Rock in the Nose

A 4-year-old boy presented to the ED with a complaint of a nasal foreign body. The child was playing with his older brother, who dared him to place a rock in his nose. After accepting the challenge, both children confessed to their mother, who brought them to the local Urgent Care. Attempts at removal via “parent kiss” and balloon catheter were unsuccessful, so he was referred to the ED for further evaluation. The child was cooperative and in no acute distress. The Wispr digital otoscope was used to perform an anterior inspection of the left nares. The image is attached.

Which of the following is true regarding nasal foreign body (FB) management?

A. Positioning the child supine facilitates visualization.
B. The most common location for nasal FB becoming stuck is between the superior and middle turbinates.
C. Blind insertion of a balloon-tipped catheter is advised.
D. None of the above.

Nasal foreign body is a very common complaint, particularly among curious toddlers and young school-aged children. Successful removal is greatly facilitated by proper positioning, gentle restraint, potential use of anxiolysis, and visualization. The author’s recommended position is to have the child sit upright in a parent’s lap—this positioning has the advantage of allowing gravity to assist with removal (ie, the FB is less likely to dislodge posteriorly and potentially become an airway hazard) as well as utilizing the parent to provide a comfort hold with a hug around the child’s arm. Blind insertion of any tool into a child’s nose is never recommended. A good light source, often provided by a second assistant, is required to illuminate the nasal passage and identify the FB. The most common location for impaction is at the level of either the inferior or middle turbinate, often with a small gap along the floor of the nasal passage. This gap is the target for advancing the balloon-tipped catheter. A tip that greatly facilitates removal is to gently lift/tilt upward on the distal end of the catheter during removal. This “scoop” method ensures the FB does not slip back over the balloon, which may happen when the FB is large or if there is swelling to the tissue.

Utilizing the above technique with the Wispr as the light source and to document removal, the rock was removed without any challenges. The child did not want to bring the rock home with him.