A Tool in Nasal Foreign Body Removal in Pediatric Patients

Melanie Johnston, PGY2 iFMEM Dalhousie University Saint John

Reviewed by Dr. Mandy Peach

 

Introduction:

The highest incidence of nasal foreign bodies is in pediatric patients, ages 2-5.¹ The removal of nasal foreign bodies in the emergency department can be challenging.

The most common objects removed are beads, nuts, chalk, eraser heads, pebbles, and other small objects.^1,2 While most nasal foreign bodies are benign, some objects can cause severe damage and need to be urgently removed.

The diagnosis of nasal foreign may be obvious as the caregiver may have witnessed the event and present acutely. Others may have delayed presentations of weeks-months after the child develops symptoms of nasal irritation/infection from the retained foreign body. In general, organic foreign bodies (flowers, plants, bugs) tend to be more irritating to the nasal mucosa and cause symptoms much earlier.²

 

Details on history and physical exam findings that should raise suspicion of a potential nasal foreign body in a paediatric patient include:

• Witnessed insertion of foreign body
• Unilateral foul-smelling purulent discharge
• Mucosal erosions/ulceration

• Unilateral epistaxis

• Headache focused on the same side as the foreign body
• Nasal obstruction
• Mouth breathing²

 

Nasal foreign bodies have the potential to dislodge posteriorly and aspirate.¹ Consider aspirated FB if new wheeze/cough/shortness of breath in a child with suspected intranasal FB and be prepared for a precipitous change in the airway. ⁶ 

 

Nasal foreign bodies are most commonly located on the floor of the nasal passage under the inferior turbinate, or superiorly  in front of the middle turbinate.²

Foreign bodies are most frequently located on the right side, due to the right handed dominance of most children.²

Figure 1. Anatomy of the nose.³

 

Examination:

Ensure good lighting to be able to visualize the canal. Place the patient in a sniffing position with caregiver assistance (they may have to firmly hold child for cooperation). Suction should be readily available for nasal discharge and to aid in visualization. Nasal speculum can be used to aid visualization of the canal. Visualization of the foreign body confirms the diagnosis.

 

Figure 2. Marble nasal foreign body in pediatric patient.⁴

 

ENT referral is warranted if:

– Foreign body suspected, but unable to visualize by anterior rhinoscopy
– Impacted foreign body with marked inflammation (eg button batteries)
– Penetrating foreign body
– Any foreign body that cannot be removed due to poor cooperation, bleeding, or limited instrumentation²

 

Foreign Body Removal Options:

There are a number of techniques for nasal foreign body removal in the Emergency Department: alligator forceps, suction, balloon catheters, cyanoacrylate glue.² Depending on the patient, these methods can be technically challenging if the patient is uncooperative, and may require the use of procedural sedation. A less invasive alternative for children not willing to cooperate with manipulation in the nasal canal is the Mothers’ Kiss.

 

Mothers’ Kiss Technique:

This technique was first described in the 1960s by a general practitioner in New Jersey and uses positive pressure to mobilize the foreign body from the nasal passage.¹ It is effective in approximately 60% of attempts⁵, and generally most effective for smooth/soft foreign bodies that totally occlude the anterior nasal cavity.² Even when not successful, it may improve visibility of the foreign body. Theoretical risks include barotrauma to both the tympanic membranes or pneumothorax, but these complications have never been reported.⁵ The pressure used by the caregiver to attempt expulsion of the foreign body is equivalent to that of a sneeze, approximately 60mmHg.¹ The main danger in removing a foreign body from the nose is the risk of aspiration.

Procedure:⁵
1) Instruct the caregiver to place their mouth over the childs’ open mouth, forming a firm seal (similar to mouth-to-mouth resuscitation).
2) Next, occlude the unaffected nostril with a finger
3) The caregiver should blow until they feel resistance (caused by the closure of the childs’ glottis), then they should deliver a short puff of air into the childs’ mouth
4) The puff of air travels through the nasopharynx, and if successful results in the expulsion of the foreign body
5) If unsuccessful, the procedure can be repeated a number of times

Figure 3: Caregiver performing “Mother’s Kiss”. Shows occlusion of unaffected nare,
with seal formed around childs’ mouth.

 

 

If the caregiver is unable to perform the procedure, the approach can be recreated with a bag-valve-mask as the positive pressure source, ensuring the mask covers only the childs’ mouth.

Figure 4: Positive Pressure Ventilation with Bag-Valve-Mask.⁶

 

 

For a visual review of these techniques, please refer to the following videos:

“Mother’s Kiss”

 Positive Pressure Ventilation

 

Bottom Line:

Nasal foreign bodies are a common occurrence in the paediatric population. Their removal in the Emergency Department can be challenging as the patient may be fearful and non-cooperative. While there are a number of methods for removal of nasal foreign bodies, the “Mothers’ Kiss” technique provides a relatively non-invasive alternative. It has been shown to be effective in removal of 60% of nasal foreign bodies, and is most effective if foreign bodies are smooth and located in the anterior nasal cavity. If the caregiver is unable to perform the procedure, the approach can be recreated with BVM as the positive pressure source. The risks of this technique are minimal, and even when unsuccessful, can assist in improving the visualization of the nasal foreign body.

 

References:

1. Cook, S., Burton, M., & Glasziou, P. (2012). Efficacy and safety of the “mother’s kiss” technique: a systematic review of case reports and case series. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 184(17), E904–E912. https://doi.org/10.1503/cmaj.111864

2. Isaacson, G., Ojo, A. (2020). Diagnosis and management of intranasal foreign bodies. Up to Date. Retrieved from https://www.uptodate.com/contents/diagnosis-and-management-of-intranasal-foreign-bodies.

3. Le, P. (2020). Anatomy, Head and Neck, Nasal Concha. Retrieved from: https://www.statpearls.com/ArticleLibrary/viewarticle/32550

4. Nose-Foreign Body Nose, Dr Vaishali Sangole. Retrieved Oct 31,2020 from: http://vaishalisangole.com/NOSE_Foreign.html

5. Glasziou, P., Bennett, J. (2013). Mothers’ kiss for nasal foreign bodies. Australian Family Physician, 42(5): https://www.racgp.org.au/afp/2013/may/mothers-kiss/.

6. Thoreckzo. (2017). Foreign Bodies in the Head and Neck. Pediatric Emergency Playbook. Retrieved from: https://pemplaybook.org/podcast/foreign-bodies-in-the-head-and-neck/

7. Pretel, M. Removing object from child’s nose using the kiss technique. Youtube- retrieved from: https://www.youtube.com/watch?v=RR3SxICqdAY.

8. Dudas, R. Nasal foreign body removal. Youtube- retrieved from: https://www.youtube.com/watch?v=PacvHiJFhNA.