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Foreign Bodies in the Nasal Cavities: a Comprehensive Review of the Aetiology, Diagnostic Pointers, and Therapeutic Measures

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Foreign Bodies in the Nasal Cavities: a Comprehensive Review of the Aetiology, Diagnostic Pointers, and Therapeutic Measures 484 Postgrad Med J 2000;76:484–487 Foreign bodies in the nasal cavities: a Postgrad Med J: first published as 10.1136/pmj.76.898.484 on 1 August 2000. Downloaded from comprehensive review of the aetiology, diagnostic pointers, and therapeutic measures A Kalan, M Tariq Abstract A high index of suspicion is necessary so that Otolaryngologists frequently encounter further diagnostic manoeuvres can be tried nasal foreign bodies, particularly among before a label of “no foreign body” is stamped children and mentally retarded patients. on the case. There are isolated reports describing the Nasal foreign bodies can be found in any removal of unusual foreign bodies from portion of the nasal cavity, although they are the nose. But no comprehensive reviews of typically discovered around the floor of the this important subject have been pub- nose just below the inferior turbinate (fig 1). lished for many years. This article in- Another common location is immediately cludes a detailed discussion of the anterior to the middle turbinate.2 These objects diVerent types of nasal foreign bodies, the are generally placed by children or mentally various clinical presentations, manage- retarded patients whose curiosity leads them to ment options, and complications associ- explore body orifices. Any article small enough ated with nasal foreign bodies. to be admitted into the anterior nasal orifice (Postgrad Med J 2000;76:484–487) has, at one time or the other, been removed 13 Keywords: foreign bodies; nose from the nose. Foreign bodies that are impacted or those that have been present for some time and have become encrusted or those Several articles have been described in the that have been impacted with force frequently otolaryngology literature describing unusual challenge removal. Live and mobile animate foreign bodies removed from the nasal space foreign bodies (such as maggots and larvae) and the nasopharynx. There have been no pose similar diYculties. comprehensive discussions on the subject of A loose foreign object in the postnasal space foreign bodies in the nose. Seldom does the can accidentally be aspirated or pushed back in otolaryngologist keep track of the number and an attempt at removal and may result in acute kinds of foreign bodies he encounters. It is such respiratory obstruction. Foreign bodies in the a common entity that it is uncommon to pay nose have been implicated as carriers of the that much attention to it. Foreign bodies in the causative organisms of diphtheria and other http://pmj.bmj.com/ nasal cavity, however, can be a great challenge infectious diseases.4 It therefore appears that and management may require great skill.1 foreign bodies in the nose can create a real At the very outset diagnosis could prove dif- problem and should not be taken lightly. ficult. To the unsuspecting, a unilateral suppu- Foreign bodies are either animate or inani- rative or mucopurulent fetid nasal discharge mate. may suggest a number of possibilities other Inanimate foreign bodies—The list of objects than a foreign body. On the other hand, the that have been reportedly removed from the presence of a foreign body may be suspected nose is endless. The most commonly identified on September 27, 2021 by guest. Protected copyright. but to prove its presence may be a trying task. inanimate foreign bodies include rubber eras- ers, paper wads, pebbles, beads, marbles, beans, safety pins, washers, nuts, sponges, and chalk.25 Other authors have reported plasti- cine, pieces of wood, a door handle,6 metal hooks and eyes, pieces of cloth, bullets, thimbles,7 shrapnel, umbrella springs, iron bolts, corks, and coins.8 Department of Ear, Endogenous materials like bone and pieces Nose, and Throat ST of cartilage have been left behind in the nasal Surgery, Royal SS cavity after surgical intranasal manipulations. Hospitals NHS Trust, MT Trauma to structures adjacent to the nose such London, UK A Kalan as orbits, paranasal sinuses, and palate can force bone spicules and cartilage fragments M Tariq IT into the nose. Supernumerary teeth have Correspondence to: erupted in the floor of the nose, presented like Mr A Kalan, 136 Barrowell osteoma, and caused nasal obstruction.910 Green, Winchmore Hill, London N21 3AX, UK Animate foreign bodies—Myiasis of the nose is (email: common in warm tropical climates of South [email protected]) Western United States and the Far East Figure 1 Common sites of impaction of foreign bodies in Submitted 9 March 1999 the nasal cavity (IT = inferior turbinate; MT = middle including India, the frequency of infestation Accpeted 27 September 1999 turbinate; SS = sphenoid sinus; ST = superior turbinate). being primarily related to the poor hygiene of www.postgradmedj.com Foreign bodies in the nasal cavities 485 Postgrad Med J: first published as 10.1136/pmj.76.898.484 on 1 August 2000. Downloaded from the inhabitants. The most common of all infes- tations is the fly maggot. Screw worms, also known as “Texas” screw worms (which is the larval state of Cochliomya macellaria and the Cochliomyia homnivorax, “the blow fly”) are serious pests to humans and cattle. A high inci- dence of human infestation would therefore be expected in cattle raising areas but this does not appear to be the case.11 This indicates that the principal factor in infestation is not the livestock but rather the constitution and habitat of the host. The ordinary maggot represents the larval stage of this blow fly. It thrives in dead tissue only and does not destroy living material. The mature larva measures two thirds of an inch long and one eighth of an inch in Figure 2 Unilateral vestibulitis in a child—diagnostic of a diameter and has the characteristic appearance foreign body in the nasal cavity. of a screw because of approximately l2 rings of spines that encircle the body. The larva various types of lesions depending on the burrows into the living tissue and it is at this localisation, with an intense local tissue reac- stage of larval development that it damages tion and liquefaction necrosis. As a result they nasal mucosal lining. Larvae of other flies like can cause septal perforations, synechiae, con- those of aestrous, hypoderma, and dermatobia striction, and stenosis of the nasal cavity. also invade the nasal cavities. Wohlfahrtia mag- Maggots and screw worms in the nose initi- nifica may also infest the nose. These infesta- ate varying degrees of inflammatory reaction tions occur more commonly in patients suVer- from a mild localised infection to maximum ing from ozaena and nasal syphilis.1 destruction of the nasal bones (both cartilagi- Ascaris lumbricoides is a species of nema- nous and bony) with formation of deep, stink- tode or round intestinal worms and will find ing suppurating caverns. The larvae hatch in lodgement in the nose when regurgitated or these caverns and a new cycle is repeated.11 coughed up. It is the most common intestinal helminth of man and frequently reaches Symptoms and signs epidemic proportions. Although it flourishes A unilateral mucopurulent nasal discharge best in warm, tropical climates, it is cosmopoli- with foul odour is the most consistent findings tan in distribution. In temperate regions it is in patients with a nasal foreign body. Occasion- generally associated with low standards of per- ally it can be bloodstained.13 The ensuing uni- sonal hygiene. lateral vestibulitis, specific of the paediatric age group, is diagnostic (fig 2). Pathology Nasal foreign bodies are generally painless. Some foreign bodies are inert and may remain In fact some foreign bodies have reportedly http://pmj.bmj.com/ in the nose for years without mucosal changes. been present in the nasal cavity for years with- However, most inanimate objects initiate con- out symptoms.14 However rarely, pain and gestion and swelling of the nasal mucosa, with headache have been experienced on the the possibility of pressure necrosis producing involved side with intermittent epistaxis and ulceration, mucosal erosion, and epistaxis. The sneezing reported by others.13 Cases describing retained secretion, the decomposed foreign bromhidrosis (foul body odour) associated body, and the accompanying ulceration can with nasal foreign bodies in children have also on September 27, 2021 by guest. Protected copyright. result in foul fetor. These changes further been published.15 impact the foreign body because of surround- In patients with animate nasal foreign ing oedema, granulations, and discharge. This bodies, the symptoms tend to be bilateral.113 is particularly seen with vegetable foreign bod- Nasal occlusion, headaches, and sneezing with ies which not only absorb water from the serosanguinous discharge usually are the pre- tissues and swell but also evoke a very brisk senting symptoms. A rise in body temperature inflammatory reaction. Occasionally, the in- occurs and a disagreeable fetid odour emanates flammatory reaction is suYcient to produce from the nasal passages. Leucocytosis results toxaemia.1 from the accompanying secondary infection. A foreign body can act as a nucleus for con- Examination of the nasal cavity may reveal cretion if it is firmly impacted or is buried in extensive destruction of the surrounding mu- granulation tissue by receiving a coating of cal- cous membranes, bone, and cartilage and the cium, magnesium phosphate, and carbonate mucosa is fragile and bleeds easily. Constant and thus becomes a rhinolith. Occasionally this motion and masses of diVerent worms may be process may occur around an area of inspis- observed. These worms are firmly attached and sated mucopus, or even a blood clot. Rhinoliths diYcult to extract. Owing to the secondary usually form near the floor of the nose and are infection and bone destruction, complications radio-opaque. are not infrequent.13 Button batteries may result in severe de- Rhinoliths are initially symptomless and later struction of the nasal septum.12 These are cause nasal obstruction only if they become composed of various types of heavy metals: enlarged.
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