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Emergency Medicine Australasia (2015) 27, 145–147
doi: 10.1111/1742-6723.12387
CLINICAL PROCEDURES
Removal of ENT foreign bodies in children Simon S CRAIG,1,2,3 John A CHEEK,1,2,3,4 Robert W SEITH1,2 and Adam WEST1,2 1 Emergency Department, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia, 2School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia, 3Murdoch Children’s Research Institute, Melbourne, Victoria, Australia, 4Royal Children’s Hospital, Melbourne, Victoria, Australia
Children manage to end up with a large variety of objects stuck in all sorts of places. This article will provide an overview of the most commonly encountered paediatric ED scenarios – aural and nasal foreign bodies.
What is it? Does it matter? Many different foreign bodies have been discovered in the aural and nasal cavities of children presenting to the ED. These include food (particularly peas and corn), beads, toys, cotton tips, paper, jewellery and insects.1–6 Live insects in the ear are particularly distressing, and should be initially killed by instillation of oil (mineral oil or olive oil) or lignocaine solution.7 Button batteries also deserve specific mention, due to their potential to cause rapid tissue damage and significant complications. As a result, urgent removal is required.8,9
How do they present? Presenting symptoms vary depending on the site of the foreign body, the age of the child, and whether or not the insertion of the object was witnessed. Older children are able to report symptoms of pain or fullness in the ear or nose, and may (or may not) admit to inserting the object. Younger
children may present after the insertion being witnessed by a caregiver, unilateral discharge from the ear or nose, or with acute pain. Aspiration as a presenting complaint is extremely rare, and is more likely to occur as a complication of instrumentation.10 Occasionally, a foreign body may be noted during physical examination for an unrelated presenting complaint such as fever.
Are there any non-invasive techniques that I can try? For aural foreign bodies, irrigation with water warmed to body temperature may occasionally be helpful. It is recommended for small rocks, dirt or sand that lies adjacent to the tympanic membrane,7 and is less helpful for organic foreign bodies, which may swell with exposure to moisture. Simple nose-blowing may sometimes successfully remove or dislodge a nasal foreign body, even in young children. Another non-invasive option for nasal foreign bodies is the ‘mother’s kiss’ technique, which requires the assistance of a trusted adult caregiver. It is a useful and safe first-line technique,11,12 however, is more than simply blowing into the child’s mouth:
Correspondence: Dr Simon S Craig, Emergency Department, Monash Medical Centre, 246 Clayton Road, Clayton, VIC 3168, Australia. Email: [email protected] Simon S Craig, MBBS (Hons), FACEM, MHPE, Emergency Physician, Adjunct Senior Lecturer, Honorary Fellow; John A Cheek, MBBS, FACEM, Emergency Physician, Adjunct Lecturer, Research Associate; Robert W Seith, MBChB, MRCPCH, FRACP, Paediatrician, Adjunct Lecturer; Adam West, MBBS, DRANZCOG, FACEM, Director, Adjunct Lecturer. Accepted 12 February 2015
“While occluding the unaffected nostril with a finger, the adult then blows until they feel the resistance caused by closure of the child’s glottis, at which point the adult gives a sharp exhalation to deliver a short puff of air into the child’s mouth. This puff of air passes through the nasopharynx, out through the unoccluded nostril and, if successful, results in the expulsion of the foreign body.11” Other techniques include using positive pressure from a bag-valve-mask, applying high flow (10–15 L/min) wall oxygen to the unaffected nostril,13 or asking the adult carer to blow into a drinking straw placed in the child’s mouth.14
What analgesia and/or sedation should I give my patient? Topical local anaesthetic/vasoconstrictor is very useful to assist with the removal of nasal foreign bodies. It is usually applied with the assistance of a flexible nozzle extension (Fig. 1), and administration may be made easier with the use of nitrous oxide. Any movement of the child during attempts at removal make the procedure much more difficult, and increase the risk of iatrogenic complications, particularly pain and bleeding. Therefore, it is important to utilise adequate non-pharmacologic (caregiver cuddles, bubbles, and electronic devices) and pharmacologic techniques in addition to an assistant keeping the head still. Most children will require some form of procedural sedation to facilitate removal of the foreign body. Options for procedural sedation and analgesia include nitrous oxide (with or without adjunctive oral
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
146
SS CRAIG ET AL.
a
Figure 1. Topical local anaesthetic/ vasoconstrictor spray with flexible nozzle.
midazolam) or ketamine. Deeper sedation is usually required for aural foreign bodies, as the external auditory canal is very sensitive and difficult to anaesthetise. If the child is unlikely to cooperate, further sedation or consideration of general anaesthesia is recommended. Multiple attempts at removing a foreign body in an uncooperative child are distressing for all concerned!
Figure 2.
Alligator forceps.
Figure 5. (a) Flexible suction catheter. (b) Cut-down flexible suction catheter. Figure 3.
Right-angle probe.
batteries), and small balloon catheters (which are inserted beyond the object, the balloon inflated, then slowly withdrawn, bringing the object with it).
What instruments are useful? Good lighting that allows the proceduralist full use of both hands is essential. Most departments have an ENT headlamp specifically designed to allow a magnified view down a narrow cavity such as the ear or nose. Appropriate equipment is required. Visualisation can be improved by the use of an appropriate nasal or aural speculum. Specific instruments are useful with particular types of foreign body. If they are not available in your department, request a myringotomy tray from the operating theatre. Options include: • Alligator forceps (Fig. 2) – Very useful for soft foreign bodies, or those with parts that can be grasped (e.g. paper, tissue, insects). Less useful for round objects, which can be pushed away by the forceps’ grasping motion. • A right-angle probe (Fig. 3) – Useful for manoeuvring alongside and past an object, rotating so that the right-angle is behind the foreign body, and then withdrawing the instrument along with the object.
b
When should I give up?
Figure 4.
Wax curette.
• A wax curette (Fig. 4) – Can be used in a similar fashion to the right-angle probe. Also useful to remove wax from the auditory canal to improve visualisation and assist with removal. • Suction – either a Frazier suction catheter, or a cut-down flexible suction catheter (Fig. 5) – Useful for round foreign bodies. Place the end of the suction catheter on the surface of the object, then apply suction. Other instruments that have been reported to be useful include bent paperclips, tissue adhesive, magnets (for metallic foreign bodies such as button
Inexperienced proceduralists are associated with a higher rate of complications. If you do not feel like you are the right person for the job, seek senior assistance, or refer to the ENT service. Particular care should be taken with deep nasal foreign bodies that may be dislodged posteriorly into the airway during instrumentation. Multiple attempts in a child who is inadequately sedated are very distressing, and can result in local trauma, bleeding and swelling, all of which increase the difficulty of subsequent removal attempts. Do not persist beyond one or two attempts – seek senior advice, or refer to ENT for removal in theatre.
Anything to worry about afterwards? It is worth checking all potential orifices in the head and neck (i.e. both
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
147
REMOVAL OF ENT FOREIGN BODIES IN CHILDREN
ears, and both nostrils) – occasionally, you may discover additional foreign bodies that need removal.
Competing interests None declared.
References 1. Pecorari G, Tavormina P, Riva G, Landolfo V, Raimondo L, Garzaro M. Ear, nose and throat foreign bodies: the experience of the Pediatric Hospital of Turin. J. Paediatr. Child Health 2014; 50: 978–84. 2. Ray R, Dutta M, Mukherjee M, Gayen GC. Foreign body in ear, nose and throat: experience in a tertiary hospital. Indian J. Otolaryngol Head Neck Surg. 2014; 66: 13–16. 3. Ryan C, Ghosh A, Wilson-Boyd B, Smit D, O’Leary S. Presentation and management of aural foreign bodies in two Australian emergency departments. Emerg. Med. Australas. 2006; 18: 372–8.
4. Shrestha I, Shrestha BL, Amatya RC. Analysis of ear, nose and throat foreign bodies in Dhulikhel Hospital. Kathmandu Univ. Med. J. 2012; 10: 4–8. 5. Svider PF, Sheyn A, Folbe E et al. How did that get there? A population-based analysis of nasal foreign bodies. Int. Forum of Allergy and Rhinol. 2014; 4: 944–9. 6. Timmers M, Snoek KG, Gregori D, Felix JF, van Dijk M. van As SA. Foreign bodies in a pediatric emergency department in South Africa. Pediatr. Emerg. Care 2012; 28: 1348– 52. 7. Roberts J, Custalow C, Thomsen T, Hedges J. Roberts and Hedges Clinical Procedures in Emergency Medicine. Philadelphia, PA: Elsevier/ Saunders, 2014. 8. Alletag MJ, Jacobson D, Santucci K, Riera A. Nasal disc battery removal: a novel technique using a magnetic device. Pediatr. Emerg. Care 2014; 30: 488–90. 9. Thabet MH, Basha WM, Askar S. Button battery foreign bodies in chil-
10.
11.
12.
13.
14.
dren: hazards, management, and recommendations. BioMed. Res. Int. 2013; 2013: 846091. Kiger JR, Brenkert TE, Losek JD. Nasal foreign body removal in children. Pediatr. Emerg. Care 2008; 24: 785–92, quiz 90-2. Cook S, Burton M, Glasziou P. Efficacy and safety of the ‘mother’s kiss’ technique: a systematic review of case reports and case series. Can. Med. Assoc. J. 2012; 184: E904–12. Glasziou P, Bennett J, Greenberg P et al. Mother’s kiss for nasal foreign bodies. Aust. Fam. Physician 2013; 42: 288–9. Navitsky RC, Beamsley A, McLaughlin S. Nasal positive-pressure technique for nasal foreign body removal in children. Am. J. Emerg. Med. 2002; 20: 103–4. Benjamin E, Harcourt J. The modified ‘Parent’s Kiss’ for the removal of paediatric nasal foreign bodies. Clin. Otolaryngol. 2007; 32: 120–1.
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Emergency Medicine Australasia (2015) 27, 145–147
doi: 10.1111/1742-6723.12387
CLINICAL PROCEDURES
Removal of ENT foreign bodies in children Simon S CRAIG,1,2,3 John A CHEEK,1,2,3,4 Robert W SEITH1,2 and Adam WEST1,2 1 Emergency Department, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia, 2School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia, 3Murdoch Children’s Research Institute, Melbourne, Victoria, Australia, 4Royal Children’s Hospital, Melbourne, Victoria, Australia
Children manage to end up with a large variety of objects stuck in all sorts of places. This article will provide an overview of the most commonly encountered paediatric ED scenarios – aural and nasal foreign bodies.
What is it? Does it matter? Many different foreign bodies have been discovered in the aural and nasal cavities of children presenting to the ED. These include food (particularly peas and corn), beads, toys, cotton tips, paper, jewellery and insects.1–6 Live insects in the ear are particularly distressing, and should be initially killed by instillation of oil (mineral oil or olive oil) or lignocaine solution.7 Button batteries also deserve specific mention, due to their potential to cause rapid tissue damage and significant complications. As a result, urgent removal is required.8,9
How do they present? Presenting symptoms vary depending on the site of the foreign body, the age of the child, and whether or not the insertion of the object was witnessed. Older children are able to report symptoms of pain or fullness in the ear or nose, and may (or may not) admit to inserting the object. Younger
children may present after the insertion being witnessed by a caregiver, unilateral discharge from the ear or nose, or with acute pain. Aspiration as a presenting complaint is extremely rare, and is more likely to occur as a complication of instrumentation.10 Occasionally, a foreign body may be noted during physical examination for an unrelated presenting complaint such as fever.
Are there any non-invasive techniques that I can try? For aural foreign bodies, irrigation with water warmed to body temperature may occasionally be helpful. It is recommended for small rocks, dirt or sand that lies adjacent to the tympanic membrane,7 and is less helpful for organic foreign bodies, which may swell with exposure to moisture. Simple nose-blowing may sometimes successfully remove or dislodge a nasal foreign body, even in young children. Another non-invasive option for nasal foreign bodies is the ‘mother’s kiss’ technique, which requires the assistance of a trusted adult caregiver. It is a useful and safe first-line technique,11,12 however, is more than simply blowing into the child’s mouth:
Correspondence: Dr Simon S Craig, Emergency Department, Monash Medical Centre, 246 Clayton Road, Clayton, VIC 3168, Australia. Email: [email protected] Simon S Craig, MBBS (Hons), FACEM, MHPE, Emergency Physician, Adjunct Senior Lecturer, Honorary Fellow; John A Cheek, MBBS, FACEM, Emergency Physician, Adjunct Lecturer, Research Associate; Robert W Seith, MBChB, MRCPCH, FRACP, Paediatrician, Adjunct Lecturer; Adam West, MBBS, DRANZCOG, FACEM, Director, Adjunct Lecturer. Accepted 12 February 2015
“While occluding the unaffected nostril with a finger, the adult then blows until they feel the resistance caused by closure of the child’s glottis, at which point the adult gives a sharp exhalation to deliver a short puff of air into the child’s mouth. This puff of air passes through the nasopharynx, out through the unoccluded nostril and, if successful, results in the expulsion of the foreign body.11” Other techniques include using positive pressure from a bag-valve-mask, applying high flow (10–15 L/min) wall oxygen to the unaffected nostril,13 or asking the adult carer to blow into a drinking straw placed in the child’s mouth.14
What analgesia and/or sedation should I give my patient? Topical local anaesthetic/vasoconstrictor is very useful to assist with the removal of nasal foreign bodies. It is usually applied with the assistance of a flexible nozzle extension (Fig. 1), and administration may be made easier with the use of nitrous oxide. Any movement of the child during attempts at removal make the procedure much more difficult, and increase the risk of iatrogenic complications, particularly pain and bleeding. Therefore, it is important to utilise adequate non-pharmacologic (caregiver cuddles, bubbles, and electronic devices) and pharmacologic techniques in addition to an assistant keeping the head still. Most children will require some form of procedural sedation to facilitate removal of the foreign body. Options for procedural sedation and analgesia include nitrous oxide (with or without adjunctive oral
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
146
SS CRAIG ET AL.
a
Figure 1. Topical local anaesthetic/ vasoconstrictor spray with flexible nozzle.
midazolam) or ketamine. Deeper sedation is usually required for aural foreign bodies, as the external auditory canal is very sensitive and difficult to anaesthetise. If the child is unlikely to cooperate, further sedation or consideration of general anaesthesia is recommended. Multiple attempts at removing a foreign body in an uncooperative child are distressing for all concerned!
Figure 2.
Alligator forceps.
Figure 5. (a) Flexible suction catheter. (b) Cut-down flexible suction catheter. Figure 3.
Right-angle probe.
batteries), and small balloon catheters (which are inserted beyond the object, the balloon inflated, then slowly withdrawn, bringing the object with it).
What instruments are useful? Good lighting that allows the proceduralist full use of both hands is essential. Most departments have an ENT headlamp specifically designed to allow a magnified view down a narrow cavity such as the ear or nose. Appropriate equipment is required. Visualisation can be improved by the use of an appropriate nasal or aural speculum. Specific instruments are useful with particular types of foreign body. If they are not available in your department, request a myringotomy tray from the operating theatre. Options include: • Alligator forceps (Fig. 2) – Very useful for soft foreign bodies, or those with parts that can be grasped (e.g. paper, tissue, insects). Less useful for round objects, which can be pushed away by the forceps’ grasping motion. • A right-angle probe (Fig. 3) – Useful for manoeuvring alongside and past an object, rotating so that the right-angle is behind the foreign body, and then withdrawing the instrument along with the object.
b
When should I give up?
Figure 4.
Wax curette.
• A wax curette (Fig. 4) – Can be used in a similar fashion to the right-angle probe. Also useful to remove wax from the auditory canal to improve visualisation and assist with removal. • Suction – either a Frazier suction catheter, or a cut-down flexible suction catheter (Fig. 5) – Useful for round foreign bodies. Place the end of the suction catheter on the surface of the object, then apply suction. Other instruments that have been reported to be useful include bent paperclips, tissue adhesive, magnets (for metallic foreign bodies such as button
Inexperienced proceduralists are associated with a higher rate of complications. If you do not feel like you are the right person for the job, seek senior assistance, or refer to the ENT service. Particular care should be taken with deep nasal foreign bodies that may be dislodged posteriorly into the airway during instrumentation. Multiple attempts in a child who is inadequately sedated are very distressing, and can result in local trauma, bleeding and swelling, all of which increase the difficulty of subsequent removal attempts. Do not persist beyond one or two attempts – seek senior advice, or refer to ENT for removal in theatre.
Anything to worry about afterwards? It is worth checking all potential orifices in the head and neck (i.e. both
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
147
REMOVAL OF ENT FOREIGN BODIES IN CHILDREN
ears, and both nostrils) – occasionally, you may discover additional foreign bodies that need removal.
Competing interests None declared.
References 1. Pecorari G, Tavormina P, Riva G, Landolfo V, Raimondo L, Garzaro M. Ear, nose and throat foreign bodies: the experience of the Pediatric Hospital of Turin. J. Paediatr. Child Health 2014; 50: 978–84. 2. Ray R, Dutta M, Mukherjee M, Gayen GC. Foreign body in ear, nose and throat: experience in a tertiary hospital. Indian J. Otolaryngol Head Neck Surg. 2014; 66: 13–16. 3. Ryan C, Ghosh A, Wilson-Boyd B, Smit D, O’Leary S. Presentation and management of aural foreign bodies in two Australian emergency departments. Emerg. Med. Australas. 2006; 18: 372–8.
4. Shrestha I, Shrestha BL, Amatya RC. Analysis of ear, nose and throat foreign bodies in Dhulikhel Hospital. Kathmandu Univ. Med. J. 2012; 10: 4–8. 5. Svider PF, Sheyn A, Folbe E et al. How did that get there? A population-based analysis of nasal foreign bodies. Int. Forum of Allergy and Rhinol. 2014; 4: 944–9. 6. Timmers M, Snoek KG, Gregori D, Felix JF, van Dijk M. van As SA. Foreign bodies in a pediatric emergency department in South Africa. Pediatr. Emerg. Care 2012; 28: 1348– 52. 7. Roberts J, Custalow C, Thomsen T, Hedges J. Roberts and Hedges Clinical Procedures in Emergency Medicine. Philadelphia, PA: Elsevier/ Saunders, 2014. 8. Alletag MJ, Jacobson D, Santucci K, Riera A. Nasal disc battery removal: a novel technique using a magnetic device. Pediatr. Emerg. Care 2014; 30: 488–90. 9. Thabet MH, Basha WM, Askar S. Button battery foreign bodies in chil-
10.
11.
12.
13.
14.
dren: hazards, management, and recommendations. BioMed. Res. Int. 2013; 2013: 846091. Kiger JR, Brenkert TE, Losek JD. Nasal foreign body removal in children. Pediatr. Emerg. Care 2008; 24: 785–92, quiz 90-2. Cook S, Burton M, Glasziou P. Efficacy and safety of the ‘mother’s kiss’ technique: a systematic review of case reports and case series. Can. Med. Assoc. J. 2012; 184: E904–12. Glasziou P, Bennett J, Greenberg P et al. Mother’s kiss for nasal foreign bodies. Aust. Fam. Physician 2013; 42: 288–9. Navitsky RC, Beamsley A, McLaughlin S. Nasal positive-pressure technique for nasal foreign body removal in children. Am. J. Emerg. Med. 2002; 20: 103–4. Benjamin E, Harcourt J. The modified ‘Parent’s Kiss’ for the removal of paediatric nasal foreign bodies. Clin. Otolaryngol. 2007; 32: 120–1.
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
![[Foreign bodies in ENT: ten-year experience].](/assets/img/hold.png)
