Foreign body removal can be safe to perform in the emergency department (ED), but before undertaking retrieval attempts, key considerations include the following:

• Clinicians should ensure they know who to call if the foreign body cannot be retrieved or if any complications occur.
• Clinicians should be familiar with the tools/instruments they have at their disposal in the ED, and consider which of these items as well as what the different techniques are that may be needed to remove a foreign body.
• Patient cooperation and comfort are critical. Clinicians should ensure they use what is necessary to ensure patient comfort; sedation and analgesia may be needed for the safe removal of a foreign body.
• Not every foreign body needs to be, or should be, removed in the ED. Retrieval in an operating room (OR) may help avoid placing patients and clinicians at risk for injury.
• Consider what type of patient follow-up may be necessary.

The radiograph reveals a vibrator in the rectum along with a pair of salad tongs that became lodged after the patient's attempts at self-removal.

Image courtesy of Medscape/David W Munter, MD, MBA.

A 19-month-old male is brought into the pediatric ED because of persistent, inconsolable crying. The parents indicate that this is very unusual behavior for their child, and they are concerned there may be something wrong, as he is normally very adventurous and often plays outside in the dirt. They state that the only other unusual aspect of his behavior is that he consistently grabs at his right ear. The parents are worried that he may have a very bad ear infection but deny the child has had any recent fevers or previous ear infections.

Examination with a handheld otoscope reveals the image shown.

What is your next step?

Images courtesy of Joăo Estęvăo A de Freitas (roach) and Medscape (tympanic membrane background).

Aural Foreign Bodies

Despite its small size, the external auditory canal may host numerous types of foreign bodies.

Living insects account for most aural foreign bodies found in adults, whereas the pediatric population frequently places food (eg, peas, beans), organic matter (eg, grass, leaves, flowers), and inorganic objects (eg, beads, rocks, dirt) into their ear canals during play, often failing to admit this to their parents.^[1] Depending on their age, children may be able to indicate that they have a foreign body, or they may present with complaints of ear pain or discharge.

The computed tomography (CT) scan shows a metallic foreign body in the right external auditory canal.

Image courtesy of Lars Grimm, MD, MHS.

Patient positioning

The external auditory canal can be visualized with patients seated upright seated (left) or in the lateral decubitus (right) position. The choice of position is made on the basis of the patient's comfort and ability to cooperate.

In children and young adults, gentle traction on the pinna superiorly and posteriorly to straighten the ear canal is often necessary. In infants, posterior or even downward traction may be necessary to obtain an adequate view.

Images courtesy of the US Navy and (1) Mass Communication Specialist 2nd Class Chelsea A Radford (left) and (2) Mass Communication Specialist Seaman Apprentice Joshua Adam Nuzzo (right), both via Wikimedia Commons.

Aural foreign body removal

The three most commonly employed techniques for aural foreign removal are mechanical extraction, irrigation, and suction.^[2] Allow the nature of the foreign body to guide the selection of technique. For example, irrigation is contraindicated for organic matter that may swell and enlarge within the auditory canal.^[2]

Mechanical extraction

Before initiating mechanical extraction, briefly reexamine the ear canal to note the location of the foreign body.^[2] Live insects in the ear canal should be immobilized before attempts at removal; mineral oil, microscope oil, and viscous lidocaine may used for this purpose.

Gently introduce bayonet or alligator forceps through the open end of the otoscope, and slowly advance the forceps until the foreign body can be grasped. Take care to avoid excoriating the auditory canal while withdrawing the forceps with the attached foreign body.^[2]

Repeat the otoscopic examination to check for any remaining foreign body, perforation of the tympanic membrane, and abrasions of the auditory canal.^[2]

See a short video demonstration of mechanical extraction here.

Images courtesy of Dreamstime/Casanowe (otoscope examination) and Wikimedia Commons/Sarindam7 (Hartman aural forceps).

Aural foreign body removal

Irrigation

To use irrigation for removal of a foreign body in the ear, first attach a 20-gauge angiocatheter to a 60 mL syringe.^[2] Position and drape the patient comfortably, and use warm irrigation fluid. Place a small basin under the ear, and then slowly and gently advance the catheter to avoid injury to the auditory canal and tympanic membrane. Gently hold the catheter in position, and gradually inject the irrigation fluid until the foreign body washes out.^[2]

As with other removal techniques, perform a postprocedural ear examination to verify there is no remaining foreign body and to rule out any damage to the ear anatomy.^[2]

See a short video demonstration of the irrigation method here.

Adapted image of an syringe courtesy of Dreamstime/Paul Fairbrother; image of ear anatomy courtesy of Wikimedia Commons/Dan Pickard.

Aural foreign body removal

Suction

Insects, organic matter, and objects with the potential to become friable and break into smaller pieces in the ear are often better extracted with the suction technique.^[2]

Connect a soft-tipped suction catheter to low wall suction, and position the patient comfortably.^[2] Maintain the position of the otoscope after visualizing the foreign body; then, as with the forceps in mechanical retrieval, gently and gradually introduce the suction catheter through the otoscope. When the catheter comes in contact with the foreign body, lightly withdraw the suction catheter tip with the attached foreign body from the external auditory canal.

Always perform a postprocedure ear examination.^[2]

See a short video demonstration of the suction technique here.

Image of a suction catheter courtesy of Uwe Gille and image of ear anatomy courtesy of Dan Pickard, both via Wikimedia Commons.

Nasal Foreign Bodies

The nose is another frequent location for lodged foreign bodies. Nasal foreign bodies are relatively common among the pediatric population, but they may also be seen in adult patients, often affecting those with developmental delay or psychiatric disorders.^[3] A guardian may have witnessed the objects being inserted, or the finding may be incidental.

Patients with nasal foreign bodies may present with unilateral nasal drainage, sneezing, pain, epistaxis, or a foul odor, but they may also be asymptomatic.^[3] Commonly inserted items include toys or toy pieces, button batteries, beads, rocks, paper, and food items such as peas, beans, and nuts.

The image shows common sites of impaction of foreign bodies in the nasal cavity. IT = inferior turbinate, MT = middle turbinate, SS = sphenoid sinus, ST = superior turbinate.

Image courtesy of Medscape.

Patient positioning

As with other foreign body extraction procedures, proper positioning of the patient is essential. The head may be placed in the "sniffing position"^[3] while the patient lies supine or sits upright, depending on the patient's cooperation and comfort. In the event that the patient is uncooperative and procedural sedation is contraindicated, safely and securely restrain the patient before proceeding.

Anesthesia is typically not necessary for removal of nasal foreign bodies, but when indicated, local anesthesia may be achieved with several drops of topical 1% lidocaine with 0.5% phenylephrine to reduce bleeding.^[3]

Intraoperative endoscopic view of a right nasal button battery foreign body courtesy of Thabet MH, Basha WM, Askar S. Biomed Res Int. 2013;2013:846091. [Open access.] PMID: 23936851, PMCID: PMC3725977.

Nasal foreign body removal

Direct visualization and instrumentation

If it is likely that the nasal foreign body can be easily extracted, removal may be attempted by an experienced clinician. Often, direct visualization and instrumentation, respectively, is all that is needed to locate and remove the object. Depending on the patient's cooperation and symptomatic severity, use of alligator or bayonet forceps or a hooked probe under direct visualization may be sufficient. If the head of an uncooperative patient cannot be stabilized, procedural sedation should be employed before mechanical removal.^[3]

For hard-to-reach and/or large objects, the use of a nasal speculum frequently aids in the direct visualization and removal of a foreign body. A nasal speculum may aid removal regardless of the technique used.

See short video demonstrations of visualization and direct instrumentation, respectively, for removal of nasal foreign bodies here.

Images of nasal speculums courtesy of Wikimedia Commons/SnowBink.

Nasal foreign body removal

Use of balloon catheters

Balloon catheters may also aid in nasal foreign body removal (eg, 12 French Foley catheter, no. 6 biliary Fogarty catheter, no. 4 or 5 vascular Fogarty catheter), particularly for small, round objects that are not easily grasped by direct instrumentation.^[3]

With the patient in the supine position, pass the tip of a lubricated balloon catheter beyond the foreign body and inflate the balloon with 1-3 mL of air or saline. Then, gently withdraw the inflated catheter to pull the object out distally.

Regardless of the method, avoid repeated extraction attempts owing to the high likelihood of causing nasal trauma and because of the potential for moving the object into a less accessible location.^[3] Contact an otolaryngologist if doubt exists about the possibility of removal or if nasal trauma occurs.

Image courtesy of Medscape.

A 35-year-old male presents to the ED with a complaint of constipation for the past 3 hours. The patient has no significant past medical history and is not on any medications.

The patient is visibly nervous and seems to be avoiding eye contact. After requesting the bedside curtains be closed, he explains that he was exiting from the shower when he slipped and landed on a shampoo bottle, which he states is now stuck in his rectum. He asks you to not reveal this information to anyone else and to please help him.

Image courtesy of Dreamstime/Viorel Dudau.

Rectal Foreign Bodies

Rectal foreign bodies can often be safely removed in the ED.^[4] If the clinician believes the object may be removed without risk, extraction should be attempted in the ED. Foreign bodies generally appropriate for such attempts should be smooth, nonfriable, and unbreakable. Thus, exclude items such as light bulbs, which could shatter easily.^[4]

If the object is thought to be sharp or if severe bowel injury or perforation is suspected to have occurred, promptly obtain surgical consultation for evaluation and removal in an OR.^[4]

The left radiograph demonstrates the outline of a plastic soda bottle in the sigmoid colon (arrows) of a male patient. The right radiograph reveals a vibrator in the rectum of a different male patient.

Images courtesy of (1) Pandey BB, Dang TC, Healy JF. BMC Infect Dis. 2005;5:42. [Open access.] PMID: 15921523, PMCID: PMC1174869 (left), and (2) Wikimedia Commons/Lucien Monfils (right).

Patient evaluation

The initial workup for a rectal foreign body should include, but not be limited to, a plain abdominal film (see the previous slide), and—if no dangerous or sharp foreign body is visualized on the radiograph—followed by a digital rectal examination.^[4]

The presence of frank blood indicates that a laceration or perforation has occurred. The patient's evaluation and management should be transferred to a surgeon for removal of the object and repair of the laceration in the OR.

If the foreign body is palpated on rectal examination, the object is considered to be low lying and a candidate for ED removal.

Image courtesy of Dreamstime/Legger.

Patient positioning

Adequate analgesia and patient positioning are critical to achieving patient comfort, obtaining direct visualization, and successful removal of the rectal foreign body.^[4] Patient relaxation can be attained with medications such as midazolam for mild sedation and morphine, fentanyl, or hydromorphone for analgesia.

Position the patient in a knee-chest position. Alternatively, place the patient in the supine lithotomy position in a bed or chair equipped with stirrups.

Images courtesy of Medscape (left) and Dreamstime/Uatp1.

Rectal foreign body removal

Direct visualization and instrumentation

Anoscope, proctoscopes, and speculums, if available, can facilitate direct visualization and removal of foreign bodies from the rectum.^[4] Using direct lighting (eg, head lamp, surgical lamp), gently insert the lubricated scope or speculum into the rectum. Once the object is visualized, grasp it with forceps and slowly withdraw. Note that it may be necessary to turn the foreign body to minimize the cross-sectional size for removal.^[4]

If the item cannot be visualized, do not make blind attempts. Obtain surgical consultation for possible examination and extraction under anesthesia.^[4]

Adapted image of an anoscope and proctoscope courtesy of Wikimedia Commons/Mikael Häggström (left); image of a rectal speculum courtesy of Dreamstime/Andrey Sukhov (right).

Rectal foreign body removal

Use of Foley catheters

During attempts to extract large objects from the rectum, the rectal mucosa often forms a seal around the foreign body, making it difficult to move the item against the suction forces. However, under direct visualization, insertion of a lubricated Foley catheter past the object breaks the airtight seal and creates an air channel, thereby allowing for movement of the foreign body. If the tip of the Foley catheter can be successfully passed beyond the object, distal inflation of the balloon and gentle traction can be applied to help move the object. This method is similar to the balloon catheter technique used to remove nasal foreign bodies that was discussed in slide 11.

Adapted image courtesy of Wikimedia Commons/Olek Remesz.

Vaginal Foreign Bodies

In general, vaginal foreign bodies may also be managed in the ED. As with rectal foreign bodies, knowledge of the relevant anatomy and appropriate diagnostic imaging facilitate decision making regarding whether removal of the object should be attempted in the ED.

If a laceration is suspected or if the object may be dangerous to remove, obtain consultation with a gynecologist.

Adapted image courtesy of Dreamstime/Ali Kocakaya.

Patient evaluation

Before performing a gynecologic examination, obtain imaging studies to determine the nature and location of the foreign body. These will help guide decision making regarding whether removal in the ED is safe to attempt.

Often, vaginal foreign bodies may not be radiopaque; in such cases, ultrasonography may be a useful tool for determining the location and nature of the object.

Image courtesy of Lars Grimm, MD, MHS.

Patient positioning

As discussed with other foreign body removal techniques, positioning and equipment are very important.

In general, the lithotomy position is used if a gynecologic bed or chair with stirrups is available. This position facilitates foreign body removal by allowing for relaxation of the muscles of the pelvic brim, thereby creating less resistance to speculum insertion and object extraction. Use of a vaginal speculum (left) and Magill forceps (right) aid in the proper visualization and removal of the item.

Images courtesy of Saltanat (left) and AfroBrazilian (right), both via Wikimedia Commons.

Vaginal foreign body removal

Insert the lubricated vaginal speculum with care to avoid laceration to the labia or vaginal mucosa and to facilitate patient comfort. Any discomfort may cause involuntary contraction of the pelvic muscles, making extraction more difficult.

Once the speculum is fully inserted, locate the foreign body using direct light from a head lamp or a surgical lamp. Lock the speculum in position and insert the Magill forceps through the speculum opening, taking care to avoid damage to the vaginal mucosa. Then, slowly extract the foreign body. Remove the speculum, making certain not to pinch the vaginal wall between the speculum blades.

In the image shown, the dotted circle indicates the approximate location of the foreign object represented by the blue dot in slide 18.

Adapted image courtesy of Wikimedia Commons/Ep11904.