Experience of management of nasal foreign bodies in Out patient department of a Tertiary Hospital

Objectives: To evaluate 113 cases of nasal foreign body removal with regard to type of foreign body, location, complications, techniques for removal, age , genderand to present the results of theevaluation. Methods: Between April 2009 to May 2011, a total of 113 nasal foreign bodies were attended inOutpatient Department ofENT, Head and Neck Surgery in Sir Salimullah Medical College, MitfordHospital,Dhaka. A retrospective reviewwas undertaken to evaluate the parameters related to the nasal foreign body and their removal and the data wereanalyzed. Results:113 cases of nasal foreign bodies were attended in Outpatient department of ENT, Head and Neck Surgery in Sir Salimullah Medical College, Mitford Hospital, Dhaka. Of these 113 cases, 101cases were removed in outpatient department and 12 cases were admitted and were removed under general anaesthesia. We found higher incidence in patients between ages 2 and 5 years. The distribution of nasal foreign body was 44.25% in male and 55.75% in female. Conclusion:Nasal foreign bodies are encountered daily in our routine clinical practice in the pediatric age group. General anaesthesia is required in uncooperative agitated patients or impacted foreign body to avoid complications.Button batteries and penetrating foreign body must be treated immediately.


IntroductIon
When children start moving by themselves, they have access to many objects that have to be explored.This process can cause the placement of objects in orifices 1 .The etiology of nasal foreign body has been attributed to curiosity or playful insertion of foreign bodies into their own or others' body parts, accidental entry of foreign bodies and habitual cleaning of the nose with objects.Nasal Foreign body is not uncommon in Bangladesh, especially in paediatric age group.Children usually introduce foreign body in nose when playing with toys, household or other things.Nasal foreign body may present with foul smell in nose,unilateral purulent nasal discharge,bleeding from nose and nasal obstruction.
The patients may present asymptomatically after having been witnessed inserting the item.The presence of a foreign body in nose may not be lifethreatening but it may cause morbidity.Complications may arise from the foreign body itself or from attempt to remove it out.The method of removal usually depends on the type of foreign body, its position and co-operation of the patient 2 .
Nasal foreign body is relatively easily removed in an outpatient department; if theforeign body is a battery or is impacted, however, special precautions have to be taken.In addition, if the child is noncooperative,general anaesthesia is usually required to prevent complications.Due to their small size, batteries can easily be inserted into various orifices such as nose, ear or mouth.Batteries are the type of foreign body most commonly associatedwith early complications despite improvements in product safety 3 .

Aim of study
The aim of this study is to analyze nasal foreign body in terms of type, site, age and gender distribution and method ofremoval.A co-operative patient is needed to detect and remove a nasal foreign body successfully.The patient is usually examined in the upright sitting position carried out for routine otorhinological examination.A child may be best examined by tilting the head back slightly so that the floor of the nose is visible to the examiner.For this an adult may need to restrain a child and hold the head steady.
In this study, 50 (44.25%)were male and 63 (55.75%) were female.The sex ratio showed femalepredominance with Male to female ratio is M : F 1 : 1.26 showed in figure 1. obstruction 2 (1.77%), bleeding from nose 2 (1.77%) and discomfort in only one case (0.   6 ,where it is 43% within 0-3 years age group but not similar to some studies like 50% by Kadish HA et.al. 5 , 55.1% by Alberto Chinskiet.al. 7 and 85.7% by Tong MC et.al. 8 In one series by A.A. Yaroko et.al. 9, the most common pediatric age groupinvolved was 3 years (48.83%)followed by 2 years (18.6%)andtheleast common was 7 to 9 years (2.33%) similar to our study.In another study by Ramesh Parajuliet.al. 10 , of the total 28 patients with foreign body in the nose, 27 (96.42%)were of the age group < 10 years which is similar to our study.In another study by Rahul K. Shahet.al. 11 ,55% were younger than 2 years, is not similar to our study.
In our study, we found nasal foreign body mainly unilateral with only one case of bilateral.Among the unilateral, 66 (58.41%) cases were found in right nasal fossa and 46 (40.71%) in left.The right to left ratio is R:L 1.43: 1.It is similar with R:L 1.23: 1 by Alberto Chinski et.al. 7 and R:L 1.46: 1 by Ogunleye AO et.al. 12 The time elapsed after insertion of objects in nose has a great significance because of complication.Metallic button batteries, commonly included in many toys, are small and shiny, making them strong candidates for nasal insertion.Once inserted into the nose, they cause destruction because of the low-voltage electrical currents, electrolysis induced electrolysis induced release of sodium hydroxide and chlorine gas; if their alkaline contents leak they could also induce tissue liquefactive necrosis.Complications are common, therefore button batteries require prompt removal. 13,14,15The use of small powerful magnets as imitation earrings could have dramatic consequences 16 .When children attempt to imitate bilateral nasal piercing with magnet-backed jewelry, the intranasal magnets may attract each other and become joined across the nasal septum, resulting in substantial pressure on the nasal septum and its delicate capillary network.This presents a timedependent risk of septal ischemia, necrosis and perforation, with pressure necrosis beginning within hours.Therefore, magnets across the septum should be treated as an urgent medical condition and managed in the emergency department. 1 7,18,19,20,21 In our study, time of residence of nasal foreign body, i.e., majority are removed within 1 week (63, 55.75%), followed by within a day ( 27 Quite often, nasal foreign body can be easilyremoved; however, unsuccessful attempts at removal may causebleeding, pain or local injury, hindering further attempts 23 .Anumber of factors have been associated with the success of foreignbody removal, including duration of foreign body residence, foreignbody characteristics (size, shape and texture), patient co-operationduring removal, trauma to the nasal cavity, ability to visualize theforeign body and surrounding structures, available equipment andthe skill of the attending physician 4 .

Conclusion
Foreign bodies in nose were found more frequently in children.Removal of nasal foreign body is one of the commonest procedures which can be done in otolaryngology outpatient department and most of the nasal foreign bodies can be easily removed in the Outpatient department.Parents/caretaker should not allow children to play with toys, household objects or other small objects to prevent the risk of insertion of foreign body in natural orifices.For easy removal and to prevent serious complications, avoid attempts in unskilled hand and repeated removal attempts.Timely referral is very important.