatic7-mmantero-inferior septalperforation,discoveredonextractionofabuttoncellby0^◦ endoscopyundersedation,notrequiringspecifictreatment.Local infectionintheformofpurulentrhinorrheawithfeveroccurred in48cases(18.46%),requiringtreatmentbynasalcavity lavage withphysiologicalsalineorlocalantisepticsassociatedto12days’

antibiotics(amoxicillin-clavulanicacid).Therewasnorecurrence.

4. Discussion

Thefewpublications onnasalforeignbodiesconcernlimited periodsrangingfrom6monthsto5years[1].In2010,Kharoubi reported700casesinAlgeria;in2004,Brownetal.reported138 cases;in2008,Gregorietal.publishedaEuropeanseriesof688 cases;and in2006,Figueiredoetal.reported420casesseenin pediatricemergency[2].

None of thesestudies estimatedthe frequency ofnasal for- eignbodieswithinthespecializedstructuresconcerned(pediatrics, ENT, emergency),except for the Algerian study,in which they accountedfor3.9%ofENTemergencyconsultationsand27.2%of

Pleasecitethisarticleinpressas: Abou-ElfadlM,etal.Nasalforeignbodies:Resultsofastudyof260cases.EuropeanAnnalsof Otorhinolaryngology,HeadandNeckdiseases(2015),http://dx.doi.org/10.1016/j.anorl.2015.08.006

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upper-airwayforeignbodiesovertheperiod1993–2003;analysis ofENTdistributionshowednasalforeignbodiesinsecondplace, with1313esophageallocations,700nasal,320auricularand240 bronchial:i.e.,1bronchialfor1.3auricular,3nasaland5esophageal foreignbodies.

Inthepresentseries,nasalforeignbodies accountedfor4.3%

ofENTemergencyconsultationsand33.3%ofENTforeignbodies;

onceagain,nasallocationswereinsecondplace:207esophageal, 260nasaland313auricularlocations:i.e.,1esophagealfor1.2nasal and1.5auricularforeignbodies(Table1).

Accidentsareoftendomestic,occurringduringagameormeal;

thetypeofobjectdependsonthosepresentinthechild’simmedi- ateenvironment[1,2].Only38%ofcasesoccurinthepresenceof anadult[3];otherwise,eitherthechildreportstheincidentspon- taneouslyorelsetheparentsdiscoveritinthecourseofwashing orprovidingothercare;inothercases,itisdiscoveredinciden- tallyduring explorationofa complication(purulentrhinorrhea, unpleasantodor,epistaxis,nasalobstructionornasaldiscomfort leadingtomouthbreathing).

Ageismostcommonlyaround3yearsinmoststudies;Kharoubi reportedameanageof4.3years[1].

Inthepresentseries,80%ofthechildrenwereagedbetween 2and5years,agesyoungerthan2andolderthan6yearsbeing unusual.Thisagedistributioncorrespondstopsychomotordevel- opment(prehension,thumb-indexopposition).

Thesexratioshowsmalepredominance(58.8%inthepresent series)inmostreports.

Thetypesofnasalforeignbodyarebroadlycomparablebetween reports,differencesbeingmainlyinproportions.

Inthepresentseries,18.8%weresyntheticbeads,withvegetable varieties(beans,sunflowerseeds,maize,fruitpips,peanuts,etc.)in secondplace.

Buttoncellswererelativelyrareinthepresentseries(0.76%), andtherewerenolivingforeignbodies.

In the literature, most nasal foreign bodies (NFB) are non- organiccompounds(NOC),whichaccountfor72–80%ofextracted objects[1,4].Themostfrequent NOCsareplasticbeadsor balls (9–31%),fragmentsofplasticoroftoys(9–18%),piecesoffoam- rubber (7–23%), pebbles or gravel (7–14%), paper (4–7%) and cotton-wool(2–10%).Organiccompounds(OC)arelessfrequent.

Lesionsinducedbynasalforeignbodiesvaryaccordingtothe typeofbodyandthedurationofitspresence:edemaofthemucosa ofthenasalcavity(irritation,inflammation) followedbysuper- infectionwith nasalsuppuration, mucosalbleeding (ulceration, hyperemia)andgranulationtissueformation(granulomatousfor- eignbodyreaction).

Buttoncells area special case, beingparticularlydangerous andabletocauseseriouslesions.Theintensityandtypeoflesion depends on thetype (size and chemical composition), number (1or more) and especially duration of presence of the battery cell(s).Mucosalulcerationisvirtuallysystematic;severelesions mayfollow:septalperforationbycartilage necrosis,necrosisof theinferiorturbinateandinferiormeatus,andvestibularrhinitis.

Button cells act via 3 mechanisms: mechanical pressure (con- tact withendonasal structures and pressure-induced necrosis), chemical(chemicalcomponentsofthecell)andelectrical(current betweenanodeandcathodecrossingtheendonasalstructures)[5].

Clinically,presentingsymptomsdependonthetypeanddura- tionofpresenceoftheforeignbodyandthecircumstancesofthe accident.Usually,someoneisawareoftheincidentandthechild isbroughtinconsultationfornasalforeignbody.Ifitisoverlooked orneglected,itinducessymptoms:recurrentunilateralrhinorrhea resistanttotreatment, cacosmia,epistaxis, nasal obstructionor facialpain.Morerarely,theremayberegionalinfection:sinusitis, orbitalcellulitis,nasalfuruncleorstaphylococcalinfectionofthe face[1].

Inothercases,discoveryisincidentaltoX-ray(dentalorfacial).

Inonecase,anasalforeignbodywasdetectedduringnasalintuba- tion[1].

Fornasalcavityexamination,thechildisimmobilizedononeof theparents’kneesandtheheadisheldinonehand.Alarge-caliber earspeculumisusedforendonasalexamination,visualizingthefor- eignbodyanddeterminingtypeandlocation.Itisusuallyfoundon thecavityfloor,againsttheseptum,behindtheheadoftheinferior turbinate.Depthinsidethecavitydependsontheobject’sform,vol- umeandtype(partialdegradationanddecomposition)andpossible associatedabnormalities(septaldeviation,chondro-vomeraldislo- cation,turbinatehypertrophy).Thesmallerandthinnertheforeign body,themoreposteriorthelocation.Mucopurulentsecretionsare oftenassociated,requiringaspiration.Examinationalsodetectsany locallesionssuchashemorrhagiculceration,nasalmucosalnecro- sisorseptalperforationbyoverlookedortoxic(e.g.,buttoncell) bodies.

Radiologicassessment isperformedifclinicalexaminationis difficultorinconclusive.

The nasal foreign body may be expelled spontaneously by sneezing, if not, certain complications are reported(in 9.5% of casesaccordingtoFigueiredoetal.):superinfection,facialcelluli- tis,vestibularrhinitis,recurrentepistaxis,septalperforationand inferiorturbinatenecrosis(buttoncell),sleepapnea,septicemia, tetanus,orrhinolithiasisbyaccumulationofcalciumsalts[4].

Nasalforeignbodies,whendiagnosed,mustbeextracted.Two categoriesoftechniquemaybedistinguished:non-instrumental andinstrumentalmaneuvers[2].

Theformershouldbeattemptedfirstwheneverpossible.Ifthe foreign body is visible inthe vestibule oris under theinferior turbinate,blowingthenosemaybeeffective,limitedonlybythe child’sageandacquisitionofthegesture.Inolderchildren,forced expirationwiththemouthclosedisequivalent.Positive-pressure techniquesareuseful,andunder-used:forthe“parent’skiss”,the childisseated,reassuredandtoldheorshewillbegettingabigkiss fromoneoftheparents:thefreenostrilisblockedandtheparent blowssuddenlyintothechild’smouth;thesuccessrateexceeds 60%,andthemaneuverisespeciallyeffectiveiftheforeignbody hasbeeninpositionforlessthan12hours[2].

InsufflationusinganAmbuWballoonhasbeenreported;coop- erationis,however,subjecttothechild’sacceptanceofthemask [6].Likewise,atubedelivering15l/minoxygentothefreenostril, withthemouthclosed,wasreportedtobeeffective[2].Theriskof positive-pressuretechniquesinducingbarotraumatothetympanic membraneexistsintheorybuthasnotbeenreported.

Therearenumerousinstrumentalmaneuvers,dependingonthe typeandformoftheforeignbody,thechild’scooperationandthe operator’sexperience.

Tomaximizethechancesofsuccess,itisimportanttovisualize theforeignbodyproperly;vasoconstrictorsandlocalanesthetics, ifnotcontraindicated,maybehelpful.Techniquesincludeuseof forcepsorhooks,cathetersorballoonprobes,aspiration,lavageor evenglue[7,8].

Forcepsandhooksareindicatedwhentheforeignbodyissolid andlocatedanteriorlyinthevestibule;theriskisofbreakingup crumblybodies,leaving somebehindoreven allowingthem to migrate,withriskofinhalation.Hookedinstrumentsmaydamage themucosa,leadingtoepistaxis[7].Balloonprobesorcatheters (FoleyNo. 5,6 or8 or Fogarty)aresuitable forsmooth, round bodies.Theinstrument islubricatedandintroducedinthenos- trilbeyondtheforeignbody;oncetheballoonhasbeeninflated, theprobeisgentlywithdrawn,andtheforeignbodywithit[7,8].

Adjustingballoonvolumecanhelpinmobilizingtheforeignbody [7].Complicationsarerare,oftenlimitedtoepistaxis.Aspiration isrecommendedforlarge,smooth,roundbodies,wherethesur- faceswillprovideradherence,theonlyriskbeingofpushingthe

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foreignbodyfurtherbackbyfaultymaneuver[7,8].Lavagewith physiologicalsalineisapossibilityforcrumblybodies,butisstrictly contraindicatedforbuttoncells,duetotheriskofelectrolysis,and inyoungchildren,duetotheriskofinhalationorrefluxofnasal secretionstowardtheEustachiantubeandsinuses[7].Cyanoacry- lateglue,asusedinskinsuture,hasbeenreported[7,8]:itisapplied tothetipofaplasticstemwhichiscarefullyintroducedinthenos- trilandheldincontactwiththeobjectforabout1minutebefore beingwithdrawn.

Livingnasalforeignbodies(larvae,wormsorinsects)should beanesthetizedahead ofextraction[7],usingsalinesolutionor xylocainespray;thelatterbothparalyzesthecreatureandprovides localanesthesia.

Indifficultcases,generalanesthesiaunderintubationorseda- tionmaybeperformedformicroscopyandendonasalendoscopy.

Antibiotherapy using amoxicillin-clavulanic acid at 80–90mg/kg/dayfor8–10daysandlocaltreatmentareindicated forcomplicatedcasesandbuttoncells.

5. Conclusion

Nasalforeignbodiesareanaccidentfrequentlyencounteredin medicalpractice,especiallyinyoungchildren(2–4yearsofage).

Theyarisefromthechild’sinteractionwiththeenvironment.The accidentis generally knowntothefamily, sothat treatmentis notdelayedandsequelaeandcomplicationsareminimized.Some

cases, however, are serious and require emergency extraction.

Extractiontechniquesvarywiththekindofobject.Thecontralat- eralcavityandtheearsshouldalsoalwaysbeexamined.Thebest treatmentremainsprevention.

Disclosureofinterest

Theauthorsdeclarethattheyhavenoconflictsofinterestcon- cerningthisarticle.

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