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Referral and warning signs
When to refer
Refer to ENT Specialist/Hospital if: Unable to visualize or remove the foreign body safely. Object is posterior or impacted. Button battery suspected (URGENT removal needed due to necrosis/perforation risk). Uncooperative child requiring sedation/anaesthesia. Significant bleeding or trauma during removal attempts.
Red flags
- Suspected button battery (requires immediate removal).
- Significant epistaxis.
- Signs of aspiration (sudden cough, wheeze).
- Evidence of significant local trauma or septal damage.
Signs and symptoms
- History of insertion (witnessed or suspected).
- Unilateral foul-smelling nasal discharge (often bloody or purulent) - Key sign if history unclear.
- Unilateral nasal obstruction.
- Nasal irritation, sneezing.
- Epistaxis (nosebleed).
- Pain.
- Foreign body may be visible on anterior rhinoscopy.
Risk factors
- Young children (toddlers, preschoolers).
- Intellectual disability.
- Psychiatric conditions.
Diagnosis
Clinical assessment
Diagnosis usually based on history and visualization of the foreign body using a nasal speculum and good light source. Unilateral foul discharge is highly suggestive.
Investigations
- Anterior Rhinoscopy (visualization with nasal speculum).
- X-ray: Only useful for radio-opaque objects (metal, batteries). Most objects (seeds, plastic, foam) are radiolucent.
Diagnostic criteria
Visualization of foreign body or strong clinical suspicion based on unilateral foul discharge.
Differential diagnosis
- Unilateral sinusitis.
- Nasal polyps.
- Adenoid hypertrophy.
- Choanal atresia (congenital).
- Nasal tumour (rare).
Management
Non-pharmacological management
- Positioning: Keep child calm, sitting upright.
- Positive Pressure Techniques (Attempt first if cooperative):
- - 'Parent's Kiss': Parent occludes unaffected nostril, places mouth over child's mouth, and gives a sharp puff of air.
- - Ask older child to blow nose forcefully while occluding unaffected nostril.
- Instrumentation (Requires good visualization, light, appropriate instruments, cooperative patient/restraint): (LOC: HC2/3)
- - Use fine forceps (e.g., Tilley's, Hartmann) to grasp objects like paper/foam.
- - Use blunt hook or right-angle probe to pass behind smooth/round objects and gently pull forward.
- - Suction may be useful if available.
- - Consider topical vasoconstrictor/anaesthetic spray to improve view/comfort (if available).
- - Avoid pushing object deeper.
Pharmacological treatment
- Topical vasoconstrictor/anaesthetic spray (e.g., Lidocaine with Epinephrine) - if available, use cautiously.
- Antibiotics generally not needed unless secondary sinusitis or significant mucosal trauma.
Monitoring
Check nasal cavity after removal to ensure completeness and rule out other foreign bodies or trauma.
Complications
- Local inflammation / infection (rhinitis, sinusitis).
- Mucosal erosion / ulceration.
- Epistaxis.
- Nasal septal perforation (rare, esp. with button batteries).
- Aspiration (if object dislodged posteriorly).
- Pressure necrosis.
Prevention
- Educating caregivers about dangers of small objects.
- Keeping small items out of reach of young children.
- Supervision of young children.
Patient education
- Explanation of the problem.
- Reassurance after successful removal.
- Advice on preventing recurrence (keeping small objects away from children).
- Signs of infection or retained fragments to watch for.
Uganda-specific notes
Common pediatric presentation. Seeds (beans, G-nuts) are frequent culprits. Unilateral foul discharge is classic sign if history unclear. Simple instrumentation often successful at HC level. Button batteries are extremely dangerous.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 21, Section 21.2.1