Trick of the Trade: Nasal foreign body removal using foley catheter

A healthy 4 year-old boy is brought in by mom for a plastic bead up his nose. The mom states, “The last time the other doctors had to be called, and it took forever. Oh, and I have to pick up his brother from school in 30 minutes. Can you get it out, doc?” The patient is squirming even as you take a quick peek at his nose, but you catch a glimmer of the bead up his right nare.

Trick of the trade: Remove nasal foreign body with Foley catheter (or Katz extractor)

1. Don protective gear and plan for adequate lighting
2. Obtain and test balloon functionality of a 6F (or 8F) Foley catheter
3. Consider wrapping the child in a sheet to ensure optimal procedural conditions
4. Insert the Foley tip just past the bead
5. Inflate the balloon with air
6. Pull the Foley out of the nose with gentle traction until the bead pops out!

Alternatively, the video above by Dr. Mellick demonstrates how a Katz Extractor can be used (start at 00:34 if you want to skip the introduction). This commercial device is based on the same idea, but it is more rigid, allowing for a single-handed technique. The catheter-based approach is often a favorite of emergency physicians over positive or negative pressure, glue, or forceps, because anecdotally it is better tolerated by patients and parents. However, the limited available literature is not able to support one technique over another.

Pitfalls:

1. Visualization: This technique still requires visualization. Do not insert the catheter blindly as the foreign body may dislodge posteriorly. If it does, immediately check the oropharynx.
2. Although not reported, this may be a technique theoretically to avoid in very posterior foreign bodies as they may be at increased risk for aspiration.

Pearls

1. Have good lighting: Use a headlamp as opposed to an otoscope for visualization, as it frees up both hands to place and inflate the catheter (prior Trick of the Trade).
2. Positioning: Just like any procedure, positioning is key, and even more so in awake young children who will only give you one chance to attempt the procedure. Use a sheet or papoose board to keep the patient properly positioned. If you have a child life specialist, use him or her.
3. Nasal vasoconstriction: Consider using oxymetazoline or 0.5% phenylephrine (Neo-Synephrine). This allows for easier passage of the catheter behind the foreign body. Also consider topical lidocaine for analgesia. Often lubricant is not necessary as there is much natural lubrication from accumulated nasal discharge.

Further Reading

1. Davies PH, Benger JR. Foreign bodies in the nose and ear: a review of techniques for removal in the emergency department. J Accid Emerg Med 2000;17:91-94. PDF
2. Heim SW, Maughan KL. Foreign bodies in the ear, nose, and throat. Am Fam Physician. 2007 Oct; 76(8):1185-89. .
3. Fox JR. Fogarty catheter removal of nasal foreign bodies. Ann Emerg Med. 1980;9:37-8.
4. Kiger JR, Brenkert TE, Losek JD. Nasal foreign body removal in children. Pediatr Emerg Care. 2008 Nov;24(11): 785-92.
5. Leach AJ. Evidence based problem solving in general practice: the foreign body in the nose. JR Army Med Corps. 2000 Feb;146(1):31-2.
6. Katz Extractor website

Disclosures: I do not have any financial ties with Katz Extractor or Foley Catheters.

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