Man with foreign body in nose

1. CASE SUMMARY

A 61‐year‐old man presented with pain and epistaxis in the emergency department due to a wire coat hanger that had been inserted into his left nostril by his 3‐year‐old granddaughter while the patient was asleep. This event followed an unusual sequence of events. First, the wire hanger was already shaped into a hooked formation, as the patient had been using it as a cleaning instrument for his bathtub drain and toilet. Second, the toddler inserted the wire hanger into the nostril of the man who was sleeping on his back; on stimulation, the patient sat up forcefully thus “setting the hook” deep into his nasal passage. Finally, as the patient attempted extraction in his home, the hook became entrenched behind the nasal septum.

The distal end of the wire hanger had been cut by emergency medical services (EMS) and left protruding from the patient's left nostril. He was hemodynamically stable and had no respiratory distress or focal neurological deficits. The patient had mild epistaxis from the affected left nostril. No signs of cerebrospinal fluid leak were detected. Reconstructed computed tomography (CT) of the head revealed a metallic hook inserted through the patient's left nostril and hooked around the posterior aspect of the nasal septum (Figures 1A and 1B). To prep the patient for extraction, he received a mixed solution of intranasal oxymetazoline and lidocaine in addition to intravenous midazolam. Oxymetazoline and 4% solution of lidocaine were administered into bilateral nostrils via an atomizer. A low dose of midazolam (2 mg) was administered as an anxiolytic before extraction. Our patient tolerated the procedure well.

FIGURE 1.

(A and B) CT scan of the face showing the metallic foreign body hooked around the nasal septum. (C) The wire coat hanger after it was removed from patient's nose in the ED

CT images were used to guide the extraction technique and to estimate the depth needed to advance. The wire hanger was advanced 2 cm and then rotated to clear the nasal bone. We rotated gently in a manner that encountered the least resistance. In this case, the wire was rotated clockwise before removal.

Following this maneuver, the wire hanger was successfully removed (Figure 1C). Repeat examination showed resolution of epistaxis.

2. FINAL DIAGNOSIS AND RELEVANT TEACHING POINTS

This case is illustrative for the emergency medicine readership as an unusual case of penetrating nasal trauma complicated by a persistent nasal foreign body. Penetrating trauma with a pointed instrument into the nostril may result in death by injuring the brain through the cribriform plate of the ethmoid bone. Case reports have described writing utensils that have been inserted through the nostril that have penetrated the sphenoid sinus and threatened the internal carotid artery. ¹ Finally, patients who undergo surgery for septal deviation have been occasionally reported to have injuries to cribriform plate leading to a subarachnoid hemorrhage and death. ² Rupture of the cribriform plate is a source for serious cerebral infections such as meningitis or brain abscesses. In this case, the CT confirmed that the wire hanger did not penetrate the cribriform plate.

Nasal foreign bodies are frequently encountered in emergency medicine practice, especially in a pediatric population. The causes are usually accidental and the extraction is typically straightforward with a variety of tools such as forceps, aspiration, adhesives or forced air. It is unusual for a foreign body to be physically trapped behind the nasal septum and require manipulation for removal. ³ Penetrating trauma to the nostrils is most commonly described in a pediatric population due to accidental insertion of a writing instrument or, in Asian cultures, a chopstick. ⁴ , ⁵ During the extraction, it is important to recognize the delicate nature of the cribriform plate and the possibility that a patient could experience a life‐threatening injury if it is traumatically disrupted. For all patients who experience penetrating trauma to the nostril, a detailed examination for leak of cerebrospinal fluid is critical. A cerebrospinal fluid leak can have a delayed presentation and missing a cerebrospinal fluid leak can lead to meningitis or other serious life‐threatening infections. ⁶

The final diagnosis in this case was a nasal foreign body that was traumatically lodged behind the nasal septum. For penetrating trauma to the nostril, there are several relevant teaching points. First, it is critical that the emergency physician inspects closely for cerebrospinal fluid leak both before and after the foreign body is removed. Second, the use of CT scan in evaluation of penetrating trauma to the face is critical to determining the depth of insertion and to assessing the presence of any bony injuries to the cribriform plate. Finally, most nasal foreign bodies can be removed by emergency physicians without specialized equipment or a trip to the operating room. Despite the complexity of this case, the foreign body was removed by the emergency physician and the patient was discharged without complications.

AUTHOR CONTRIBUTIONS

CH and ACM contributed to drafting and critical revision of the manuscript. ACM takes responsibility for the submission as a whole.

Han C, Meltzer AC. Man with foreign body in nose. JACEP Open. 2020;1:645–647. 10.1002/emp2.12039