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References

Chai CK, Tang IP, Tan TY, Jong DE. A review of ear, nose and throat foreign bodies in Sarawak General Hospital: a five-year experience. Med J Malaysia. 2012; 67:17-20
Parajuli R. Foreign bodies in the Ear, Nose and Throat: an experience in a Tertiary Care Hospital in Central Nepal. Int Arch Otorhinolaryngol. 2015; 19:121-123
Ngo A, Ng KC, Sim TP. Otorhinolaryngeal foreign bodies in children presenting to the emergency department. Singapore Med J. 2005; 46:172-178
Ramdoo K, Manjaly J, Tatla T. Delayed presentation of an undiscovered nasopharyngeal foreign body. BMJ Case Rep. 2014; https://doi.org/10.1136/bcr-2014-204246
Chan TC, Ufberg J, Harrigan RA, Vilke GM. Nasal body removal. J Emerg Med. 2004; 26:441-445
McCormick S, Brennan P, Yassa J, Shawis R. Children and mini-magnets: an almost fatal attraction. Emerg Med J. 2002; 19:71-73
Yasny JS, Stewart S. Nasal foreign body: an unexpected discovery. Anesth Prog. 2011; 58:121-123
Mallikarjauna R, Nalawade T. Incidentally detected nasal foreign body on routine dental radiograph. BMJ Case Rep. 2012; 1-3 https://doi.org/10.1136/bcr-2012-007369
Lovel SF, Lovelock DJ, Shaw AJ. An unusual intranasal foreign body in an unsuspecting 9-year old. Int J Paed Dent. 2005; 15:78-81
Thabet MH, Basha WM, Askar S. Button battery foreign bodies in children: hazards, management, and recommendations. BioMed Res Int. 2013; https://doi.org/10.1155/2013/846091
Fundakowski CE, Moon S, Torrs L. The Snare Technique: a novel atraumatic method for removal of difficult nasal bodies. J Emerg Med. 2013; 44:104-106
Kumar S, Singh DB, Singh AB. An unusual nasopharyngeal foreign body with unusual presentation as nasal regurgitation and change in voice. BMJ Case Rep. 2013; https://doi.org/10.1135/brc-2013-010005
Passali D, Gregori D, Lorenzoni G, Cocca S, Loglisci M, Passali FM, Bellussi L. Foreign body injuries in children: a review. Acta Otorhinolaryngol Ital. 2015; 35:265-271
Yasny JS, Stewart S. Nasal foreign body: an unexpected discovery. Am Dent Soc Anesthesiol. 2011; 58:121-123
Brown L, Tomasi A, Salcedo G. An attractive approach to magnets adherent across the nasal septum. Can J Emerg Med. 2003; 5:356-358

Foreign bodies in the nasal cavity: incidental findings during routine orthodontic radiographs

From Volume 45, Issue 4, April 2018 | Pages 351-354

Authors

Yung Lam

BDS, MFDS RCS(Glasg)

Dental Core Trainee in Restorative Dentistry, Leeds Dental Institute, Uttoxeter Road, Derby DE22 3NE, UK

Articles by Yung Lam

Alison Murray

BDS, MSc, MOrth RCS(Eng), FDS RCPS(Glasg)

Consultant Orthodontist, Royal Derby Hospital, Derby

Articles by Alison Murray

Anjli Patel

BDS, MFDS MSc, MOrth RCS(Edin), FDS Orth RCS(Edin)

Senior House Officer, Chesterfield Royal Hospital

Articles by Anjli Patel

Abstract

Abstract: Foreign bodies in the nasal cavity are common amongst young children as they begin to explore their senses. The occurrence in teenagers often goes unreported from a fear of embarrassment therefore resulting in a delay in presentation or until they become symptomatic. The sequelae of foreign bodies in the nasal cavity include prudent discharge, epistaxis, sinusitis and respiratory symptoms. If left untreated this can lead to mucosal necrosis, cutaneous fistula, rhinolith formation and chronic pain. Here, two patients who had foreign bodies in their nasal cavity, which were only discovered as an incidental finding as part of their orthodontic assessment, are reported.

CPD/Clinical Relevance: Clinicians should be mindful of the sequelae of foreign bodies in the nasal cavity and the need for thorough assessment of radiographic investigations, particularly in children.

Article

Yung Lam

Foreign bodies (FB) in the nasal cavity are an unfortunate but common occurrence in children. The highest incidents are amongst young children 0–5 years-old as they explore their senses and it has been shown to drop significantly after the age of ten.1,2 It has also been shown to be more prevalent in boys than girls.3 FBs in the nasal cavity usually occur unilaterally and the most common objects are seeds, nuts and beads.1

The FB can be classified into two groups, organic and inorganic. Organic substances such as food, wood, paper and rubber absorb water and therefore are more likely to cause an inflammatory response and become symptomatic. These cases will need medical attention. The sequelae of foreign bodies in the nasal cavity include prudent discharge, epistaxis, sinusitis and respiratory symptoms.3,4,5 If left untreated this can lead to mucosal necrosis, cutaneous fistula, rhinolith formation and chronic pain.5,6

Inorganic matter such as plastic, metal and stone are usually inert and can remain in situ and be asymptomatic for many years before being discovered, often as incidental findings.7,8,9 However, there are two inorganic objects that are very hazardous on inhalation/ingestion; they are magnets and batteries. Children are known to try imitating adult piercing using magnetic jewellery, such as those worn on the nose. They are often made of a type of magnet called neodymium, produced by mixing iron, boron and neodymium powders before pressing them into the required shape. This type of magnet is considered to be the strongest available, being five to ten times stronger than plain iron magnets.6 The magnetic force can be so strong that it can cause pressure necrosis just after a few hours, inflicting severe pain and making the use of metallic instruments for their removal problematic. The second objects, button batteries, spontaneously leak alkaline electrolyte when exposed to moisture and can cause liquefying necrosis of adjacent tissues.10 The size and shape of button batteries, that is round and smooth, also make them the most challenging to remove.5,11 The lack of symptoms can lead to late diagnosis and thereby increase the risk of complications.

Techniques used to remove FBs include direct instrumentation using forceps, Foley catheters, suction, nasal wash, positive pressure and adhesives.5

An FB in the nasal cavity also runs the risk of aspiration, therefore careful removal as soon as it is detected is indicated.5,12 Dental radiographs used to assess the full dentition and jaws also capsulate the nasal cavity. It is therefore important to evaluate the radiograph and patient's history thoroughly and consider FB as differential diagnosis on interpretation of dental radiographs.

Here, two cases are presented in which FBs were an incidental finding on orthpantomographs (OPTs) discovered prior to orthodontic treatment.

Case report 1

A 13-year-old female, LB, was referred to Derby Teaching Hospitals NHS Trust Orthodontic department, as she was unhappy about her ‘crooked teeth’. The patient gave a history of not being able to breath through her nose properly and had been under the care of the ENT team for three years prior to her referral to the Orthodontic department. Routine radiographs were taken as part of her orthodontic assessment, upon which an incidental finding of a foreign body in the nasal cavity was discovered. The object was very radio-opaque, cylindrical in shape, with dimensions of approximately 15 x 15 mm in size and located mid-point, anteriorly of the nasal cavity (Figures 1 and 2).

Figure 1. Cephalometric radiograph of LB showing a circular opaque foreign object in nasal cavity (circled).
Figure 2. LB's OPT radiograph showing cylindrical opaque mass in nasal cavity (circled).

When questioned, the patient did not recall any trauma or possible foreign body incidents.

The patient was subsequently transferred to ENT and the foreign object was successfully removed by endoscopic surgery under a general anesthetic. The FBs were two spherical magnets amalgamated together, measuring 15 x 20 mm in size.

It was not until after the removal of the foreign object that the truth was elicited from the patient. It transpired that she was given a science kit for Christmas a few months before and decided to experiment to see if the magnets would work between her two nostrils! They certainly did and the force was so strong she was unable to remove them. She was too embarrassed to tell anyone and even to admit to it when they were discovered on the radiographs. Since the magnets were so firmly fixed together and had been present for at least three months before removal, this resulted in perforation of the nasal septum (Figures 3 and 4). The patient recovered well and proceeded to undergo her orthodontic treatment.

Figure 3. Endoscopic views up the right nostril (arrow indicating FB): (a) a dark solid mass of foreign body is clearly visible; (b) the magnet is lodged in the nasal septum.
Figure 4. The foreign body on removal – two spherical neodymium magnets fused together, measuring approximately 15 x 20 mm.

Case report 2

An 11-year-old male, LH, was referred to the Orthodontic department at Derby Teaching Hospitals from his general dental practitioner (GDP) due to his extensive hypodontia. An OPT was enclosed, which showed the patient to be in mixed dentition and having congenitally missing upper right lateral, both lower second premolar and all second and third molar teeth. There appeared to be a faint halo opacity approximately 10 mm in size, just above the nasal cavity floor lining and adjacent to the developing upper right canine apex (Figure 5). There was no mention of this from the referring practitioner.

Figure 5. LH's OPT sent in by GDP with referral letter, showing ill-defined radio-opaque object in nasal cavity (circled).

The differential diagnoses included a foreign object and radiographic artefact. A radiologist's opinion was sought, who advised a repeat of the OPT in six months. This was carried out and subsequently gave a clearer diagnosis that it was in fact a foreign object (Figure 6). The culprit was a button and it was successfully removed by endoscopic surgery under a general anaesthetic (Figure 7). The patient recovered well and has since started his orthodontic treatment (Figure 8). The patient's mother informed us that the patient had suffered from terrible halitosis prior to the removal of the button. However, the patient still maintains, even after removal of the foreign body that he has never ever pushed a button up his nose!

Figure 6. LH's OPT taken six months after referral, showing a noticeable radio-opaque object in the nasal cavity (circled).
Figure 7. Image of a button that was similar to the one removed from the patient's nasal cavity.
Figure 8. LH's OPT taken for assessment, prior to commencement of orthodontic treatment and after foreign body removal (three years after initial referral), showing successful healing and no permanent sequelae.

Discussion

The cases reported above have outlined common FB injuries that have been found in the nasal cavity but on older children.13 Their incidental findings illustrate the importance of thorough analysis of radiographic imaging in identifying FB injuries in children,4,8,14 particularly given the oversight in the histories given by the patients that exemplifies the length teenagers will to go to conceal themselves from embarrassment.

In both cases, there were signs and symptoms representative of dislodgement of the FB in the nasal cavity, which were: difficulty in breathing through the nose and halitosis of the nasal cavity, respectively. Nevertheless, in neither case was the presence of FBs suspected or explored, leading to a delay in diagnosis and treatment.

In LB's case, she had been investigated previously for breathing problems and it was immediately concluded that the foreign objects had been present for a long time. Close questioning, however, confirmed that the magnets had been in position for a relatively short period of time, so her nasal septum had been compressed between two spherical neodymium magnets for more than three months only. The strength of the magnets was so strong they had fused together and had to be removed as a unit (Figure 3). Much earlier detection or, indeed, confession by LB and removal of the magnet could have prevented her resultant perforated septum.6,15

In the case of LH, the GDP's OPT was inconclusive of a FB and, as the patient concealed his symptoms, this led to a delay in the diagnosis. However, on reflection, it could be reasoned that an upper occlusal radiographic view would have been justified and could have led to an earlier diagnosis of the FB. This also demonstrated the lengths that LH was willing to go to in order to conceal the presence of a FB in his nasal cavity.

Conclusion

The presence of a foreign body in the nasal cavity should be a differential diagnosis for cases presenting with symptoms relating to the sinus, especially in children. Dental radiographic imaging, principally OPTs that are often used to assess the developing dentition, also provide a good overview of the nasal cavities. Therefore, it is important to evaluate the OPT thoroughly and investigate any suspicion of a foreign object within the air spaces. Early detection and removal of a FB is paramount in order to prevent any permanent damage and in resolving the patient's symptoms and discomfort.