Removal of foreign bodies (FBs) from the nose in children is a relatively urgent procedure because of the risks of aspiration. The same mechanical principles of removal apply to the ear.
The nose should be examined using a nasal speculum under good illumination. The tip of the nose should be raised and pressed with the tip of a thumb. Do not attempt to remove foreign bodies from the nose by grasping with ‘ordinary’ forceps.
Summary of methods of removal
It is best to pass an instrument behind the FB and pull it forward. Examples of instruments are:
Snaring the FB is the method most suitable for soft foreign bodies (e.g. paper, foam rubber, cotton wool). It is more applicable to the nose. Examples of instruments are:
Application of suction that uses instruments such as:
a rubber catheter
a fine sucker.
Irritation of FBs in nose (e.g. white pepper sprinkled in nose to induce sneezing).
Instruments for removal of foreign bodies: (a) eustachian catheter; (b) foreign-body remover; (c) crocodile forceps
The snaring technique is most suitable for soft objects such as paper, foam rubber and cotton wool.
Under good light and being careful not to push the object further back into the nose, snare the material with either crocodile forceps or a foreign-body remover and gently remove.
The method shown in Figure 10.11 simply requires good vision, using a head mirror or head light and a thin probe.
Removal of foreign body from ear: (a) probe inserted under foreign body; (b) tip of probe is lifted by depressing outer end of probe; (c) continuing levering ‘rolls’ the foreign body out
Insert the probe under and just beyond the FB (Fig. 10.11a).
Lever it in such a way that the tip of the probe ‘rolls’ the FB out of the obstructed passage (Fig. 10.11b, c).
This technique seems to be successful with both hard and soft foreign bodies.
This method requires an old-fashioned hairpin (the type with crinkly edges) bent to an angle of about 30°.
Push the pin back beyond the FB.
Depress the pin to ensnare the object.
Gently withdraw the FB (Fig. 10.12).
Extracting the foreign body using a hairpin
This method is relatively painless and highly effective; other methods of removing FBs may push them deeper into the nares.
Bent paper clip technique
A simple, effective and disposable instrument can be made with a paper clip.
As demonstrated in Figure 10.13, open the paper clip with the hairpin bends at both ends intact.
Angulate the smaller end of the clip. The sharp ends of the hairpin bends should be bent towards the straight stems of the clip so that they do not cause trauma. The degree of angulation can be increased by the use of small-artery forceps if desired. The larger loop acts as a handle to get an effective grip.
The angulated end, passed gently over the foreign body in the nose or ear canal, acts as a scoop to remove the foreign body.
Extracting the foreign body using a bent paper clip
Note: It is important to remember that only foreign bodies that can easily be seen in the ear or nose could be removed by this method. The paper clip instrument is not suitable for the removal of deeper foreign bodies. Patient cooperation is also very important.
Rubber catheter suction technique
The following is a relatively simple and painless way of removing foreign bodies from the ears and noses of children.
The only equipment required is a straight rubber catheter (large type) and perhaps a suction pump. The procedure causes minimal distress to a frightened child, avoids the need for a general anaesthetic, and is less traumatic than mechanical extraction for objects such as a round bead.
Cut the end of the catheter at right angles (Fig. 10.14a).
Smear the rim of the cut end with petroleum jelly.
Apply this end to the FB and then apply suction.
Extracting the foreign body using a rubber catheter: (a) catheter cut straight across near its extremity; (b) application of suction (orally or by pump)
Oral suction may be used for a recently placed or ‘clean’ object, but gentle pump suction, if available, is preferred (Fig. 10.14b).
It is advisable to pinch closed the suction catheter until close to the foreign body, as the hissing noise may frighten the child.
Pneumatic otoscopic attachment vacuum technique
The following method is ideal for the removal of a foreign body from the nose or ear of a child where it can be very difficult to extract without the use of a general anaesthetic. The method is similar to using a rubber catheter with the end cut off, and applying it to the foreign body using oral suction.
Use the pneumatic otoscope attachment by removing the end fitting.
Squeeze the bulb to create a vacuum effect.
Place the end of the rubber tubing against the foreign body (Fig. 10.15).
Release the hand-squeeze on the bulb in order to create suction.
Extract the object.
The rubber tubing is placed against the foreign body
This method works very well for smooth, round foreign bodies such as beads.
Tissue glue and plastic swab technique
This technique employs the simple method of applying a rapidly setting adhesive to bond the FB to the extracting probe. It works best in dry conditions and for a smooth non-impacted foreign body.
Apply a thin coat of cyanoacrylate or tissue glue to the end of a hollow plastic swab stick or orange stick.
Insert the stick into the ear canal (or nostril) to allow the glue to bond with the FB (if clearly accessible and suitable) for about 1 minute.
Remove the FB using gentle traction, perhaps assisted by external pressure from the fingers.
Caution: Avoid touching the skin or mucous membrane.
If glue is accidentally applied to the skin, dissolve the glue with acetone.
First line blow technique
Press the ‘normal’ nostril and encourage a seated cooperative child to blow out (snort) from the nose.
The ‘kiss and blow’ or ‘mother’s kiss’ technique
This method, also known as the ‘mother’s kiss’ technique, is used for a cooperative child with a firm, round foreign body such as a bead or hard pea impacted in the anterior nares.2,3
Gently occlude the normal (not affected) nostril with a finger. Place the mouth over the child’s mouth, blowing into the mouth until a slight resistance is felt. (This indicates that the glottis is closed.)
Then give a sharp high velocity blow (exhalation) to cause the foreign body to ‘pop out’.
To encourage cooperation with the technique the child can be asked to give the doctor a ‘kiss’ (or any ruse to allow placement of the lips over the child’s open mouth). Better still, explain the technique to the child’s parent and encourage the parent to perform it. (Mother is best!)
On all occasions that this technique has been used (adapted from an article in The New England Medical Journal), the foreign bodies ‘popped out’ after two attempts, thus avoiding general anaesthetic with intubation.