Positive pressure technique for removal of nasal foreign bodies

Summary

Nasal foreign bodies represent a common ENT problem in children. Ninety percent of these can be removed without otorhinolaryngologic intervention. Numerous documented techniques exist, employing instruments, which pose problems in children. Positive pressure technique avoids the need for instrumentation, therefore bypassing the disadvantages met by other techniques. Positive pressure technique is both safe and effective, highlighted by a success rate of 62.5% in 8 patients presenting acutely. Promising result of this small study warrantees further study in larger number of paediatric population. In contrast to previous documentation, children nursed prone tolerated the procedure better. Hollow objects were resilient to this technique and require other methods of removal. Positive pressure technique should be considered to remove foreign bodies from the paediatric nose especially in emergency department setting.

Introduction

Foreign bodies in the nose are a common ENT problem in children. The maximum incidence is between the ages of 9 months to 8 years and is also associated with male gender and low socio-economic status [3]. In the acute setting, the presentation may include epistaxis. In a child with a unilateral purulent nasal discharge, one must exclude a FB above all [13]. Nasal blockage may develop following the solidification of secretions surrounding the FB and the formation of rhinoliths in the minority of long standing cases. A delay in removal may lead to inflammation and swelling of the nasal passages, further complicating their removal. Failure to remove foreign bodies may lead to bleeding, ulceration and aspiration.

Most foreign bodies lodge on the floor below the inferior turbinate or anterior to the middle turbinate [5]. This makes it easy to identify foreign body. However, the lack of cooperation in a child, along with an element of fear associated with display of instruments for removal of these foreign bodies makes this task impossible, when in fact 90% of foreign bodies can be removed without otorhinolaryngologic intervention [2].

The development of a simple technique for removal of nasal foreign bodies has remained relatively static. The utilisations of the jobson horne probe, formbys hook, alligator forceps, suction technique, forgaty or foley catheter and cyanoacrylate glue are all well documented [1], [3], [4], [6]. In fact, all these techniques make use of instrumentation creating a frightening experience for the child. Furthermore, engaging in the use of instrumentation with a difficult child may cause unnecessary trauma to the nose and requires some otolaryngological experience.

PPT (Fig. 1) was first described in the 1960s as an efficient technique to mechanically dislodge nasal foreign bodies without the need for instrumentation [3], [9], [11]. Documentation of this technique has remained sparse due to the lack of random controlled trials to assess its efficiency [1].

This article highlights consideration of positive pressure as a first line technique for removal of nasal foreign bodies in children especially in accident and emergency departments.