Preparation

All procedures
• Gloves (non-sterile)
• Nasal speculum (if available)
• Light source

Mechanical extraction
• Bayonet forceps or cerumen curette
• Vasoconstrictor (e.g., oxymetazoline)
•12 Fr Foley catheter

Glue
• Cyanoacrylate glue (e.g., dermabond)
• Cotton-tipped applicator or paper clip

Procedure Steps

Step 1: Health history and physical assessment

Health history

• Children presenting with unilateral nasal discharge with a foul odor should be assumed to have a nasal foreign body until proven otherwise.
• Assess for pain, discharge, visible foreign body, anxiety.

Physical assessment

• Visualization of foreign body with nasal speculum and/or light source.
• A topical vasoconstrictor (ex: oxymetazoline) can help dry the nares of blood and/or mucus to allow for better inspection/examination of the nasal cavity.
• A topical anesthetic (e.g., lidocaine) may assist in patient comfort and cooperation.

Step 2: Position the patient

Position the patient supine or in a position of comfort.

Step 3: Determine the technique to be used

Considerations:
• The nature of the foreign body should help guide the decision regarding the chosen technique.
• Choose a technique that will most likely allow successful removal of the foreign body on the first attempt.
• A foreign body that might break into smaller pieces with the use of forceps may be better removed with using a positive pressure technique, glue, or a catheter.

Positive Pressure Technique

This is most effective for cooperative patients, typically over the age of 3 years. Instruct patient to occlude unaffected nostril and blow nose to dislodge foreign body.

The “parent’s kiss” technique is useful for infants and toddlers.
• Position patient supine
• Have caregiver occlude unaffected nostril
• Instruct caregiver to blow forcefully into the patient’s mouth to dislodge foreign body from nostril.

Mechanical Extraction

• Position patient for comfort.
• Re-examine nose with otoscope/nasal speculum to confirm presence and position of foreign body.
• Gently and slowly insert the curette or forceps.
• Soft objects or those with protruding surfaces/irregular edges can be removed using the alligator or bayonet forceps.
• Objects that are round or breakable, insert cerumen curette just past foreign body then carefully withdraw.

Catheter Technique

• Apply vasoconstrictor; consider topical anesthetic as needed.
• Using a 12 Fr catheter, insert the tip into the naris past the foreign body
• Slowly inflate the balloon using approximately 2 mL of air or water
• Gently and slowly withdraw the catheter with the balloon inflated to pull the object out of the nose.

Glue

• Apply a small amount of glue to the blunt end of the cotton-tipped handle applicator or the tip of the unfolded paper clip.
• Gently and slowly touch the tip with glue to the object (some glues may take 60 seconds to adhere to the object).
• Pull object out of the nose.

Step 4: Re-examine naris

Ensure all objects have been removed.

Step 5: Control epistaxis if present

See chapter titled “Epistaxis Management” for full procedure.

Aftercare

• Teach patients not to put anything in the ears or nose.
• Do not put anything smaller than your elbow in your ear (including cotton-tipped applicators).
• Acetaminophen or ibuprofen can be taken every 4-6 hours for pain.

Patient Education

Follow-up

• Monitor for signs and symptoms of infection and seek follow-up care if present:
  • increase in pain
  • drainage
  • foul odour
  • increase in temperature

Key Takeaways

• Cooperation and immobilization of the patient are key to successful removal.
• Removal of the foreign body is necessary, but cannot always be achieved in a primary care setting; referral to an otolaryngologist may be required.
• Presence of foul-smelling nasal discharge in an infant/toddler suggests presence of a foreign body and must be considered this until proven otherwise.