How To Remove a Foreign Body From the Nose

• Simple nasal foreign body*

* Common, self-inserted objects as in examples above (not including projectiles, impalements, or other complex situations)

Absolute contraindications

• Inability to see the foreign body or reach it with available instruments

Relative contraindications

• Impacted foreign body associated with significant inflammation and/or edema

• Foreign body that is small, transparent, and/or situated far posteriorly or superiorly

• Failed attempts at removal

Consult an ear, nose, and throat (ENT) specialist (who may need to do nasal endoscopy) if there is doubt about the ability to remove the object or if repeated attempts at removal have been unsuccessful. Multiple attempts increase the risk of injury and/or movement of the object deeper into the nose where it is more difficult to retrieve.

• Injury to nasal mucosa and resultant bleeding

• Aspiration of the object, particularly in sedated patients

• Chair with headrest or an ENT specialist's chair

• Light source and head mirror or headlamp with adjustable narrow beam

• Gloves, mask, and gown

• Cotton swabs or pledgets to apply topical drugs

• Nasal speculum

• Suction source and Frazier-tip and/or other suction-tip suction catheters of various sizes

• Bayonet or alligator forceps

• Wire loop and hook curettes

• Balloon-tipped catheter (5 to 8 French Fogarty catheter or Katz extractor)

• Button batteries and magnets must be removed immediately. Batteries may cause chemical burns (from leakage of battery contents) or electrical injury of the nasal tissue, and magnets can cause pressure necrosis of nasal structures, including the septum. Consider urgent ENT consultation in these cases.

Anatomy & Function: Nose and Pharynx

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• The lateral wall of the nose has 3 turbinates. These can be fragile and should not be mistaken for foreign bodies or tumors.

• The nasal septum is often deviated and, if deviation is found on examination, extra care should be taken when introducing instruments to prevent trauma to the septum.

• The patient should sit upright in the sniffing position with head extended, preferably in a specialized ENT chair. The patient's occiput should be supported to prevent sudden backward movement. The patient's nose should be level with the physician's eyes.

• Have the patient gently blow the nose to remove mucus and perhaps the foreign body. If the nose is dripping, suction the nasal passageway carefully to remove mucus without pushing the foreign body further posterior.

• Apply a topical anesthetic and vasoconstrictor to reduce sensitivity and mucosal swelling.

• Wait 3 to 5 minutes to allow the anesthetic and vasoconstrictor to take effect. If there is still significant edema, apply a second treatment of topical vasoconstrictor.

• Insert a nasal speculum with your index finger resting against the patient's nose or cheek and the handle parallel to the floor (so the blades open vertically).

• Slowly open the speculum and examine the nose using a bright headlamp or head mirror, which leaves one hand free to manipulate suction or an instrument.

• Use a Frazier-tip suction catheter to remove any mucus obscuring the view.

• For certain soft objects and hard objects with a graspable edge located anteriorly, grasp and remove the object using forceps (eg, alligator or bayonet forceps).

• Remove harder or larger objects located anteriorly by placing a wire loop or hook curette behind the object and gently pulling.

• Remove smooth, round objects using a suction catheter; place the suction tip against the object with the finger control open. Then cover the finger control to apply suction and gently remove the object.

• Remove objects not amenable to an anterior approach with a balloon-tipped catheter (eg, an 8 French urinary catheter). Insert the lubricated deflated balloon behind the object. Be careful not to push the object further into the nasal passage. Slowly inflate the balloon with air—about 2 mL in small children, 3 mL in older children, and 5 mL in adults. Slowly withdraw the balloon, pulling the object forward until resistance is met, then remove the object. Deflate the balloon and remove it from the nose.

• After removal of magnets or batteries, refer patients for otolaryngology evaluation due to the risk of nasal soft tissue damage from the foreign body.

• Antibiotics are typically not indicated following removal of a foreign body.

• Do not open the nasal speculum laterally or use in an unsupported manner. (Brace a finger of the hand holding the speculum on the patient's cheek or nose.)

• Trying to grab round, smooth objects with forceps often makes them slip deeper.

• Cease attempts at removal if they are unsuccessful. Making repeated attempts is a common cause of unnecessary trauma.

• In general, removal by direct visualization and instrumentation is preferable to other techniques.

• Elevating the patient's chair to eye height is easier on the practitioner's back than bending down.

• Examine the contralateral nasal cavity, oral cavity, and ear canals for additional foreign bodies.

• Reexamine the nose after removal of a foreign body to prevent missing another foreign body.