Acquired Disorders of the Nose

Keywords

• foreign body

• bromhidrosis

• mother's kiss

• Katz catheter

• disk batteries

• magnet

Etiology

Foreign bodies (food, beads, crayons, small toys, erasers, paper wads, buttons, batteries, beans, stones, pieces of sponge, and other small objects) are often placed in the nose by young or developmentally delayed children and constitute ≤1% of pediatric emergency department visits. Nasal foreign bodies can go unrecognized for long periods of time because they initially produce few symptoms and are difficult to visualize. First symptoms include unilateral obstruction, sneezing, relatively mild discomfort, and, rarely, pain. Presenting clinical symptoms include history of insertion of foreign bodies (86%), mucopurulent nasal discharge (24%), foul nasal odor (9%), epistaxis (6%), nasal obstruction (3%), and mouth breathing (2%). Irrigation results in mucosal swelling because some foreign bodies are hygroscopic and increase in size as water is absorbed; signs of local obstruction and discomfort can increase with time. The patient might also present with a generalized body odor known as bromhidrosis.

Diagnosis

Unilateral nasal discharge and obstruction should suggest the presence of a foreign body, which can often be seen on examination with a nasal speculum or wide otoscope placed in the nose. Purulent secretions may have to be cleared so that the foreign object can actually be seen; a headlight, suction, and topical decongestants are often needed. The object is usually situated anteriorly, but unskilled attempts at removal can force the object deeper into the nose. A long-standing foreign body can become embedded in granulation tissue or mucosa and appear as a nasal mass. A lateral skull radiograph assists in diagnosis if the foreign body is metallic or radiopaque or if foreign body is suspected but physical exam with sinus endoscopy or anterior rhinoscopy is negative.

Treatment

An initial examination of the nose is made to determine if a foreign body is present and whether it needs to be removed emergently. Planning is then made for office or operating room extrication of the foreign body. Prompt removal minimizes the danger of aspiration and local tissue necrosis, and this can usually be performed with the aid of topical anesthesia, with forceps or nasal suction. Common noninvasive techniques include simple nose blowing and the “mother's kiss” technique. The “mother's kiss” approach has been successful in acute situations where a person occludes the unaffected nostril and then, with a complete seal over the child's mouth, attempts to dislodge the foreign body by blowing into the mouth. A similar approach uses an Ambu bag over the mouth with the unaffected nostril occluded. Other noninvasive options include blowing air into a drinking straw in a child's mouth and applying high flow oxygen (10-15 L/min) to the unaffected nostril. Alternatively, a Katz catheter (made specifically for the removal of foreign bodies from the nose and ear) can be inserted above and distal to the object, inflated, and drawn back with gentle traction. If there is marked swelling, bleeding, or tissue overgrowth, general anesthesia may be needed to remove the object. Infection usually clears promptly after the removal of the object, and generally no further therapy is necessary. Magnets can be used to extract metal foreign bodies, 2% lidocaine can be used to kill live insects before removal, and irrigation should be avoided with vegetable matter or sponges because of the risk of foreign body swelling. Age (>5) and disk-shaped foreign body are predictors for operating room removal of foreign body.