Pediatr Radiol DOI 10.1007/s00247-013-2821-z
CASE REPORT
Intranasal foreign body mimicking a fat-containing lesion Ruby Lukse & Douglas Walled & Mark Raden & Jeremy Neuman
Received: 1 July 2013 / Revised: 18 September 2013 / Accepted: 4 October 2013 # Springer-Verlag Berlin Heidelberg 2013
Abstract We present a 21-month-old child with a foreign body (an intranasal almond) measuring fat attenuation on CT. To the best of our knowledge, this appearance has not been previously described and can be confused with other diagnoses resulting in inappropriate or delayed treatment. Keywords Child . Foreign body . Nose . Computed tomography
Introduction Foreign body ingestion in children has been extensively discussed in the literature. However, to our knowledge, there has never been a case description of an intranasal foreign body measuring fat attenuation in a child. This unusual appearance led to some confusion regarding the diagnosis and delayed treatment.
in the emergency department, there was right nasal serous discharge without visualization of a foreign body. Paranasal sinus radiographs revealed a normal appearance of the sinuses without radiopaque foreign body. Nonenhanced thin-section computerized tomography (CT) images of the paranasal sinuses with reconstructions in the sagittal and coronal planes revealed a 1×0.8×0.8-cm structure that measured less than water density (−9 Hounsfield units) in the right nasal passage approximately 3 cm from the opening of the right external naris (Fig. 1). The differential diagnosis at the time was an intranasal dermoid, an abscess or a foreign body. The girl was discharged with antibiotics and a follow-up appointment with otorhinolaryngology. She developed fever as an outpatient and endoscopic nasal cavity exploration was undertaken, revealing the presence of an almond fragment enclaved between the middle and inferior turbinate. The foreign body was successfully removed (Fig. 2).
Discussion Case report A 21-month-old girl with no significant medical history presented to the emergency department at our institution with 3 weeks of right nasal serous discharge. The girl was previously prescribed amoxicillin, but the symptoms had not improved. Subsequently, the child was seen in otorhinolaryngology as an outpatient earlier in the week, but physical examination was incomplete due to extensive epistaxis and discharge. The child had no other symptoms. On physical exam R. Lukse (*) : D. Walled : M. Raden : J. Neuman Department of Radiology, Staten Island University Hospital, Staten Island, NY 10305, USA e-mail: [email protected]
Foreign bodies are a common problem in children, sometimes resulting in complications. The first years of a child’s life represent a phase of exploration, especially when they first become mobile (crawling and walking), allowing access to many new objects. These objects can then be placed in various orifices such as the ears, nose and throat. Intranasal foreign bodies are seen most frequently in children under 4 years old [1]. It is unlikely to be encountered in children younger than 9 months of age as prior to this time the child is unable to perform a pincer grip. In contrast to foreign bodies in other places that typically produce noticeable symptoms, intranasal foreign bodies can go unrecognized for a substantial period of time [2]. A predominance of foreign bodies in the right nasal cavity is thought to be due to the larger number of righthanded children [1]. When symptoms are present, they
Pediatr Radiol Fig. 1 Intranasal foreign body in a 21-month-old girl. Axial (a) and coronal (b) CT images of the paranasal sinuses after administration of 25 ml of intravenous contrast demonstrates a 1-cm non-enhancing, welldefined, low attenuation (−9 to −1 Hounsfield unit) lesion in the right nasal cavity approximately 3 cm from the external naris (arrow)
include unilateral mucopurulent nasal discharge with a foul odor, epistaxis is less common [3] and bromhidrosis (foul body odor) has been described in rare cases [4]. Button batteries and magnets pose a unique problem, as they may cause necrosis and perforation of the nasal septum, as in the gastrointestinal tract [5, 6]. A child presenting with a unilateral nasal discharge should be suspected of harboring an intranasal foreign body until proven otherwise [3]. Various intranasal foreign bodies have been described in the literature, with organic objects including nuts and beans being more common than inorganic ones such as sponge fragments and small plastic objects [1, 6]. They can be found anywhere in the nose, although the most common location is around the floor of the nose just below the inferior turbinate [3]. Radiologic imaging studies including conventional plain radiography, CT and US can be used to evaluate for the possibility of a foreign body when there is clinical uncertainty. Plain radiography, although the most frequently used imaging modality for foreign body identification, can only detect radiopaque foreign bodies (which are the minority of intranasal foreign bodies) or nonspecific paranasal sinus opacification. Ultrasonography is advantageous in that it can be used in real-
Fig. 2 Extracted foreign body. A fragment of an almond was removed
time to detect superficially located foreign bodies, especially radiolucent objects, without radiation exposure. The main disadvantage of US is that detection of a foreign body within air-filled structures such as the paranasal sinuses or nares is severely limited. Although not routinely used, CT can be helpful in difficult or uncertain foreign body cases and is the best imaging modality for visualization of foreign bodies in air. The shape, size and attenuation of a foreign body can be accurately assessed on CT while allowing for possible preoperative localization [7]. To our knowledge, this is the first described case in the literature of an intranasal foreign body demonstrating fat attenuation. Various techniques are available for nasal foreign body removal, most of which are at least somewhat invasive. Leaving the foreign body in the nose places the patient at risk for rhinoliths, erosion into adjacent structures, and infections including sinusitis, otitis, cellulitis and even meningitis [2]. Seeds and nuts, such as an almond in this case, may have inherent fat attenuation due to their lipid content. Therefore, their radiologic appearance can resemble true pathology and may pose a diagnostic dilemma. The differential diagnosis for a fat-containing intranasal lesion includes dermoid and lipoma. Air trapped in the naris and around the foreign body, thereby mimicking an abscess, may lead to further confusion. To confirm that nuts can appear as fat attenuation on CT, we imaged common types of nuts with a 64-slice General Electric Optima 660 CT scanner (GE Healthcare, Milwaukee, WI, USA) and measured the Hounsfield units. Three individual nuts of each variety were scanned after being submerged in water for 7 days. Although there was wide variation in the attenuation values of nuts, they often demonstrated fat attenuation (Fig. 3). Interestingly, O’Uchi et al [8] have previously reported high T1 MRI signal in an aspirated peanut, also presumably related to the inherent fat content [8]. In conclusion, radiologists and clinicians must have a high index of suspicion for a foreign body when confronted by an
Pediatr Radiol
intranasal lesion even if the lesion demonstrates fat attenuation. Misdiagnosis of a fat-containing foreign body as a true pathological lesion may lead to unnecessary examinations and treatment. In addition, early intervention is important to prevent potentially serious complications. Integration of clinical history and physical examination with imaging findings is required.
Conflicts of interest None
References
Fig. 3 CT images of pistachio (a), peanut (b), cashew (c) and almond (d) in water after 7 days. All varieties had Hounsfield unit measurements less than 0. Note the similar appearance of the almond in (d) with the intranasal almond in Fig. 1
1. Figueiredo RR, Azevedo AA, Kos AO et al (2006) Nasal foreign bodies: description of types and complications in 420 cases. Braz J Otorhinolaryngol 72:18–23 2. Kelesidis T, Osman S, Dinerman H (2010) An unusual foreign body as a cause of chronic sinusitis: a case report. J Med Case Rep 4:157 3. Kalan A, Tariq M (2000) Foreign bodies in the nasal cavities: a comprehensive review of the aetiology, diagnostic pointers, and therapeutic measures. Postgrad Med J 76:484–487 4. Golding IM (1965) An unusual cause of bromhidrosis. Pediatrics 36: 791–792 5. McRae D, Premachandra DJ, Gatland DJ (1989) Button batteries in the ear, nose and cervical oesophagus, a destructive foreign body. J Otolaryngol 18:317–319 6. Chinski A, Foltran F, Gregori D (2011) Nasal foreign bodies: the experience of the Buenos Aires pediatric otolaryngology clinic. Pediatr Int 53:90–93 7. Aras MH, Miloglu O, Barutcugil C (2010) Comparison of the sensitivity for detecting foreign bodies among conventional plain radiography, computed tomography and ultrasonography. Dentomaxillofac Radiol 39:72–78 8. O’Uchi T, Tokumaru A, Mikami I (1992) Value of MR imaging in detecting a peanut causing bronchial obstruction. AJR Am J Roentgenol 159:481–482
CASE REPORT
Intranasal foreign body mimicking a fat-containing lesion Ruby Lukse & Douglas Walled & Mark Raden & Jeremy Neuman
Received: 1 July 2013 / Revised: 18 September 2013 / Accepted: 4 October 2013 # Springer-Verlag Berlin Heidelberg 2013
Abstract We present a 21-month-old child with a foreign body (an intranasal almond) measuring fat attenuation on CT. To the best of our knowledge, this appearance has not been previously described and can be confused with other diagnoses resulting in inappropriate or delayed treatment. Keywords Child . Foreign body . Nose . Computed tomography
Introduction Foreign body ingestion in children has been extensively discussed in the literature. However, to our knowledge, there has never been a case description of an intranasal foreign body measuring fat attenuation in a child. This unusual appearance led to some confusion regarding the diagnosis and delayed treatment.
in the emergency department, there was right nasal serous discharge without visualization of a foreign body. Paranasal sinus radiographs revealed a normal appearance of the sinuses without radiopaque foreign body. Nonenhanced thin-section computerized tomography (CT) images of the paranasal sinuses with reconstructions in the sagittal and coronal planes revealed a 1×0.8×0.8-cm structure that measured less than water density (−9 Hounsfield units) in the right nasal passage approximately 3 cm from the opening of the right external naris (Fig. 1). The differential diagnosis at the time was an intranasal dermoid, an abscess or a foreign body. The girl was discharged with antibiotics and a follow-up appointment with otorhinolaryngology. She developed fever as an outpatient and endoscopic nasal cavity exploration was undertaken, revealing the presence of an almond fragment enclaved between the middle and inferior turbinate. The foreign body was successfully removed (Fig. 2).
Discussion Case report A 21-month-old girl with no significant medical history presented to the emergency department at our institution with 3 weeks of right nasal serous discharge. The girl was previously prescribed amoxicillin, but the symptoms had not improved. Subsequently, the child was seen in otorhinolaryngology as an outpatient earlier in the week, but physical examination was incomplete due to extensive epistaxis and discharge. The child had no other symptoms. On physical exam R. Lukse (*) : D. Walled : M. Raden : J. Neuman Department of Radiology, Staten Island University Hospital, Staten Island, NY 10305, USA e-mail: [email protected]
Foreign bodies are a common problem in children, sometimes resulting in complications. The first years of a child’s life represent a phase of exploration, especially when they first become mobile (crawling and walking), allowing access to many new objects. These objects can then be placed in various orifices such as the ears, nose and throat. Intranasal foreign bodies are seen most frequently in children under 4 years old [1]. It is unlikely to be encountered in children younger than 9 months of age as prior to this time the child is unable to perform a pincer grip. In contrast to foreign bodies in other places that typically produce noticeable symptoms, intranasal foreign bodies can go unrecognized for a substantial period of time [2]. A predominance of foreign bodies in the right nasal cavity is thought to be due to the larger number of righthanded children [1]. When symptoms are present, they
Pediatr Radiol Fig. 1 Intranasal foreign body in a 21-month-old girl. Axial (a) and coronal (b) CT images of the paranasal sinuses after administration of 25 ml of intravenous contrast demonstrates a 1-cm non-enhancing, welldefined, low attenuation (−9 to −1 Hounsfield unit) lesion in the right nasal cavity approximately 3 cm from the external naris (arrow)
include unilateral mucopurulent nasal discharge with a foul odor, epistaxis is less common [3] and bromhidrosis (foul body odor) has been described in rare cases [4]. Button batteries and magnets pose a unique problem, as they may cause necrosis and perforation of the nasal septum, as in the gastrointestinal tract [5, 6]. A child presenting with a unilateral nasal discharge should be suspected of harboring an intranasal foreign body until proven otherwise [3]. Various intranasal foreign bodies have been described in the literature, with organic objects including nuts and beans being more common than inorganic ones such as sponge fragments and small plastic objects [1, 6]. They can be found anywhere in the nose, although the most common location is around the floor of the nose just below the inferior turbinate [3]. Radiologic imaging studies including conventional plain radiography, CT and US can be used to evaluate for the possibility of a foreign body when there is clinical uncertainty. Plain radiography, although the most frequently used imaging modality for foreign body identification, can only detect radiopaque foreign bodies (which are the minority of intranasal foreign bodies) or nonspecific paranasal sinus opacification. Ultrasonography is advantageous in that it can be used in real-
Fig. 2 Extracted foreign body. A fragment of an almond was removed
time to detect superficially located foreign bodies, especially radiolucent objects, without radiation exposure. The main disadvantage of US is that detection of a foreign body within air-filled structures such as the paranasal sinuses or nares is severely limited. Although not routinely used, CT can be helpful in difficult or uncertain foreign body cases and is the best imaging modality for visualization of foreign bodies in air. The shape, size and attenuation of a foreign body can be accurately assessed on CT while allowing for possible preoperative localization [7]. To our knowledge, this is the first described case in the literature of an intranasal foreign body demonstrating fat attenuation. Various techniques are available for nasal foreign body removal, most of which are at least somewhat invasive. Leaving the foreign body in the nose places the patient at risk for rhinoliths, erosion into adjacent structures, and infections including sinusitis, otitis, cellulitis and even meningitis [2]. Seeds and nuts, such as an almond in this case, may have inherent fat attenuation due to their lipid content. Therefore, their radiologic appearance can resemble true pathology and may pose a diagnostic dilemma. The differential diagnosis for a fat-containing intranasal lesion includes dermoid and lipoma. Air trapped in the naris and around the foreign body, thereby mimicking an abscess, may lead to further confusion. To confirm that nuts can appear as fat attenuation on CT, we imaged common types of nuts with a 64-slice General Electric Optima 660 CT scanner (GE Healthcare, Milwaukee, WI, USA) and measured the Hounsfield units. Three individual nuts of each variety were scanned after being submerged in water for 7 days. Although there was wide variation in the attenuation values of nuts, they often demonstrated fat attenuation (Fig. 3). Interestingly, O’Uchi et al [8] have previously reported high T1 MRI signal in an aspirated peanut, also presumably related to the inherent fat content [8]. In conclusion, radiologists and clinicians must have a high index of suspicion for a foreign body when confronted by an
Pediatr Radiol
intranasal lesion even if the lesion demonstrates fat attenuation. Misdiagnosis of a fat-containing foreign body as a true pathological lesion may lead to unnecessary examinations and treatment. In addition, early intervention is important to prevent potentially serious complications. Integration of clinical history and physical examination with imaging findings is required.
Conflicts of interest None
References
Fig. 3 CT images of pistachio (a), peanut (b), cashew (c) and almond (d) in water after 7 days. All varieties had Hounsfield unit measurements less than 0. Note the similar appearance of the almond in (d) with the intranasal almond in Fig. 1
1. Figueiredo RR, Azevedo AA, Kos AO et al (2006) Nasal foreign bodies: description of types and complications in 420 cases. Braz J Otorhinolaryngol 72:18–23 2. Kelesidis T, Osman S, Dinerman H (2010) An unusual foreign body as a cause of chronic sinusitis: a case report. J Med Case Rep 4:157 3. Kalan A, Tariq M (2000) Foreign bodies in the nasal cavities: a comprehensive review of the aetiology, diagnostic pointers, and therapeutic measures. Postgrad Med J 76:484–487 4. Golding IM (1965) An unusual cause of bromhidrosis. Pediatrics 36: 791–792 5. McRae D, Premachandra DJ, Gatland DJ (1989) Button batteries in the ear, nose and cervical oesophagus, a destructive foreign body. J Otolaryngol 18:317–319 6. Chinski A, Foltran F, Gregori D (2011) Nasal foreign bodies: the experience of the Buenos Aires pediatric otolaryngology clinic. Pediatr Int 53:90–93 7. Aras MH, Miloglu O, Barutcugil C (2010) Comparison of the sensitivity for detecting foreign bodies among conventional plain radiography, computed tomography and ultrasonography. Dentomaxillofac Radiol 39:72–78 8. O’Uchi T, Tokumaru A, Mikami I (1992) Value of MR imaging in detecting a peanut causing bronchial obstruction. AJR Am J Roentgenol 159:481–482
