Though nasal foreign bodies (NFBs) are benign in nature, they are likely to cause mucosal damage, bleeding, infection, and also aspiration in extreme cases. To develop better success for NFB removal mainly in the first try, a simple 4-step approach has been devised, and presented by Tian-Tee Ng and Michael Nasserallah in their paper titled 'The art of removing nasal foreign bodies'.

A common presenting complaint seen in the emergency department is one of a nasal foreign body (NFB) which is usually noticed in the paediatric population, and in patients with psychiatric illness or developmental disabilities. Children have more interest in exploring their bodies so there are more chances of them placing objects in their nasal cavities.

There are two types of NFBs:

• Organic: Examples include paper, sponge, nuts, and beans
• Inorganic: Examples include beads, pieces of toys, foam, batteries or magnets 

Treatment & Management

Mostly, laboratory investigations are not necessary. In case there is a doubt or any suspicion or poorly visualised battery or magnet, imaging can be performed. Before starting the treatment of NFB in a child, a proper history should be taken. The pathognomonic sign of a retained NFB is seen in cases of a child having a foul-smelling unilateral nasal discharge.

Techniques available for removal of NFBs:

1. A bright light source such as a headlamp is needed for the removal of NFBs.
2. Other needed instruments include a nasal speculum, various size probes, curettes, and alligator forceps.
3. If the NFB is a paper or sponge material, it is dragged out directly by the use of alligator forceps.
4. Curette and probes are best used for removing smooth and spherical objects by placing them behind the object and then pulling the object forward.
5. Another method of removal is by forced exhalation and this may involve the parent or the use of a bag valve mask (BVM).
6. To remove or lower an object into the nasal passages, suction may be used. Flexible suction catheters or Yankhauer can be utilised on patients based on their size.
7. If the patient is very cooperative, glue can be applied in such cases. By applying a cotton swab with a small amount of glue to a spherical, well-visualised object, the object can be dragged forward and out.
8. The practitioner should have suction readily accessible, and it is imperative that the child’s parent or a caregiver hold the child tightly as is done in a papoose or with sheets in the sniffing position. 
9. Under sedation, the foreign body is capable of freeing and causing aspiration if it moves posteriorly. Hence, a precondition to prepare for an advanced airway if required should be in place.
10. A topical vasoconstrictor can be used to envisage the object, to reduce bleeding and to dry the secretions. However, this is not recommended in the cases where there is a possibility of a button battery as there are chances of increased acid leakage.

Points to keep in mind

1. A child having NFB normally only permits one or two attempts for removal of the NFB, so this should only be done by an experienced medical personnel.
2. An experienced medical person should perform all first attempt failed removals.
3. If there is lodging of any button batteries, magnets, or posterior displacement of any objects, an otorhinolaryngologist (ENT) referral should be made since a nasal endoscopy or removal of the NFB in the operating room may be needed.
4. Due to the increased risk of choking and aspiration, flushing is not recommended anymore.

*Reference:

Tian-Tee Ng and Michael Nasserallah.The art of removing nasal foreign bodies.Open Access Emerg Med. 2017; 9: 107–112.