If a child puts something, such as a maize seed or a bean, into his nose, it will have to be removed, or it will cause chronic suppuration and obstruction. Removing it is seldom an emergency, and is easier and much less dangerous than removing a foreign body from the ear. Commonly, the child or his parents know that there is a foreign body inside, and know where it is. Suspect one when: (1) One side of a child's nose only (usually the right) is blocked or discharges (common). A unilateral foul-smelling bloody nasal discharge, with obstruction is a foreign body unless it is a tumour (rare in most communities). (2) He has a perforation of his palate (rare).
FOREIGN BODIES [s7]IN THE NOSE Clear his nose and try to see the foreign body. If you cannot see it (rare), take a lateral X-ray. Try to get the child to blow or sneeze the foreign body out. Close his other nostril and tickle his nose to make him sneeze.
CAUTION ! (1) If you suspect a foreign body, assume it is there, until you are absolutely certain it is not. (2) Don't believe a negative X-ray.
ANAESTHESIA. (1) Local anaesthesia is suitable, if you can see it, it is not too far back, and he is reasonably co- operative. It will minimize the risks of inhalation, if your anaesthetist is not skilled. (2) Intravenous ketamine, if local anaesthesia is unsuitable. (3) Give him a general anaesthetic. Pass a tracheal tube, and pack his pharynx to prevent him inhaling the foreign body.
EQUIPMENT. You will need a good light, suction, angled forceps, and some kind of hook, such as a Eustachian catheter, a bent probe, or a bent paper clip held in a haemostat. Put a large speculum on an auriscope, and remove its back lens.
THE METHOD varies, depending on the anaesthesia you use.
If you are using local anaesthesia, spray his nose well with local anaesthetic solution (without exceeding the dose, see A 5-1), and wait for 5 minutes. Ask his mother to sit him on her lap, hold his legs between hers, and to put her arms round him. Ask a nurse to hold his head. Put your chair close to his mother's, with your legs outside hers. Either use a head mirror, or have a good light behind you.
If you are using general anaesthezia, lay him on his side, so that if you push the foreign body into his pharynx, it will not go into his airway.
Try to bring the foreign body out anteriorly[md]if you push it posteriorly, he may inhale it (this should not happen if his throat has been adequately packed).
If the object is firm, pass your chosen hook beyond it, usually above it, turn the hook behind it and deliver it. Don't try to grab it with forceps, or you will push it further in. Try to draw it towards the floor of his nose, and away from its roof. Then use angled forceps to remove it. A foreign body is most likely to impact in the roof of his nose. Here it is dangerously close to the floor of his anterior cranial fossa and the medial wall of his orbit.
If the foreign body is soft, use forceps. You may be able to suck small foreign bodies away. Otherwise, use small alligator forceps, or any forceps with blunt angulated tips.
If he bleeds, use gentle suction. Packing (25.6) is seldom necessary.
CAUTION ! Make sure there are no more foreign bodies present.
Fig. 25-8a INDIRECT LARYNGOSCOPY. A, warming the mirror. B, the light path to a patient's larynx. C, his cords opposed. D, his cords separated. E, a view of his larynx. F, a carcinoma of his glottis[md]see Section 32.39.
1, the dorsum of his tongue. 2, his vallecula. 3, his epiglottis. 4, his vestibular folds. 5, his vocal cords. 6, his pyriform fossae. 7, his aryepiglottic folds. 8, his arytenoid cartilages.