This post is based on a talk I gave for the London School of Paediatrics in June 2020 and will focus on foreign bodies in the nose and ear. If you’d like to read about ingested foreign bodies, please read this from Andrew Tagg.
Foreign bodies in the ear or nose
Children often present to the emergency department with something alien in their ears or nose. They’re usually in the preschool age group and have been experimenting by sticking things in their various orifices. Most children can be found with a finger up their nose reasonably regularly, but sometimes other objects too. These can be among the more light-hearted ED attendances, but only if you have some strategies to deal with them.
4-year-old George comes into your ED with his exasperated mother. She explains that he’s been telling her he has a phone in his ear for the last two days. “Obviously, he hasn’t”, she says, “but please, would you just have a quick look so I can tell him to stop going on about it”. You have a quick look in his ear and see something blue.* How will you proceed?
Some general considerations to aid success
Preparation is key. This means preparing the child, and yourself, for the procedure.
Think of foreign body removal as a one-time offer. You’ll generally have only one good go at it, so preparation is everything. This means getting the right people involved, ideally, a play specialist or someone else whose only role is to distract and calm the child. Make sure they know what will happen if they are old enough to understand. If they cannot keep still, position them appropriately on their parent’s lap or maybe wrapped in a blanket. Foreign body removal is generally not painful (or shouldn’t be), but for children who are able, nitrous oxide can be a valuable aid for its anxiolytic properties in addition to distraction.
Prepare yourself. Make sure you use the right technique and equipment for the job. There are several options:
The Kissing Technique
This is a valuable technique for removing FBs from the nose and works especially well for solid objects such as beads. Getting the parent on board with it and briefing them about the technique is key:
- Sit the child sideways on the parent’s lap with one of the child’s arms tucked away under the parent’s arm
- Brief the parent that you want them to cover the child’s mouth with their own while you occlude the unaffected nostril
- Get the parent to deliver a short sharp breath and, hopefully, the FB will shoot out!
For parents who either can’t master the technique or face it, the same effect can be achieved with a bag-valve-mask: choose a mask that covers the child’s mouth and occludes the pop-off valve to increase the pressure. Ask a colleague to hold the mask and the unaffected nostril while you squeeze the bag sharply.
Other useful tools and techniques
Head torch – this is a game-changer in foreign body removal. It prevents you from trying to hold a torch in your mouth while holding an ear in one hand and a tool in the other.
Yankauer suction is good for removing objects with a smooth surface, e.g. beads and polystyrene balls. Warn the child it’ll not be quiet, and let them hear it before you start so they don’t jump away.
Syringe and water – suitable for items that float or disintegrate, e.g. tissue, Play-Doh, polystyrene beads. Add a cut-down NG tube on the end to make a smaller nozzle. Fill with warm water (for comfort) and irrigate generously.
Jobson Horne probe – helpful to get behind objects in the ear canal that won’t come out with suction. In this case, it will only work if there’s a little gap and you can get behind it.
Wax hook – can be used to get behind foreign bodies, as above, or to hook into softer objects such as bits of tissue or peas. Make sure you don’t leave some behind with this method.
Crocodile forceps – helpful with small or softer objects or those with an uneven surface where there’s something to grab.
TOP TIP: magnetize the shaft to make it easier to pick up metal FBs
Magnets – can be used by rubbing them down the side of the nostril to work a foreign body down and out.
TOP TIP: the magnets on name badges are often useful for this if you don’t have a store of magnets specifically for the purpose.
Cotton bud and glue – can be used to remove foreign bodies from the ear canal if they’re challenging to get behind or to grab. Apply a drop of whatever tissue adhesive you use to the end of a cotton bud and hold it on the offending item for 30 seconds or so, then pull out. This requires a steady hand and a reasonably still child. Be aware that this method can lead to adherence of the offending item to the ear canal.
Foley catheter – pass it behind a foreign body in either the nose or ear, inflate the balloon and then pull out, bringing the piece of corn.
If at first, you don’t succeed… stop
Complications can arise from failed attempts at removal, especially those involving the ear canal. These can range from pain, bleeding, distress, and the loss of trust to rare but severe complications, including middle ear damage, hearing loss, vertigo, facial nerve paralysis and meningitis (Dance et al., 2009). Stop, re-group, and consider the options if an attempt isn’t going well. It may be that a referral or a different approach is required.
Or maybe, don’t even start
If there is minimal chance of success, either because the FB is deep, impacted, or ungrabbable, or the child cannot cooperate for whatever reason, think twice before starting. It may be better to bring them back when you have play specialist support or to refer them to ENT for specialist assistance.
You involve the play specialist and prepare George to remove the foreign body in his ear. Wearing your headtorch, you gently pull on his pinna, you insert a pair of crocodile forceps into his ear canal, and pull out… a teeny tiny toy phone! Vindicated, George squares up to his mum: “I told you!”.
*This is a true story (anonymized) from a long time ago, and one of my favourite ED presentations ever!
Chan, T. C., Ufberg, J., Harrigan, R. A., & Vilke, G. M. (2004). Nasal foreign body removal. Journal of Emergency Medicine, 26(4), 441–445. https://doi.org/10.1016/j.jemermed.2003.12.024
Dance, D., Riley, M., & Ludemann, J. P. (2009). Removal of ear canal foreign bodies in children: What can go wrong and when to refer. British Columbia Medical Journal, 51(1), 20–24. https://www.bcmj.org/articles/removal-ear-canal-foreign-bodies-children-what-can-go-wrong-and-when-refer