Nasal Foreign Body

Common in young children, usually beads or plastic objects self-inserted.

See Blocked Ear for aural foreign body — technique and referral thresholds are broadly shared between the two sites. See Inhaled Foreign Body for an object that has passed into the airway.

Clinical presentation

The nasal cavity is divided by the septum and subdivided by three turbinates. Foreign bodies are usually found between the septum and the inferior or middle turbinate, or between the nasal floor and the inferior turbinate. Unilateral mucopurulent discharge, malodour or unilateral epistaxis in a young child should raise suspicion even without a witnessed insertion — counsel parents to return if these develop when a foreign body is suspected but not seen on examination.

Removal

Positive-pressure technique (“mother’s/parent’s kiss”) first, if the object is obstructive and the patient cooperative — especially within the first 12 hours after insertion. Seat the patient, occlude the contralateral nostril, and have the parent blow briskly into the patient’s mouth to force the object out. Simple nose-blowing can work if the child is old enough to do it reliably.

If that fails, direct removal under visualisation:

• Microsuction is strongly recommended for most objects in the anterior nasal cavity, and also clears secretions that obscure the view.
• Alligator forceps, curved hooks or a wax curette, positioned behind the object and pulled forward — moderately recommended, depending on the object’s shape/location and the child’s cooperation. Since objects typically sit wedged between two structures, stabilise the head to minimise mucosal injury from the instrument (the area is well vascularised and minor bleeding is common).
• Irrigation is not recommended — aspiration risk, particularly in a distressed child, even though this hasn’t actually been reported in the literature for a healthy child with intact airway reflexes.
• Topical co-phenylcaine (anaesthetic/vasoconstrictor), applied at least 5 minutes before the attempt, reduces pain, bleeding and secretions — age-adjust the dose and don’t use it under 2 years.
• Re-examine both nostrils after removal to confirm nothing remains — a second object is easy to miss.

The success rate is highest on the first attempt, so have equipment ready and a cooperative or adequately restrained patient before starting — a headlight frees both hands, and a nasal speculum/thudicum (or simply lifting the tip with the head extended) improves the view of the anterior nasal passage.

Children under 2 can be swaddled for immobilisation; older, uncooperative children are more likely to need sedation than repeated attempts at the bedside.

Complications and referral

Local trauma, infection, bleeding and (for aural foreign bodies) TM perforation are the main complications — risk rises with multiple failed attempts, a non-graspable object, and longer duration of impaction, which is the core argument for referring after one or two failed tries rather than persisting. Minor bleeding usually settles on its own. If infection is suspected, treat with saline nasal spray or flush, considering an intranasal steroid and oral antibiotics as needed.

Button batteries and disc magnets are a same-day emergency — refer immediately to ENT regardless of symptoms, since these cause ongoing tissue injury (electrolysis against moist mucosa) for hours after insertion, not just at the time of contact. Sharp, non-graspable or penetrating objects, or a child who can’t tolerate examination, may need presentation to the emergency department for removal under sedation with ENT involved. For everything else — inert objects, asymptomatic presentations, or simply lacking the right equipment or experience — a routine (non-urgent) ENT referral is appropriate; local paediatric ENT services may have a dedicated referral pathway separate from the general referral system, worth knowing in advance rather than discovering it mid-consultation.