EAR AND NOSE FOREIGN BODIES are a frequent occurrence in pediatric medicine settings. A child may present to the emergency department (ED) with a complaint of fever, runny nose, epistaxis, ear pain, or other seemingly unrelated complaints when, in fact, a foreign body is to blame. The emergency nurse practitioner (ENP) should utilize astute physical examination to identify the root cause of the complaint and employ the best treatment option to achieve relief. With appropriate preparation, equipment, knowledge, and skill, many of these patients can be treated safely and effectively in the ED.
BACKGROUND
Children presenting to the ED with head, ear, eye, nose, and throat (HEENT) complaints are not uncommon. According to the National Electronic Injury Surveillance System (NEISS) database, ear foreign bodies accounted for an estimated 429,881 ED visits, whereas nasal foreign bodies accounted for an estimated 371,162 visits during the previous decade. The NEISS database collects and provides data regarding consumer product-related injuries in the United States. The database was queried for the most recent 10 years from 2012 to 2021, younger than 1 year to 17 years, and a diagnosis for "foreign body" for the location "ear" with a separate query utilizing the same parameters for location "nose."
Some patients present immediately following the object(s) being placed in the ear or nose, and others may present days, or weeks later; still others are found incidentally when the patient is seen for a completely unrelated complaint. Children with unreported nasal foreign bodies most often present with foul-smelling, unilateral nasal discharge. Other symptoms that warrant evaluation for a possible nasal foreign body in children include unilateral headache, epistaxis, and blood-stained discharge (Baranowski, Al Araj, & Sinha, 2022). Although most patients with ear canal foreign bodies are asymptomatic, they may present with a sensation of ear fullness, loss of hearing, or pain (Marios, Tubbs, & Feldman, 2016).
MANAGEMENT
Any child presenting with an ear or nasal foreign body should have a careful assessment of the bilateral ears and nares to ensure additional foreign bodies are not overlooked. Although a foreign body may be of particular concern to a parent, it is important to discuss all risks and benefits of removal with them prior to the procedure. Additionally, there is evidence to support minimizing attempts at removal to avoid traumatizing or physically injuring the child as well as to avoid worsening of the condition (Dann et al., 2019; Roberts, 2019).
Identification of the foreign body will guide the provider's treatment decisions. Categories of foreign bodies, for the purpose of this discussion, have been outlined as noncompressible versus compressible (Oyama, 2019). Examples of each foreign body type are provided in Table 1. Emergency department providers should be proficient in multiple removal techniques, as one procedure is likely not appropriate for every foreign body type (Dann et al., 2019). The procedures outlined below are based on the literature review of currently supported techniques for pediatric ear and nose foreign body removal. The literature was largely similar in content including required equipment, instructions for removal based on foreign body composition, anatomic location, patient preparation, positioning and compliance, and provider skill and knowledge (Baranowski et al., 2022; Campo, Lafferty, Costantino, Ufberg, & Wilbeck, 2021; Grigg & Grigg, 2018; Lotterman & Sohal, 2021; Oyama, 2019; Roberts, 2019).
Procedure Preparation
Large urban hospital settings may have access to child life specialists to assist in foreign body removal procedures; however, small hospitals and clinics likely do not have access to this resource. The ENP can utilize the following tips to decrease child and/or parent anxiety related to the procedure:
* Explain in age-appropriate language what will happen during the procedure. To explain swaddling, the ENP may say "We're going to give you a big hug with this sheet to help you hold still while we tickle your ear to take out the bead."
* Show the child equipment that will be used for the procedure and explain any noises they may hear (i.e., suction). Allow the child to see and touch the equipment prior to the procedure.
* Allow the parent to participate by holding the child (if they are able to do so effectively and safely as instructed by the ENP)-this may be comforting to both patient and parent.
* Use distraction including turning on music, TV, tablets, etc.
If the ENP observes an object that they do not anticipate easy removal with available instrumentation then removal should not be attempted (Roberts, 2019). Similarly, if the above techniques are unsuccessful in achieving patient cooperation, it is not recommended that the patient is sedated in the ED to attempt removal. Sedation in this setting may increase the risk for complications, thus the recommendation for ear, nose, and throat (ENT) referral in these circumstances (Heim & Maughan, 2007; Roberts, 2019).
Nose Procedures
Presentation of nasal foreign bodies is most often found in the pediatric population. Right hand dominance in much of the population leads to foreign bodies most frequently being placed in the right nare, as the dexterity of a child does not support contralateral foreign body placement (Awad & ElTaher, 2017, Baranowski et al., 2022; Oyama, 2019; Zavdy et al., 2021). Nasal foreign bodies are most commonly found below the inferior turbinate or anterior to the middle turbinate (Cetinkaya, Arslan, & Cukurova, 2015).
Prior to removal of nasal foreign bodies excluding button batteries, a topical anesthetic (lidocaine 4%) and a vasoconstrictor solution (oxymetazoline or phenylephrine) may be applied. This will aid in removal by decreasing mucosal edema and lessening discomfort for the patient (Campo et al., 2021; Heim & Maughan, 2007; Isaacson & Ojo, n.d.; Roberts, 2019). The ENP should anticipate that utilizing these medications may not aid in removal of the foreign body but actually complicate the procedure, as children are often not tolerant of nasal sprays. Techniques for removal of nasal foreign bodies including positive pressure, manual instrumentation, suction, and the use of cyanoacrylate are outlined in Table 2. Because of the high risk of aspiration or choking, irrigation is not an appropriate method of nasal foreign body removal (Baranowski et al., 2022).
Positive Pressure
The "parent's kiss" method may be used when a parent or caregiver is willing to assist in foreign body removal. This technique is most successful with larger objects such as beads or beans. With the child lying supine, have the parent occlude the unaffected nare. Instruct the parent to place their mouth over the child's mouth, forming a firm seal, then forcefully exhale into the child mouth. The same principle may be applied utilizing a bag valve mask (Campo et al., 2021). Positive pressure techniques are depicted in Figure 1.
Manual Instrumentation
For successful removal with manual instrumentation, the foreign body must be clearly visualized. For objects that are easily grasped, alligator forceps may be used. Objects that are not able to be held with forceps may be removed using a balloon catheter, such as a pediatric Foley catheter (5 or 6F) or other commercially available catheter. The tip of the catheter should be inserted into the nare and past the object. Gently inflate the balloon and withdraw anteriorly, guiding the object out of the nose.
Suction
The standard tool for foreign body removal via the suction technique is the Frazier suction catheter; however, other catheter types may be used in certain instances. Place the tip of the catheter against the foreign body and gently retract the catheter in an attempt to remove the object. When attempting to remove noncompressible foreign bodies, this technique is most likely to be successful if the object is loose in the nasal cavity. Suction may be more successful in removing compressible objects while avoiding breakdown of the object material. This method of foreign body removal may be used to completely remove the foreign body or to aid in moving an object lower into the nasal passage to allow for removal by other techniques.
Cyanoacrylate
Medical adhesive glue and a cotton applicator may be used to remove round or otherwise difficult-to-grasp objects that are clearly visible to the provider. A small amount of adhesive is applied to the end of the applicator and placed directly against the foreign body. Allow the adhesive to dry (~60 s) and then carefully extract the applicator with the foreign body attached. This technique should only be utilized in patients who are extremely cooperative and able to sit still for at least 90 s. Caution should be used to avoid attaching adhesive to nasal mucosa. If the applicator/adhesive becomes attached to the nasal mucosa, the ENP may utilize a petroleum-based solution/ointment to dissolve the adhesive.
Ear Procedures
Children presenting with ear foreign bodies are also a common occurrence in emergency medicine. Helbing, Straughan, Pasick, Benito, and Zapanta (2021) note that there were 20,545 ear foreign body cases from 2010 to 2019 according to the NEISS database. Females presenting with ear foreign bodies are most commonly found to have a piece of jewelry or first aid material whereas males are more likely to present with paper products, desk items (pens, pencils, erasers etc.), rocks, or BBs (Helbing et al., 2021; Xiao, Kshirsagar, & Rivero, 2020). Like nasal presentations, foreign bodies are more commonly found in the right side (Awad & ElTaher, 2017). Objects often become wedged in the natural narrowing of the ear canal where the cartilaginous and bony portions join. The skin of this area is tightly adherent, leading to significant discomfort when manipulated (Grigg & Grigg, 2018).
Techniques for removal of ear foreign bodies including irrigation, manual instrumentation, suction, and the use of cyanoacrylate are outlined in Table 3.
Irrigation
Fill a 20-ml or larger syringe with body temperature water and attach an 18-gauge or larger angiocatheter. Place the tip of the angiocatheter beside or behind (if possible) the foreign body, and depress the syringe plunger expelling the water through the angiocatheter with slow and steady force. Observe for the foreign body to be washed out of the canal. Consideration of water temperature is important to avoid vestibular stimulation and prevent a thermal injury to the canal and or tympanic membrane (TM). Irrigation should not be utilized to remove foreign bodies that may expand (beans, sponges, and paper), button batteries, or if the integrity of the TM is questionable.
Manual Instrumentation
For cooperative patients with ear foreign bodies that are directly visualized, manual instrumentation using alligator forceps or ear curettes may successfully remove the object. If a patient is not able to cooperate and sit still, care must be taken to adequately and safely restrain the patient to avoid movement during the procedure. The ENP should follow their facility protocols for safe restraint including the use of commercially available restraint devices or swaddling with a sheet (see Figure 2). Parents or ancillary staff may also assist in holding and positioning the child with attention to immobilization of the head (see Figure 3). Objects that are not easily grasped, but may be swept out of the canal, may be retrieved by reaching a curette behind the foreign body and gently pulling toward the opening of the canal. When attempting removal with a curette, caution should be used to avoid contact between the curette and the TM. If a foreign body is against the TM, this may require ENT specialist referral. As with nasal foreign body removal, alligator forceps are used for objects that can be adequately grasped and gently pulled from the ear canal.
Suction
Prior to beginning this procedure, warn the patient of potential noise. As with use of suction to remove nasal foreign bodies, place the tip of the catheter against the foreign body and retract. Suction may be successful in removing compressible objects while avoiding breakdown of the object material. Suction techniques may not provide enough negative pressure to remove an object lodged in the ear canal.
Cyanoacrylate
The procedure and technique utilizing cyanoacrylate adhesive for ear foreign body removal are largely the same as that for nasal foreign body removal. Caution should be used to avoid attaching adhesive to skin of the ear canal or accidental advancement of the foreign body deeper into the canal. This technique should only be utilized in patients who are extremely cooperative and able to sit still for at least 90 s.
Special Considerations
Insect foreign body presentations are more commonly found in children older than 10 years (Marios et al., 2016). Any insect in the ear should be killed prior to removal attempts (Lotterman & Sohal, 2021Oyama, 2019; Roberts, 2019). Methods to kill the insect include the use of mineral oil, lidocaine (gel or liquid), and alcohol. Mineral oil has been shown to be more effective; however, use of nonviscous agents will aid in visualization of the insect for removal (Campo et al., 2021; Lotterman & Sohal, 2021; Oyama, 2019). Once the insect has been killed, removal may occur by any of the above methods taking particular care to avoid dismembering the insect and removing it fully.
Xiao et al. (2020) notes an estimated 5,400 cases annually of embedded earrings in children. Of these cases the vast majority are in females. These embedded foreign bodies often require instrumentation and possible surgical intervention (Xiao et al., 2020). Providers in the ED may attempt removal of an earlobe-embedded foreign body when the earring, including the full post and back are present (with the back embedded) by utilizing both hands to grasp the earlobe while applying pressure to the anterior side of the earlobe, pushing posteriorly. This should allow the back to rise to a point that it may be removed followed by removal of the earring (Campo et al., 2021). If this method is unsuccessful, or the earring is not present and only the back is embedded, the provider may make a small incision to the posterior pinna and utilize additional instrumentation such as hemostats to spread the skin and remove the foreign body (Campo et al., 2021). The wound may then be cleaned with saline and treated with topical antibiotic ointment. If the above attempts are unsuccessful, ENT or specialist referral should be made.
Complications
Although the majority of ear and nose foreign bodies in children are benign and removal by ED providers is typically a safe procedure, the potential complications of a retained foreign body and of the removal should be understood.
Retained Foreign Body
The risk of complications increases when a foreign body remains in the ear or nose for more than 72 hr (Awad & ElTaher, 2017). This allows for urgent, but not emergent, ENT referral for most foreign bodies that cannot be removed in the ED. The major exception to this is button batteries, as the current effects and leakage of battery contents cause necrosis. In the setting of nasal foreign bodies, the necrosis caused by button batteries may lead to septal perforation in as less as 4 hr (Baranowski et al., 2022). Disc magnet foreign bodies can lead to similar effects on the nose. Patients with nasal foreign bodies accompanied by purulent nasal discharge and other findings consistent with bacterial sinusitis should be treated with oral antibiotics (Isaacson & Ojo, n.d.). Due to the risk of TM injury, other ear foreign bodies that require immediate removal and the potential need for emergent ENT referral include insects and potentially penetrating objects (Friedman, 2016; Marios et al., 2016).
Procedural
Localized tissue trauma, leading to swelling and epistaxis, is the most common complication of nasal foreign body removal (Friedman, 2016). Any postprocedure epistaxis should be managed as usual (Campo et al., 2021). The most concerning complication of attempted nasal foreign body removal is posterior displacement of the object, as this could lead to aspiration and secondary morbidities (Baranowski et al., 2022).
Serious complications of ear foreign body removal are uncommon but include TM perforation and injury to the ossicular chain. The most frequently seen complication of ear foreign body removal is irritation or abrasions of the ear canal. Antibiotic eardrops may be prescribed to promote healing, although the skin of the canal will typically heal quickly when kept clean and dry (Heim & Maughan, 2007; Lotterman & Sohal, 2021). In the unfortunate event that the TM is perforated during attempted foreign body removal, the patient should be prescribed otic safe antibiotic eardrops and provided with referral and follow-up with ENT.
Teaching Pearls for Home Care
* Parents should be educated on the use of kiss technique so that future ED visits for nasal foreign bodies may potentially be avoided (Baranowski et al., 2022).
* Button batteries pose significant risks for children. Parents should be aware of any items that contain these batteries and should never allow a child to have unsupervised contact with such items (Baranowski et al., 2022).
* Allowing children to only have access to age-appropriate toys, food, and household items is key to preventing foreign bodies of the ear and nose (Cetinkaya et al., 2015).
* Ear foreign bodies may be prevented in infants and young children if parents are encouraged to delay ear piercing until children are at least 4 years of age (Helbing et al., 2021).
CONCLUSION
Ear and nose foreign body removal in the pediatric patient can be complex due to patients' inability to communicate effectively, poor compliance with procedures, and fear of pain. With adequate knowledge, equipment, and education, ear and nose foreign bodies are often successfully managed in the ED setting.
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