Introduction

Nasal foreign bodies are a relatively common presentation to a paediatric emergency department (ED), although there is little published literature on the subject. They are not life threatening, but can cause significant morbidity.

History

Nasal foreign bodies predominantly present in children from 2 to 5 years of age. Children with nasal foreign bodies are usually brought in within 24 hours of insertion/impaction. Delayed presentation is mostly with unilateral purulent nasal discharge, which is usually offensive. Other possible symptoms include foul breath, nasal pain, sneezing, snoring and mouth breathing.

Examination

The type of foreign body is extremely variable, although it is most commonly a plastic toy or bead. The foreign body is usually readily visible.

Investigations

Investigations are not usually required. Imaging is usually indicated for other possible causes such as tumour.

Treatment

Except for button batteries (see also Chapter 7.6), removal of the foreign body is not urgent. Most foreign bodies can be successfully removed in the ED with adequate preparation and planning. Prior to the attempted removal, use of a topical anaesthetic nasal spray, such as lidocaine + phenylephrine, is recommended. Sedation and/or appropriate restraint of the child may be required. A good light source and an assistant to hold the child’s head still are essential.

The appropriate procedure for removal will depend upon the foreign body size, shape, consistency and location in the nares. These include:

General anaesthesia and removal by ear, nose and throat (ENT) staff is required for the failed removal and the unco-operative child.

Complications

Possible complications include epistaxis, local and more widespread infection. Uncommonly, septal perforation has occurred secondary to a button battery. Mucosal injury may occur within hours.

Introduction

Aural foreign bodies in children are also a relatively common presentation to EDs. Again morbidity can be significant.

History

A greater proportion of children present beyond 24 hours from insertion compared with nasal foreign bodies and in many cases the time frame may not be determined. It may be a result of the event being witnessed, reported by the child due to irritation or pain, or as an incidental finding. The object may have been placed due to existing ear canal irritation due to wax impaction or otitis. Live insects are a common finding, and may result in marked discomfort.

Examination

Visualisation of the foreign body is usually by otoscopy. The type and location of the object has a significant role in the difficulty of removal.

Investigation

Investigations are not indicated.

Treatment

Removal of foreign bodies from the lateral one-third of the external auditory canal is much easier and more successful than from the medial two-thirds. The latter is the osseous portion and is narrower, more vascular and very tender. Therefore removal is more likely to require sedation or general anaesthesia and ENT expertise.

Button batteries are again a risk (see also Chapter 7.7), causing necrosis of the ear canal or tympanic membrane and should be removed as soon as possible. A live insect should be killed or immobilised with microscopic immersion oil, mineral oil or local anaesthetic solutions (2% lidocaine). It can then be removed using irrigation or forceps. Putty is often very difficult to remove and may require otomicroscopic removal. Sharp objects also usually require ENT removal.

Failure to remove in the ED will require ENT referral. Inspection following removal is advised to ensure there is no persisting foreign body and to assess for trauma or inflammation. Aural antibiotic drops with steroid are often recommended, particularly if there is evidence of trauma or inflammation.

Complications

Trauma to the ear canal is common as a result of the foreign body and/or its removal. More seriously, trauma to the tympanic membrane or ossicles can occur. Otitis externa can occur as a result of trauma.

Introduction

Caustic ingestion in children is an uncommon presentation and significant injury with stricture formation is rare because the volume ingested is usually small. The ingested agents are variable and include alkalis (more common) and acids in liquid, granule or solid form. The likelihood of significant injury is dependent upon how alkali or acidic the agent is (i.e. its pH). Strong liquid alkali is particularly dangerous.

History

In children, in contrast to adults, ingestion is largely accidental and, as a result, significant injury far less common. Most cases occur in children less than 3 years of age and, like accidents in general, occur in boys more frequently than girls. Most ingestions occur at the home of the child. The most common alkali agent ingested is dishwasher detergent and commonest acidic agent is acetic acid. Button batteries have a significant corrosive and burn risk if lodged or impacted in the oesophagus (see Chapter 7.6).

Many children are asymptomatic. If they do occur, symptoms include vomiting, drooling, pain on swallowing and dysphagia, chest pain and refusal to drink. Less commonly, stridor may occur secondary to upper airway burns and obstruction.

In one series, the most predictive symptoms of significant injury and scar formation were prolonged drooling and dysphagia (100% sensitivity and 91% specificity). In another, haematemesis and respiratory distress were always associated with severe injury.

Examination

Many children will have normal examination findings, but oral burns may be demonstrated by inflammation, oedema or white areas. In at least half of these, that will be the limit of injury. Occasionally, significant burns occur beyond an unaffected oral cavity.

Investigations

Chest X-ray has demonstrated pulmonary irritation in up to 13% in some series. However, there is evidence that radiological investigations have little impact upon management and therefore cannot be recommended routinely, except to localise a button battery.

Oesophagoscopy may be performed according to symptoms, particularly ongoing drooling and dysphagia, vomiting/haematemesis and stridor. The type of caustic substance, its form and pH should be considered.

Treatment

Resuscitation, involving airway and breathing management, is the priority in severely affected cases. Upper airway obstruction may warrant intubation. However, there is a case report of successful use of nebulised adrenaline (epinephrine) for acute marked stridor following hypochlorite ingestion.

Dilution using water or milk may be useful for solid or granule ingestions. Children who remain asymptomatic may be discharged. Button batteries should be removed endoscopically, followed by a period of observation.

There is no proven effective treatment for oesophageal burns, especially in the prevention of stricture development. Antibiotics and corticosteroids have been commonly used, but have not been shown to be of any value.

Complications

Stricture formation is rare and, in a combination of nine series giving a total of 1961 children who had caustic ingestions, occurred in only 3.2%. This was despite a mean incidence of oesophageal burns of 21.4% and of deep burns of 4.7%. Upper airway obstruction has been mentioned and is potentially life threatening.

Prevention

Labelling, formulation, and child-proof containers and caps, have proved effective in prevention, when legislated. Storage of strong caustics should be in locked cupboards or similar, and handling should occur out of the reach of children. More hazardous caustics are available in developing countries and severe injury occurs more frequently.