SEARCH

SEARCH BY CITATION

INTRODUCTION

  1. Top of page
  2. INTRODUCTION
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. CONCLUSION
  7. Acknowledgements
  8. BIBLIOGRAPHY

Management of nasal foreign bodies (FBs) is a common problem in the ear, nose, and throat (ENT) practice. Pediatric nasal FBs are usually treated in the emergency department, but, in many institutions, directly by the ENT specialist on call. However, the management of the extraction of nasal FBs sometimes can be frustrating and distressing for the physician, the patient, and the patient's parents. If removal is not feasible in the emergency setting, then hospitalization is mandatory, and a general anesthesia or sedation is required for the extraction.

Although endoscopes are part of the ENT's diagnostic and therapeutic armamentarium, data in the literature on extraction of nasal FBs in awake children encompass, mostly, the use of rigid scopes; however, this procedure is not free from accidental injuries and complications, particularly in children. We describe a simple new technique for selected nasal FB removal in awake children, using the flexible endoscope both as a camera and an extractor.

MATERIALS AND METHODS

  1. Top of page
  2. INTRODUCTION
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. CONCLUSION
  7. Acknowledgements
  8. BIBLIOGRAPHY

The technique includes one physician, one nurse, and one caregiver. The instruments used are a flexible endoscope and a video station. The technique was recently employed by the author (G.G.) during the removal of nasal FBs in three children, ages 2, 4, and 5 years, some hours upon insertion. The objects removed were a pen's cap, a peanut, and a jewel. Upon arrival in our tertiary referral hospital, the patients were accepted by the pediatric emergency department, and subsequently an ENT consultation was requested. On admission in our clinic, the event's history was taken from the caregivers and, if possible, from the child, after which the procedure was explained to both using simple words. We find of particular use, when dealing with younger children, phrases such as, “would you like us to take out the little mouse from your nose?” In our experience with pediatric transnasal endoscopy, children seem to understand and cooperate more if the situation is explained by similar words. Subsequently, the 2-year-old child was held on the parent's legs, with arms and legs both blocked in position by the caregiver, and the head held semiflexed by the nurse. The other two children were able to bear the procedure and cooperate, so they were positioned seated on the operative bed and gently held by the caregiver and the nurse. Neither topical anesthesia nor vasoconstrictive agents were administered in any of the three cases. The nasal valve area was cleared by nasal blowing or with a rubber suction catheter. Then a classic anterior rhinoscopy was executed, aimed to assess the object's size, location, shape, and the status of the nasal cavity. The hook-scope extraction technique was then performed.

Technique

The procedure started with the advance of the flexible endoscope (3.7 mm diameter) in the nasal fossa, with the aim to visualize the FB (Fig. 1). Upon recognition of the FB, the mucosal status was assessed, and, as long as obstructive mucosal edema was not observed, the procedure advanced to the next step. The scope's head was then turned superiorly to identify the nasal area above the superior margin of the FB, which was clear in all patients. This area is the pathway (P) that permits communication between the anterior object nasal area (AOA) with the posterior object nasal area (POA) (Fig. 2). The existence of such a pathway is a conditio sine qua non for the feasibility of the technique. The endoscope was subsequently advanced in the AOA and the P areas, slipped above the FB, and, finally, descended in the POA area facing the nasal floor in a maneuver that bypasses the object (Fig. 3A and 3B). During this part of the procedure particular attention was paid so as not to inadvertently dislocate the object towards the choanae. The posterior extension of the FB and the status of the posterior nasal cavity were rapidly assessed, after which the tip of the scope was turned anteriorly towards the object, encasing the FB like a hook or an uncinate (Fig. 3C). The FB was then disengaged-mobilized, by gently pulling the scope anteriorly towards the nasal vestibule, keeping it locked in the flexed mode and the object enclosed within its hook (Fig. 4). Following extraction, a diagnostic endoscopy was performed to reassess the status of the entire nasal cavity.

thumbnail image

Figure 1. Anatomic specimen: scope's approach to the foreign body blocked between the inferior turbinate and the nasal septum (0° scope view after removal of the membranous septum).

Download figure to PowerPoint

thumbnail image

Figure 2. Cadaveric specimen: view of the lateral nasal wall. O = object area; AOA = anterior object area; P = pathway; POA = posterior object area.

Download figure to PowerPoint

thumbnail image

Figure 3. Anatomic specimen: 0° scope view of the procedure from the nasal choanae. The object is located between the inferior turbinate and the septum. (A) scope above the object, (B) scope bypassing the object, (C) scope encasing the object.

Download figure to PowerPoint

thumbnail image

Figure 4. Two-dimensional reproduction of the hook-scope maneuver.

Download figure to PowerPoint

RESULTS

  1. Top of page
  2. INTRODUCTION
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. CONCLUSION
  7. Acknowledgements
  8. BIBLIOGRAPHY

In all three cases, the entire procedure was carried out in less than 15 minutes, including initial assessment and preparation. From insertion of the nasal scope to removal of the object, the average time was 15 seconds to 20 seconds, with minimal distress for the patients. No complications or injuries were noted during the procedure and no further therapy was required. All the patients were discharged immediately after the procedure.

DISCUSSION

  1. Top of page
  2. INTRODUCTION
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. CONCLUSION
  7. Acknowledgements
  8. BIBLIOGRAPHY

An encounter with a pediatric nasal foreign body is not a rare ENT clinical problem. It usually concerns patients between 2 years and 6 years.1 Most frequently, FBs are identified as toys, sweets, jewels, rocks, batteries, and magnets; their shape commonly presents as spherical, however almost every form can be noted.2, 3 Although often asymptomatic, sometimes nasal FBs can cause sneezing, epistaxis, nasal obstruction, nasal discharge, pain, and eventually rhinosinusitis.1, 4, 5 Batteries and magnets deserve particular mention because they require immediate treatment, as they can cause septal necrosis and perforation within hours.6 The most frequent anatomic sites of FBs encounter are between the anterior third of the inferior turbinate and the septum, or the area anterior to the middle turbinate.3, 7 Identification of the object's location, size, form, and the status of the nasal mucosa is crucial for the choice of the extraction method; concomitantly the parent's and, if possible, child's cooperation constitute very important factors for the successful extraction in the conscious patient. Removal by the emergency physician or the ENT surgeon can involve many methods and instruments; some of the most used are stimulated sneezing, forced nasal exhalation, intranasal positive pressure creation, nasal washing, balloon catheters, adhesives, suction, and mechanical extraction with probes, hooks, forceps and similar equipment.2, 5, 7, 8

In Pavia's University Hospital, all pediatric cases of nasal foreign bodies are referred for an ENT evaluation and treatment so as to minimize morbidity, hospitalization rates, and possible injuries and/or complications associated with the extraction procedures.9, 10 Thus, the experience gained in children's FB extraction is quite important. Until recently, our approach in the conscious child moved from an initial evaluation and attempted extraction under anterior rhinoscopy to a rigid endoscopic removal. If that failed, a sedation-general anesthesia rigid endoscopic removal was arranged. When rigid endoscopic extraction is performed, children are kept supine. In the present technique, younger children's endoscopic FB removal procedure could be performed keeping them seated with parental assistance and with the head in a semiflexed position, so as to avoid posterior object dislocation and, rarely, airway emergencies. In older children, and if particularly cooperative, a semirecumbent or even supine position can be used.

The core of the technique is that the foreign body is actually embraced by the endoscope, which subsequently acts as an extractor. We think that some benefits of this technique are use of standard ENT equipment; clear visualization of the foreign body, its extension, and form; and an assessment of the nasal status for possible damages before extraction. The technique is effective even in extracting posteriorly located and round objects that are difficult to grasp. As a possible limitation, we should note the required pediatric experience with the sinonasal endoscopy. Moreover, the principal author (G.G.) wishes to underline that the procedure can only be performed if the nasal area above the object is clear, so that the scope can bypass the FB. Finally, we think that if not in expert hands, the endoscope may become damaged after many operations. This could possibly happen if nongentle moves are performed and if the nasal mucosa-object adhesion does not permit a smooth extraction. In such cases, pharmacological vasoconstriction of the anterior nasal mucosa and some local anesthetic could partially disengage the object and facilitate the procedure. However, this was not required in our three cases. The same procedure can be carried out, as well, in the sedated child, although extraction in that case would be best performed by a two-hands rigid endoscopic approach.

CONCLUSION

  1. Top of page
  2. INTRODUCTION
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. CONCLUSION
  7. Acknowledgements
  8. BIBLIOGRAPHY

Extraction of nasal FBs in children is a very common problem for emergency and ENT staff. It can be accomplished through many methods, from provoked sneezing to surgical extraction under general anesthesia. Our simple technique engages the flexible endoscope, both as a camera and dislocator-extractor. It can be used in the removal of selected objects and points to possibly reducing the hospitalization rates and the need for removal under general anesthesia. However, it should be performed by an otorhinolaryngologist with some experience in pediatric endoscopy. Extended case series are required to assess the effectiveness of our technique and, eventually, propose a practical algorithm for endoscopic FB removal.

Acknowledgements

  1. Top of page
  2. INTRODUCTION
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. CONCLUSION
  7. Acknowledgements
  8. BIBLIOGRAPHY

The authors wish to thank Dr. E.J. Blenke for the critical review of the manuscript.

BIBLIOGRAPHY

  1. Top of page
  2. INTRODUCTION
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. CONCLUSION
  7. Acknowledgements
  8. BIBLIOGRAPHY