Foreign body in the nose - Emergency

management in children
Purpose
This document provides clinical guidance for all staff involved in the care and management of a child
presenting to an Emergency Department (ED) in Queensland with a suspected or confirmed foreign body
in the nose.
This guideline has been developed by senior ED clinicians and Paediatricians across Queensland, with
input from ENT specialists, Queensland Children’s Hospital, Brisbane. It has been endorsed for use across
Queensland by the Queensland Emergency Care of Children Working Group in partnership with the
Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit,
Clinical Excellence Queensland.

Key points
• Consequences of nasal foreign bodies range from local irritation at insertion site, to serious
complications including death.
• Urgent ENT referral (onsite or via Retrieval Services Queensland (RSQ)) is required for
button batteries and paired magnets due to the risk of necrosis of surrounding tissue.
• The first attempt at removal of a foreign body from the nose has the best chance of success.
• Refer to ENT for removal if first attempt (via any method) is unsuccessful.

Introduction
Nasal foreign bodies are more common in the following children:
• aged two to five years
• intellectual impairment (may have multiple foreign bodies and repeated episodes)
Common foreign bodies include food, paper and small toy parts. Most nasal foreign bodies are found
in the anterior nasal cavity between the floor of the nose and inferior turbinate.1 High rates (92-98%) of
successful removal in ED have been reported.

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 Button batteries
Button batteries require immediate removal due to the risk of necrosis of the surrounding tissue.

There are two main mechanisms by which button batteries can cause necrosis:
• where there is sufficient retained battery charge, hydrolysis and creation of hydroxide ions
in adjacent tissues leads to mucosal burn at battery’s negative pole
• direct pressure
Despite prompt removal, the risk of injury can continue up to weeks post-insertion due to residual
alkali and weakened tissues.

Assessment

ALERT – Button batteries require immediate removal to prevent necrosis of surrounding tissue
and septal perforation.

When to suspect a foreign body in the nose

Most children with a nasal foreign body are asymptomatic. A history of insertion may be reported by the
child or the caregiver. Delayed presentations are usually triggered by parents noticing blood stained
purulent discharge or a bad smell.

Regardless of a history of insertion, consider a nasal foreign body in children presenting with any of the
following symptoms:
• nasal occlusion
• epistaxis
• malodourous, purulent or blood-stained nasal discharge (usually unilateral but may be bilateral if
multiple foreign bodies or in case of septal perforation)
• facial swelling and/or facial pain

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 Differential diagnoses for suspected nasal foreign body
Upper respiratory tract infection
Rhinitis
Sinusitis
Unilateral choanal atresia
Tumour

Investigations
X-rays are not routinely recommended as the objects inserted are rarely radiopaque but must be
considered if there is a possibility of a button battery or paired magnets which cannot be directly visualised.

Contact Retrieval Services Queensland (RSQ) to arrange urgent transfer of a child with a
suspected button battery and no X-ray facilities are onsite

Management
Refer to Appendix 1 for a summary of the emergency management for a child with a nasal foreign body.

Urgent ENT referral (onsite or via RSQ) is required for the following children:
• button battery in nose
• history of insertion and bleeding or airway issues

Refer to ENT as per local practices in the following circumstances:

• multiple unsuccessful attempts at removal prior to ED presentation
• foreign body is posterior and not easily visualised
• paired magnets or magnet and metallic object across nasal septum
• chronic or impacted foreign bodies with marked inflammation
• penetrating or hooked foreign bodies

Principals of foreign body removal

• first attempt offers the best chance of success
• choose the best method based on exact location, shape and composition of foreign body
(see methods below)
• be aware of the risk of trauma and/or posterior displacement and aspiration in a poorly
compliant child

Preparation for foreign body removal

• engage two staff members to assist (in addition to carer)
• provide developmentally appropriate information and encouragement and use demonstration
or role play to prepare the child for the procedure
• position the child appropriately (upright or lying down)
- upright positioning encourages a sense of control thereby minimising distress

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 - ideal upright positioning is on the carer’s lap with his/her head supported by staff
member
- may be easier to secure younger children lying down
- refer to CHQ Nursing Standard 62111: Clinical Holding – Holding and Supporting
Children) (QH only)
• use auditory and visual distraction techniques and promote child’s coping skills
• prior to mechanical extraction, consider applying topical local analgesia such as Co-
Phenylcaine Forte (5% Lignocaine, 0.5% Phenylephrine) at appropriate doses using flexible
nozzle extension (maximum single dose of 3 mg/kg Lignocaine) 10 minutes prior to removal
(not routinely recommended prior to removal by positive pressure techniques).
• use a head lamp (+/- magnification) to optimise visualisation and allow the use of two
hands
• consider using a nasal speculum to maximise visualisation (place in a cephalo-caudal
orientation to avoid the nasal septum)
Blind attempts at removal are not recommended due to risk of posterior dislodgement and
aspiration.

ALERT – Topical nasal drops including local anaesthetic and vasodilators are contra-indicated
in button battery cases. They may increase the risk of posterior displacement and aspiration or
local necrosis.

Methods of removal
Recommended methods of removal include positive pressure or mechanical extraction. Positive pressure
methods aim to push the foreign object anteriorly either completely out of nasal passage or into a visible
range where it can be grasped by other instruments. These methods carry a theoretical risk of barotrauma
including periorbital subcutaneous emphysema. Irrigation and use of glue are not routinely recommended.
Sedation is not recommended as may increase the risk of aspiration.
The risk of aspiration in foreign bodies that are unable to be removed is estimated to be 1 in 1,500 patients.2
Referral for elective removal is therefore acceptable with appropriate safety-net advice for the family.

Positive pressure removal methods for nasal foreign body

Method Indication Description
Self-blow / • recommended for removal of • child is encouraged to blow their
exhale technique small, smooth, spherical objects nose whilst occluding the nostril
in a cooperative patient (usually opposite to the foreign body
greater than three years of age)
Parent’s kiss • recommended for removal of • caregiver seals the child’s mouth
small, smooth, spherical objects with their mouth whilst occluding
• well tolerated even in small the unaffected nostril then gives a
children without requiring restraint short sharp puff of air to dislodge
the foreign body.

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Mechanical extraction removal methods for nasal foreign body
Method Indication Description
Forceps • recommended for soft, irregular • gently grasp the object with the
(including Magill, small objects forceps and pull out of nares
alligator, packing, • not recommended if object is • avoid repeated grasping attempts
toothed and non- smooth, round or friable as may push more posteriorly
toothed forceps)
Probe • recommended for hard non- • probe tip passed beyond and
(e.g. Jobson-Horne graspable objects which do not posterior to object and removed
probe) fully occlude nares by pulling object anteriorly and
out of the nare
Suction • recommended for smooth or • use micro suction tube
spherical visible mobile objects (Schuknecht tube or Frazier tip)
attached to wall suction to form a
solid seal between tube and
object
Balloon catheter • recommended for smooth round • lubricate the catheter and
(e.g. small foley or foreign bodies which do not fully advance past the object, partially
commercial occlude the nasal passage inflate the balloon and withdraw
catheter) • risk posterior displacement of
foreign body
Magnetic device • consider for removal of metallic • slowly and safely introduce the
objects such as ball bearings or magnet into the nose until an
(see image below) button batteries if visible audible or palpable click is
• risk pushing foreign body further produced at which point carefully
into nose withdraw

Refer to ENT as per local practice if first attempt at removal of foreign body (via any method) is
unsuccessful.

Post-removal care
• inspect nasal orifice to exclude co-existing foreign body and trauma
• examine other nasal and aural orifices for additional foreign bodies

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 Potential complications following removal of nasal foreign body
• rhinorrhoea
• epistaxis
• ulceration of the nasal mucosa
• perforation of nasal septum
• nasal or choanal stenosis
• infection
• ingestion
• sinusitis
• periorbital cellulitis
• meningitis
In the event of epistaxis, apply direct pressure to control the bleeding. Refer to Epistaxis guideline
(QH only).
Refer to ENT as per local practice in child with significant complications

Escalation and advice outside of ED

Clinicians can contact the services below to escalate the care of a paediatric patient as per local practices.
Button battery cases require urgent transfer if removal onsite is not possible. Other nasal foreign bodies
requiring specialist referral are usually managed as an outpatient.

Button battery insertions

ALERT – Button batteries require immediate removal to prevent necrosis of surrounding

tissue.

Service Reason for contact Contact

ENT For urgent removal of Onsite or via Retrieval Services Queensland (RSQ).
button battery. For facilities with no onsite service contact RSQ (Ph: 1300 799
127) to request urgent transfer of a child:
• requiring removal of button battery (as time-critical)
• requiring X-rays if button battery is suspected but unable
to be visualised and no X-ray facility onsite (as time-
critical).
RSQ (access via QH intranet)
Notify early of children potentially requiring transfer.

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 Other insertions
Reason for contact by clinician Contact
For the management of children with the following nasal Onsite/local ENT service as per local
foreign bodies: practices.
• posterior and not easily visualised
• paired magnets or magnet and metallic object
across nasal septum
• chronic or impacted with marked inflammation
• penetrating or hooked
• remain despite multiple attempts at removal prior
to ED presentation
• unable to be removed following a single attempt
in ED
For specialist advice regarding significant complications
following successful removal of foreign body in ED.

Disposition
A child may be discharged following successful removal of the foreign body.
On discharge, provide accident prevention advice to caregiver/s including:
• safe storage of small objects including marbles, coins, button batteries and balloons to ensure out
of reach of infants and young children
• ensuring toys for play are appropriate for developmental age

Follow-up
• advise caregiver/s to seek medical attention if child experiences any signs or symptoms of
complications such as fever, purulent nasal discharge, epistaxis, facial pain and/or swelling

• referral to ENT as per local practice any child with significant complications following foreign body
removal

References
1. Kiger, J.R., Brenkert, T.E., Losek J.D., (2008), ‘Nasal Foreign Body Removal in Children’, Pediatric Emergency Care, Vol. Nov
24 (11) pp 785-792
2. Qureshi, A.A., Lowe, D.A., McKiernan, D.C, (2009) ‘The origin of bronchial foreign bodies: a retrospective study and literature
review’, European Archives of Otorhinolaryngology, Vol. 266 pp. 1645-1648

Guideline approval
Document ID CHQ-GDL-60022 Version no. 1.0 Approval date 19/06/2019
Executive sponsor Executive Director Medical Services Effective date 19/06/2019
Author/custodian Queensland Emergency Care Children Working Review date 19/06/2022
Group

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 Supersedes CHQ-GDL-00742
Applicable to Queensland Health medical and nursing staff
Document source Internal (QHEPS) + External
Authorisation Executive Director Clinical Services (QCH)

Keywords Foreign body, nose, nasal, button battery, ENT, paediatric, emergency,
guideline, children, 60022
Accreditation references NSQHS Standards (1-8): 1, 3, 8

Disclaimer
This guideline is intended as a guide and provided for information purposes only. The information has been prepared using a
multidisciplinary approach with reference to the best information and evidence available at the time of preparation. No assurance is
given that the information is entirely complete, current, or accurate in every respect. We recommend hospitals follow their usual practice
for endorsement locally including presenting it to their local Medicines Advisory Committee (or equivalent) prior to use.
The guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice. Variation from the guideline, taking
into account individual circumstances may be appropriate.
This guideline does not address all elements of standard practice and accepts that individual clinicians are responsible for:
• Providing care within the context of locally available resources, expertise, and scope of practice
• Supporting consumer rights and informed decision making in partnership with healthcare practitioners including the right to
decline intervention or ongoing management
• Advising consumers of their choices in an environment that is culturally appropriate and which enables comfortable and
confidential discussion. This includes the use of interpreter services where necessary
• Ensuring informed consent is obtained prior to delivering care
• Meeting all legislative requirements and professional standards
• Applying standard precautions, and additional precautions as necessary, when delivering care
• Documenting all care in accordance with mandatory and local requirements
Children’s Health Queensland disclaims, to the maximum extent permitted by law, all responsibility and all liability (including without
limitation, liability in negligence) for all expenses, losses, damages and costs incurred for any reason associated with the use of this
guideline, including the materials within or referred to throughout this document being in any way inaccurate, out of context, incomplete
or unavailable.

© Children’s Health Queensland Hospital and Health Service 2019

This work is licensed under a Creative Commons Attribution Non-Commercial V4.0 International licence. To view a copy of this licence,
visit [Link]
You are free to copy, communicate and adapt the work for non-commercial purposes, as long as you attribute Children’s Health
Queensland Hospital and Health Service and comply with the licence terms.
For copyright permissions beyond the scope of this licence contact: Queensland Emergency Care of Children working group, Children’s
Health Queensland Hospital and Health Service, email QPEC@[Link].

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Appendix 1

Child presents to ED with foreign body in nose

Button battery
suspected?

No Yes

Urgent removal required to

Removal not urgent
prevent tissue necrosis

• Keep NBM
• Targeted facial X-ray if cannot
Criteria for ENT
be directly visualised
referral?
(contact RSQ to arrange
(Box A)
transfer for X-ray if no on-site
X-ray)
No Yes

Single attempt at removal (see

Guideline for possible methods)

Successfully
removed and no
significant trauma?

Yes No

Discharge home with advice re Urgent referral to ENT

potential complications & Refer to ENT service. (onsite or via Retrieval
accident prevention Services Queensland (RSQ))

Box A: Criteria for ENT referral

Refer a child with the following foreign bodies to ENT (do not attempt removal in ED):
• posterior and not easily visualised
• paired magnets or magnet and metallic object across nasal septum
• chronic or impacted with marked inflammation
• penetrating or hooked
• remain despite multiple attempts at removal prior to ED presentation

Consider seeking senior Refer to onsite/local ENT as per local Refer to ENT (onsite or via Retrieval
emergency/ ENT advice as per practices. Contact CATCH on (07) Services Queensland (RSQ) on 1300
local practices 3068 4510 if no local ENT service 799 127) for urgent removal

CHQ-GDL-60022- Appendix 1 V1.0

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