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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 3  |  Issue : 3  |  Page : 107-110

Nasal injuries: The place of foreign bodies


Department of Otolaryngology, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria

Date of Submission18-May-2016
Date of Acceptance30-Sep-2016
Date of Web Publication2-Nov-2016

Correspondence Address:
Jones Ndubuisi Nwosu
Department of Otolaryngology, College of Medicine, University of Nigeria, Enugu Campus, Enugu
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-2010.193185

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  Abstract 

Objectives: The study was aimed to access foreign body (FB) injuries of the nose, the variety, age group affected, management, and complications as seen in our center. Materials and Methods: It was a retrospective study of 27 consecutive patients with suspected FB in the nasal cavity, seen and managed in the Otolaryngology (ENT) Department of a tertiary health facility in a suburban town, Southeast Nigeria over 18 months. The case notes of the patients in the emergency department, ENT clinic, and ward were consulted for the relevant data that were analyzed and presented in descriptive and tabular forms. Results: Male cases were less than females in the ratio of 1:1.7. All the patients involved were 5 years old and less with an average age of 2.54 years (standard deviation: 0.99). Beads 8 (29.6%) was the most popular FB retrieved. All the FBs were removed in the ENT department without general anesthesia, and no complication was recorded. Conclusions: FBs in the nose were more commonly seen in children. The types of FBs varied along the common objects, the children come in contact with. Seamless removal can be achieved with the right personnel operating in a conducive environment.

Keywords: Complications, foreign bodies, injury, nose


How to cite this article:
Nwosu JN. Nasal injuries: The place of foreign bodies. J Health Res Rev 2016;3:107-10

How to cite this URL:
Nwosu JN. Nasal injuries: The place of foreign bodies. J Health Res Rev [serial online] 2016 [cited 2020 Jul 11];3:107-10. Available from: http://www.jhrr.org/text.asp?2016/3/3/107/193185


  Introduction Top


Nasal injuries arising from foreign body (FB) may occur in any age group depending on the route but are usually seen in children, most commonly in 2–3-year-old children. They may be organic (sponge, foam, cotton wool, rubber, paper, wood, peas, beans, nuts, and others) or inorganic (buttons, beads, rings, metals, plastic parts, stones, etc.). Bony sequestra particularly in syphilitic disease or neoplasm may be found. The FBs may enter the nose through one or more routes such as the anterior nares most commonly, posterior choanae as in food entering during an episode of vomiting or while coughing at the time of eating, and penetrating wounds. Swaps or cotton wool may be left behind while cleaning.

Inorganic FBs are often asymptomatic and may only be an incidental finding. Organic FBs, on the other hand, are irritants and usually elicit inflammatory reaction of the nasal mucosa leading to nasal discharge. By and large, an impaction of FB in the nasal cavity is followed by an inflammatory reaction which is accompanied by a discharge. If the FB is neglected for a long period, calcium and magnesium carbonates and phosphates (calcium salts) may be deposited over and around it to form a rhinolith, which will require removal under general anesthesia. A very large irregular rhinolith, conforming with the elevations and depressions of the lateral nasal wall, has been removed from a patient aged 20 years under local anesthesia.[1] Rhinoliths, though uncommon in pediatric patients,[2] are nasal concretions formed around an FB, blood, or mucus. Neglected FBs in the nose among others are a cause of cacosmia. FB in the nose may progress with epistaxis, septal perforation, and rhinosinusitis depending on its duration and location. It is thus expedient to attend to nasal FBs at the earliest opportunity. This study was aimed to document the prevalence of nasal FBs in our setting, the age group most affected, presentations, nature, and types of FBs, methods of removal, and associated complications among others. It is hoped that the outcome of the study would engender the formulation of a protocol to be adopted by junior residents in tackling future cases and obviate harp-hazard approaches and its attendant complications.


  Materials and Methods Top


This was a retrospective study conducted on consecutive patients who presented with FB in the nose to the hospital and managed in the otolaryngology (ENT) department over 18 months from July 2014 to December 2015. The study is a retrospective analysis of all the patients that had FBs in the nasal cavity seen and treated in the hospital for a period of 1½ years (18 months) as indicated above. Patients of all groups and sexes treated for nasal FBs whose case notes provided adequate information were included in the study. Patients with FBs in parts or orifices of the body other than the nasal cavity were excluded from the study. The institution is a tertiary health facility located in a suburban town with robust flow of patients. Data were collected from clinic, ward, and emergency department records. The parameters accessed included patients' demographics, presenting features, types of FBs, removal processes, laterality of FB impaction, and complications following removal. The use of investigations, where applicable, was also documented.

Statistical analysis

The accumulated data were analyzed with descriptive statistics and presented in descriptive and tabular forms.

Ethical clearance was obtained from the Ethics Review Committee (Institutional Review Board) of the hospital before the commencement of the study.


  Results Top


There were 27 cases of nasal FBs studied, with 37.04% males and 62.96% females giving a ratio of 1:1.7. The patients involved were aged 5 years and below with the vast majority of them aged 3 years and less 22 (81.48%) and the remaining 5 (18.52%) >3 years of age [Table 1]. The mean age was 2.54 years (standard deviation: 0.99), and the range was from 1 year to 5 years with a median of age of 2 years. The majority of the FBs were lodged in the right nasal cavity in both males and females [Table 2]. Patients presented with witness insertion of foreign 8 (29.6%), unilateral foul smelling nasal discharge 7 (25.9%), incidental finding 5 (18.5%), nasal pain 3 (11.1%), and others 4 (14.8%) [Table 3]. Organic FBs outnumbered inorganic FBs in this series though the single most common foreign body recovered was beads 8 (28.6%) [Table 4]. The FBs were removed using Jobson Horne's probe, small crocodile forceps, cupped forceps, old metallic Eustachian tube catheters, and suction as appropriate. General anesthesia was not used, but the patient was well positioned and movement restricted before removal was attempted. There was no complication recorded during the removal process.
Table 1: Sex distribution of patients with nasal foreign bodies and their ages

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Table 2: Laterality of foreign bodies among the patients and their sexes

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Table 3: Presentation of patients with nasal foreign bodies

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Table 4: Types of foreign bodies found, sexes, and sides affected

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  Discussions Top


FBs in the nose are not uncommon and are more common in children than in adults. All the cases in the study were aged ≤5 years and most commonly affected children aged 0–3 years, as was the case in others.[3],[4],[5],[6],[7],[8] However, cases of nasal FBs in adults do exist,[4],[9] especially in mentally challenged individuals.

Females outnumbered males in the study whereas in others,[5] males predominated, and in some others,[10] there was no gender predilection observed. The number of cases studied, the type/nature of FB, and location of the study may explain this observation.

Witnessed insertion of FB and unilateral foul smelling nasal discharge were the most frequent presentations of the cases in this study which is similar to other studies.[4],[5],[9] Asymptomatic presentation [10] and unilateral rhinorrhea [3] were the leading symptoms in some others. As nasal FBs are generally painless, it is not out of place to find that the nasal cavity harbored FB for years without symptoms.[11] Presentation with unilateral nasal discharge raises the suspicion of nasal FB. Unilateral foul smelling discharge in a child is pathognomonic of FB in the nose until proved otherwise. Application of a vasoconstrictor such as xylometazoline hydrochloride (Otrivin) or 0.5% Phenylephrine to reduce edema and shrink the mucosa and subsequent examination of the nasal cavity (anterior rhinoscopy) and use of fiber-optic nasopharyngoscope or a 0° rigid endoscope will reveal the FB. Unilateral nasal blockage is not a prominent feature in this study and when present does not provide a reliable diagnostic criterion for FB as many unilateral nasal lesions such as tumors, sinusitis, choanal atresia, polyps, septal hematoma, and infections such as syphilis and diphtheria produce unilateral nasal obstruction in both children and adult [12] and have to be ruled out.

A variety of FBs were recovered in the series, largely organic though beads ranked highest. This was similar to findings by many other authors. In Ngo et al.,[5] the most common objects were beads, toy parts, and organic matter (e.g. sweets, seeds, and peanuts). In contrast, the most common nasal FBs in Chiun et al.[9] series were seeds and nuts 99 (36.7%), followed by plastic toys or beads 95 (35.2%) and in Mangussi-Gomes et al.[13] beans topped all the FB types in the nasal cavity. Other authors have reported rubber erasers, paper wads, safety pins, washers, nuts, sponges, and chalk.[14]

Although this study recorded no animate nasal FB, live animate nasal FBs are not infrequent in certain conditions. Nasal myiasis [13] has been documented. Infective conditions such as suppurative sinusitis and atrophic rhinitis can attract flies to deposit eggs, which hatch to produce maggots in the nasal cavities. Malignancy of the nose/paranasal sinuses and postradiation osteoradionecrosis may cause foul smelling nasal discharge, which may ultimately lead to the deposition of maggots.

In this study, the removal of the FBs was achieved with Jobson Horne's probe, crocodile forceps, cupped forceps, old metallic Eustachian catheters, and suction as indicated without general anesthesia. The type, nature, shape, and accessibility of the FB among others were considered before the choice of instrument and attempted removal. These have been similarly used.[5] Other methods of removal have been elaborated in literature. They include suction methods for removal of round FBs,[15],[16] a deep breath through the mouth and then forcefully expelled through the nose with the uninvolved nasal cavity closed in a cooperative patient and [17] forced mouth-to-mouth breathing with the occlusion of the contralateral nasal cavity (positive pressure ventilation through the mouth).[18],[19],[20] Positive pressure can equally be administered through the mouth using Ambu bag [21] or through the nose with oxygen tubing.[22] Use of a Foley's catheter [23] or a Fogarty biliary catheter.[7],[24] has been presented. Furthermore, the use of a wire loop or hook fashioned from paper clip has been described.[25],[26] Rarely, the FB is pushed backward into the nasopharynx [27] and retrieved through the mouth. This requires the use of general anesthesia with endotracheal intubation to protect the airway.

Live animate FBs such as maggots and larvae are handled differently. It requires the application of 25% chloroform solution into the nasal cavities to kill the maggots/larvae with repeated application as necessary. Blowing the nose for awake/conscious cooperative patients, and suction, flushing, or curettage for nonawake patient is used, respectively, to remove the FB.

Investigations were not used in the study. However, when the FB could not be found, ancillary investigations such as X-ray of the paranasal sinuses and lateral view of the neck, chest, and abdomen will show radiopaque FBs. Rhinolith is one case where radiography usually confirms the diagnosis and reveals its extent. Diagnostic nasal endoscopy helps to inspect the nasal cavity thoroughly and locate a clinically nonvisible nasal FB. Some authors were of the opinion that ancillary investigation is only indicated in patients with suspected FBs when careful physical examination and nasal and laryngeal endoscopy failed to produce additional evidence.[28],[29]

In this case series, no complications were recorded. This could be attributed to prompt intervention, and removal performed by skilled personnel adopting the appropriate techniques. Despite this, we make haste to submit that unskilled attempts to remove the FB may be fraught with adverse consequences. Complications may arise from the FB itself, the examination or attempted removal. Caustic FBs such as button batteries can cause mucosal damage and liquefaction necrosis of the surrounding tissue and so should be removed or referred urgently.[30],[31] In Ngo et al.'s series,[5] there were four cases of button battery FB: one had the complication of epistaxis, laceration, and perforation of the nasal septum, whereas another had ulceration of the nasal septum all documented present before removal of the FB. Attempts at removal may push the FB into the nasopharynx and consequent aspiration.[32] Nasal FBs have been shown to be carriers of organisms that cause diphtheria and other infectious diseases.[33] Hence, FBs in the nose are no less important than any other medical condition and should be recognized and seen as such.


  Conclusions Top


FBs are a cause of nasal injury. FBs in the nose are more frequently seen in children, especially those under 5 years. A variety of FBs would be found that mirror the common objects within the reach of the children. Removal could be easily achieved without consequence in a cooperative patient by skilled personnel adopting the appropriate method with the desired equipment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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