Prolonged Undiagnosed Nasal Foreign Body Case Report

Abstract

The case report presented is a 22-year-old female with an undiagnosed nasal foreign body (NFB) in her right nasal cavity for 18 years. Previous physical examination and anterior rhinoscopy by other health care specialists failed to detect the NFB. She was treated conservatively by many ENT specialists as sinusitis with antibiotics therapy and anti-allergy drugs for many years with no improvement. Due to persistent sinus symptoms unrelieved by conservative treatment further investigation with a paranasal sinus computed tomography (CT) scan was completed that identified the NFB. The NFB was successfully removed surgically with the aid of nasal endoscopy under general anesthesia. The NFB was diagnosed as a piece of calcified externally cotton vegetation. This case highlighted the importance of complete investigation of persistent symptoms including imaging with a non-contrast spiral CT, in addition to a dilated physical examination, clinical and pathologic lab exam.

Introduction

A wide variety of upper aerodigestive tract foreign bodies (FBs) are encountered in the profession of ear, nose, and throat (ENT) practice. Most common FBs are coins, marbles, buttons, batteries, and other. Nasal foreign bodies (NFBs) are generally painless. Foreign bodies of vegetable origin absorb water from tissues and swell causing an intense inflammatory reaction that can be sufficient to produce toxemia. One study found that most patients with nasal symptoms, the most frequent objects were non-organic synthetic beads, followed by vegetable forms [1]. Thus, FBs in the nose can create a real problem and should not be taken lightly [2].

Some NFBs have reportedly been present in the nasal cavity for years without symptoms [3]. Successful diagnosis and treatment of NFBs depend on a careful examination of the nasal cavity. Diagnosis of NFB is difficult, especially in children or asymptomatic patients [4]. If not diagnosed, and the FB remains in the nasal cavity for many years covered by mucosa and develops a rhinolith [1]. Although a NFB is a rare finding in adults, it remains a differential diagnosis until proven not the cause for the presenting symptoms. Sometimes, a patient may not recall the cause or clear history of an NFB [4]. It is recommended to keep an open mind regarding this, to make an early diagnosis, and prevent complications. Foreign bodies in the nasal cavity can be a great challenge and management may require great skill [5].

The first symptoms of inanimate NFBs are ipsilateral nasal obstruction, serosanguinous discharge, headaches, sneezing, oral respiration, epistaxis, and ipsilateral odorous nasal discharge [6]. Also, a rise in body temperature occurs and a disagreeable fetid odor emanates from the nasal passages. Some FBs are benign and others such as batteries are dangerous and can damage the nasal mucosa [7, 8]. The anterior rhinoscopy and sometimes in difficult cases endoscopic examination can help to diagnose the FB [8]. An unusual case reported a NFB that had remained after septal surgery [9].

Case Presentation

The patient was a 22-year-old female who suffered nasal obstruction in the right nasal cavity and periodic epistaxis for 18 years. She had a history of falling into a park when she was 4-year old. She had complained of frequent symptoms such as headache, rhinorrhea, occasional epistaxis, nasal obstruction, and decreased sense of smell on the right side of the nasal cavity. During these years, several general practitioners, and specialists such as otolaryngologist, immunologist, internist examined the patient. She was treated for sinusitis, allergic rhinitis, tension headache, and so on. Different medication regimens were prescribed for her such as antibiotics, intranasal steroid and decongestant sprays, and antihistamines.

Physical examination and anterior endoscopic rhinoscopy were performed with a headlamp and nasal speculum. The only finding was nasal mucosa inflammation in the right nasal cavity. NFB was not detected and there were no findings in favor of nasal mucosa damage, mass, or vascular lesions. So, because of the patient's history of unrelieved symptoms unresponsive to treatment, we became suspicious of a missed NFB and, requested more investigations in this case. The complete blood cell count (CBC) and coagulation tests were normal and there was no finding of coagulation disorder. The patient underwent a PNS-CT scan without contrast. When a NFB was diagnosed, it was removed promptly.

Non-contrast spiral-CT with multiple axial and coronal images through the PNS were obtained (Fig. 1a) which revealed: “there is a lesion with a peripheral hyperdensity about 9 × 6 × 18 mm in the inferior aspect of right nasal cavity” (Fig. 1b and c). Macroscopic view of the NFB object when removed revealed, a hard 9 × 6 × 18 mm particle (Fig. 2a and b). This confirmed diagnosis in correlation with a physical examination after a CT scan.

Fig. 1.

Non-contrast spiral-CT with multiple axial and coronal images through the PNS

Fig. 2.

The Endoscopy under general anesthesia removed view of the Nasal Foreign Body

Post CT scan, the NFB was removed by endoscopy under general anesthesia (Fig. 2a and b).

To conclude this was a NFB, the specimen was sent to the pathology laboratory and identified as follows: “Received specimen in formalin labeled as a FB in nose consisting of an avoid hard mass, measuring 2 × 1 × 0.7 cm section consisting of a piece of cotton vegetative FB that calcified externally.”

In a follow-up visit, the patient had no complications such as epistaxis, headache, anosmia, or malodorous nasal discharge. One month after postnasal FB removal, she was symptom free and all intranasal medications were stopped. The patient had no nasal symptoms at one-year post surgery.

Discussion

A review of previous case studies found that most NFB reports were in children and rarely in adults. Adults who present with NFB usually had injury from accidents or coexisting mental disorders.

In this study patient was a 22-year-old female who suffered from nasal obstruction in the right nasal cavity and periodic epistaxis for 18 years. Previous published case studies such as, Kate Hulse and et al., reported a case with NFB for 5 years. In addition, Pavan M. Patil and et al. reported a rare case of a toothbrush head as an NFB in 42 years old woman that was lost in her nasal cavity after a fall [2, 4].

The NFB is usually located in the anteroinferior part of the cavity, trapped by the inferior turbinate. More rarely the obstruction is found posteriorly or superiorly, pushed back by previous attempts at extraction [1].

In the presenting case, this inanimate object initiated the immune response of congestion and swelling of the nasal mucosa and placed the patient at risk for pressure necrosis ulceration, mucosal erosion, and epistaxis. In this case, the vegetative FB not only absorbed water from the tissues and swelled but also stimulated a very brisk inflammatory reaction. This finding was supported by previous case study [10]. In some cases, a NFB acts as a nucleus for concretion that firmly impacts and buries in the granulation tissue by receiving a coating of calcium, magnesium phosphate, and carbonate and thus becomes a rhinolith. The retained secretions of the decomposed FB and the accompanying ulceration caused an ensuing bromhidrosis. These changes further impacted the FB because of surrounding edema, granulations, and discharge. Besides, this process may occur around an area of inspissated mucopus, or even a blood clot.

Several important complications can also occur with the presence of a NFB, including formation and development of erosion into a contiguous structure, toxic shock syndrome, and development of infections in surrounding structures including acute sinusitis or otitis media, periorbital cellulitis, meningitis, acute epiglottitis, diphtheria, and tetanus. In a study in India, a conically impacted button battery in the nasal cavity caused a septal perforation, nasal adhesions, and saddle nose deformity [7, 11, 12].

As illustrated in this case presentation diagnosing the cause for the persistent symptoms and distress greatly improved the quality of life with positive outcomes in this patient. Therefore, Clinical practice guidelines need to be created based on sound medical evidence and review of the literature to ensure all patients receive optimal care. Consequently, proving a FB needed a great challenge with reasonable evidence for the prevention of later complications.

Findings of this case study highlight the importance of complete investigation of persistent symptoms including imaging with a non-contrast spiral-CT in addition to a dilated physical examination, clinical and pathologic lab exam.

Conclusion

This case study elucidates the need for a thorough examination of persistent presenting problems including imaging studies along with a complete history and physical exam. Although a missed, undiagnosed NFB is rare, swift removal reduces complications with improved quality of life.

Authors’ Contributions

Study concept and design: NP and HB; Critical revision of the manuscript for important intellectual content: NP, PMZ, and ZZ; Writing-original draft: NP, HB, and ZZ. Abstracted, wrote the manuscript: NP, ZZ and Surgical method: HB and ZZ; review and editing: NP, LW, and AKA.

Financial Support and Sponsorship

The authors declare no organization support of this study was provided.

Compliance with Ethical Standards

Conflict of interest

There are no conflict of interest.

Competing interests

There are no competing financial or non-financial interests to declare.

Informed Consent

Written Informed consent was obtained from the participant.

Declaration of Patient Consent

The authors certify that they have obtained appropriate patient consent forms.