Children commonly shove objects up their noses or in just about any orifice they can find. It is our job to try to get these items out. Depending on the size and shape of the foreign body (FB), there are many techniques described for their removal. Objects that are not round and smooth can be removed directly using straight or alligator forceps.
Explore This IssueACEP News: Vol 28 – No 01 – January 2009
Items that are round and smooth can be difficult to grasp with forceps and may be pushed farther inward with each attempt to grab them. For such objects in the nose, one of the following indirect methods may be more appropriate. While covering the unaffected nostril, the child can blow forcefully through the affected nostril. Or, if the child cannot provide adequate force, a parent can blow into the child’s mouth instead. Although messy, this technique can be successful.
Alternatively, a small pediatric or neonatal Foley catheter can be inserted beyond the FB. After the Foley balloon is inflated, pulling it forward will also pull the FB forward. Both of these indirect techniques are hindered by the extensive soft tissue swelling that occurs in response to a foreign body, preventing it from being dislodged and/or preventing the catheter from passing beyond the object.
Fortunately, most objects that cannot be removed after a few attempts can be safely left in place for removal on a follow-up visit to an ENT specialist.
Button, or disk, batteries, however, are a special case. Batteries can cause destruction to surrounding tissues via liquefaction necrosis as the chemicals within them leak. For this reason, button batteries should be removed immediately to prevent further damage. In addition, unlike other objects that if swallowed will pass through the digestive tract without harm, batteries can cause necrosis to the tissues of the GI tract as well. All attempts should be made to prevent their being swallowed, and turning a relatively simple FB case into one requiring endoscopic removal.
PITrick of the trade: If magnets are useful during construction, why not in the emergency department? Most hardware stores sell a very small but very strong magnet. (See photo 1.) It is quite narrow and comes attached to a telescoping wand for reaching behind large obstacles and into crevices to retrieve screws, nuts, bolts, and small tools that have fallen out of reach. Coincidentally, this tool also fits perfectly into a toddler’s nose.
Before attempting this technique, ensure that the item being retrieved is a ferromagnetic metal. A great way to verify this is to test a similar item beforehand to ensure that it is attracted to the magnet with adequate force. A quality of ferromagnetic metals is that they can be strengthened by the addition of other magnets in series.
By attaching an even stronger magnet—such as the pacer magnet kept in most EDs—to the handle of the telescoping magnet, you can strengthen the magnetic force at the tip.
The advantages of using a magnet for removal of a foreign body are that this technique is not affected by the shape of the object, and it can be performed with minimal visualization. Furthermore, the risk of pushing the foreign body farther into the nose is minimal.
Once you have made contact with the object (you may or may not be able to feel this), it has become affixed to the magnet and can be pulled out. This technique should not, however, be used with objects with sharp edges that may lacerate the nasal tissues as they are pulled through. If the object being removed becomes lodged, gentle twisting and traction should help dislodge it.
Not all FBs are inserted. Patients can present with FBs that have become circumferentially stuck around fingers and other appendages.
In one case, a patient had decided to place 12 quarter-inch-thick (6 mm) steel rings around the shaft of his penis. We started our attempt to remove the rings by using the standard ring cutter. After only a few minutes, the ring cutter broke while making only a small scratch on the surface of the rings. Steel is much harder than the usual precious metals found in jewelry.
A Dremel tool was considered, but we thought that this might generate too much heat in the rings and adjacent penile tissue. With closer inspection of the rings, it became apparent that the thickness of these rings was about the same as that of a Steiman pin, which is also made of steel.
PITrick of the trade: Many of the medical devices used in orthopedics resemble things you can find at Home Depot. A Steiman pin is traditionally placed through the proximal tibia and cut on both ends with a “bolt” cutter. Although it serves the same function as a nonmedical bolt cutter, this cutter is made of stainless steel.
By making two cuts on each steel ring 180 degrees apart, this tool quickly cut through all the rings. (See photo 2.) To protect the underlying tissues from being inadvertently pinched by the cutter, we removed the padding from a malleable finger splint and inserted it between the ring and the skin at the site of each cut.
Dr. Afarian is faculty at the University of California, San Francisco–Fresno Emergency Medicine Residency Program and, despite frequently shopping there, he has no financial interest in Home Depot. Dr. Lin practices emergency medicine at San Francisco General Hospital (SFGH) and is the associate residency director at the UCSF-SFGH emergency medicine residency program. Contact Dr. Lin at email@example.com for comments or suggestions for other “tricks of the trade.”