CHAPTER I

INTRODUCTION

←
Most cases of foreign bodies in the nose and nasal cavity are not serious
and occur in toddlers and children from 1-8 years. Because children develop the
ability to pick up objects at about the age of 9 months, this problem is much less
common before then.1
←
Curious young children may insert small objects into their nose in a
normal attempt to explore their own bodies. Potential objects placed in the nose
may include food, seeds, dried beans, small toys (such as marbles), crayon pieces,
erasers, paper wads, cotton, and beads. In 1994-1997, it was be reported 68
children from 1-12,5 year old was be diagnosed as foreign body in the nose, at the
Hospital of Robert Debre, Paris.1

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 CHAPTER II

REFFERENCE

A. ANATOMY
The external structure of the nose consist of a pyramidal framework
supported by bony and cartilaginous structures that provide projection of the nose
from the plane of the face. Adequate support of the nasal superstructure is critical
in allowing normal inspiration. Attached to the lateral walls of the nose internally
are pairs of mucosal, that covered appendages known as turbinates.2

Each nasal cavity is divided into specific regions, which include the nasal
vestibule, nasal septum, lateral nasal wall, and nasopharynx .The nasal vestibule is
located most anteriorly and extends from the margin of each naris to the nasal
valve, the narrowest portion of the nasal cavity. The nasal valve is supported by
the upper alar cartilage, which maintains its patency during the negative intranasal
pressure generated during inspiration. The nasal vestibule is lined by squamous
epithelium that contains nasal vibrissae and sebaceous glands. The nasal vestibule
acts as the initial protective filtration area for the airway during inspiration. The
nasal septum forms the medial wall of each nasal cavity and is composed of both
bony and cartilaginous segments covered by mucous membrane. The lateral nasal
wall forms the lateral aspect of each nasal cavity and extends from the nasal valve
anteriorly to the choana posteriorly. Posterior to the choanae is the nasopharynx,
which connects the nasal cavity to the oropharynx and contains within it the
adenoid tissue and eustachian tube orifice.2

The lateral nasal wall consists of three bony horizontal projections called
turbinates or conchae. The turbinates are covered by mucous membrane and serve
to greatly increase the surface area of the nose, there by permitting greater contact
between the unfiltered, unconditioned, inspired air and the functional mucous
membrane of the nose. Below each of the turbinates are clefts or meatus into
which various structures intimately associated with the nasal cavity drain. The
nasolacrimal duct drains into the inferior meatus approximately 30 mm from the

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anterior naris. Nasal mucosal disease may produce edema and obstruction of this
duct, leading to epiphora. The frontal, maxillary, and anterior ethmoidal sinuses
drain into the middle meatus, while the posterior ethmoidal sinuses drain into the
superior meatus. The sphenoidal sinus ostium is located superior to the choanae
and drains medial to the superior turbinate and lateral to the posterior end of the
nasal septum. All of the sinus ostia measure only 3 to 4 mm in size and are
therefore susceptible to closure by even a small amount of mucosal inflammation.2

Nasal Vascularization

The blood supply of the nose is profuse and is important when considering
both normal nasal function and the various disease processes that occur within the
nose. Both the external and internal carotid arteries contribute to this rich nasal
blood supply. The external carotid artery provides vascularization through the
sphenopalatine artery, the terminal branch of the internal maxillary artery. The
internal carotid artery provides vascularization through the anterior and posterior
ethmoidal arteries, terminal branches of the ophthalmic artery. The nasal
vasculature involves an extensive sinusoidal network of large-capacitance vessels
located in the mucosa deep to the subepithelial capillaries. These vessels are found
primarily in the mucosa of the inferior turbinate and anterior septum and act to
change the nasal surface area and regulate nasal resistance, enhancing the
conditioning and filtering of air through the nose. This regulation is accomplished
through the autonomic innervation of the nasal mucosal vasculature.2

Nasal Innervation

Sensory innervation of the nasal cavity occurs through the ophthalmic and
maxillary branches of the trigeminal nerve and through the special sensory fibers
of the olfactory nerve. The autonomic nervous system supplies both
parasympathetic and sympathetic fibers, which act to regulate the degree of
vascular tone, turbinate congestion, and nasal secretion. Presynaptic
parasympathetic fibers travel along with the facial nerve as far as the geniculate
ganglion and then continue in the greater superficial petrosal nerve before joining

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with the deep petrosal nerve to form the nerve of the pterygoid canal or vidian
nerve. Through the vidian nerve, the parasympathetic fibers enter and synapse in
the sphenopalatine ganglion before terminating in the nasal mucosa. Sympathetic
fibers pass through, but do not synapse, in the sphenopalatine ganglion before
terminating in the nasal vasculature. In addition, fibers of the trigeminal nerve
also pass through the sphenopalatine ganglion and transmit sensations of pain,
temperature, and touch. 2

Lymphatics

The lymphatics of the nasal vestibule drain forward toward the lip and
external aspects of the nose. The lymphatics of the nasal fossa drain posteriorly,
one collecting trunk in the olfactory region and a second below. They carry the
lymph posteriorly to either the lateral retropharyngeal or subdigastric nodes.2

B. Foreign body in the nose

1. Definition

.Foreign bodies in the nose is something that entry to the nose or stay in
the nose, that no origin from the nose normally.3

2. Aetiology

They may enter the nose by several routes :


Through the anterior nares, most commonly

Through the posterior choanae. Food may enter during attack of
vomiting

Through penetrating wounds 3,4

3. Pathology

Anything small enough to pass the anterior nares may be pushed into the
nose. Foreign bodies may be organic or inorganic. Paper, beads, buttons, and
pebbles are common. Swab or cotton-woolpledgets may be left accidentally.

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 Bony sequestra may be found, particularly in syphilitic disease or neoplasm.
An inflamatory reaction quickly follows ompaction and is accompanied by a
discharge. 3,4

4. Clinical features

A history of the introduction of a foreign body may not be obtained, especially

in very young children. The sign and symptom of foreign bodies in the nose is
Unilateral nasal discharge. It is the characteristic symptom. Foreign bodies are
reraly bilateral


Nose bleeding may occur

Sneezing may follow the immediate irritation and may expel the foreign
body.


Foreign body is commonly found on or near floor of the nasal fossa. It is
often obscured by inflammatory exudate and may remain hidden for many
years. A radiograph will confirm, if the foreign body is radio-opaque. 3,4,5

5. Treatment

Removal in only the treatment. Forcible nose-blowing may expel the

foreign body. If this fails, it must be removed under direct vision through the
anterior nares. This should be done under general anaesthesia, with a pack in
the nasopharynx. It is sometimes necessary to push it into the nasopharynx.3,4

The patient is placed in the usual upright position for routine

otolaryngological examination, and the nasal fossa illuminated with a head
mirror or fibrelight headlight. It is important that the light source should be
very bright. The following instruments should be available: nasal speculum,
curved hook, Jobson Horne probe, selection of angled crocodile forceps,
angled nasal dressing forceps of various sizes, nasal sucker and source of
suction. A jar to receive specimens to send to the pathology department should
also be prepared. The nasal speculum is inserted with the left hand, and with
the right hand the curved hook is passed beyond the object and the tip rotated

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 to rest just posterior to the object. The object is then gently drawn forwards
and removed completely, or brought almost to the nasal vestibule and then
removed with forceps. The above technique should be used whenever there is a
risk of displacing the object backwards into the nasopharynx, as with spherical
objects such as beads. 5

CHAPTER III

Case Report

III. A. Anamnesis

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Identity

Name : N.F.
Sex : Female
Age : 4 years old
Address : Pogung Sleman
MR : 1.16.25.41

Chief complaint : foreign body in the nose

Present illness history :

3 hours before hospitalized her mother said that her daughter entered plastic to the
left nose. Her mother tried to put the plastic, but she failed. The patient didn’t
complaint about dyspneu, epistaxis, cough. She was painless. The patient didn’t
complaint about ear and throat.

Past illness history

History of the same disease (-)

Family illness history

History of the same disease (-)

III. B. Physical examination

General status : compos mentis, good nutritonal status

Vital sign

Pulse : 88 x/minute

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 RR : 22 x minute

Temp. : 36,8 oC

Weight : 22 kg

ENT examination

Nose : Rhinoscopy anterior sinistra: the foreign body in the meatus nasi inferior
Rhinoscopy anterior dextra : within normal limit
Ear : CAE and tympanic membrane with in normal limit
Throat : With in normal limit

III. C. Diagnosis

The patient was be diagnosed as foreign body in the left nose

III. D. Treatment

Evacuated the foreign body

III. E. Problem

Complication

III. F. Plan

Education

CHAPTER IV

Discussion

Foreign bodies in the nose are much more common in children. Children
constitute the large majority of patients with foreign bodies in the nose. The

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foreign body will be any small object encountered by the child, and it will usually
be introduced through the anterior naris. Children with cleft palate will also have
food from the mouth entering the nose, and occasionally other foreign material
which the child is exploring with the mouth.
If it has been inserted by the patient it is more commonly in the right nasal
cavity, since right-handedness predominates in the general population. The foreign
body may be in any part of the nasal fossa.
Some foreign bodies are inert and may remain in the nose for years
without mucosal changes. Many however lead to inflammation and infection of
the mucous membrane, which in turn leads to fetid mucopurulent discharge and
epistaxis, these symptoms being unilateral, except with animate infestations.
Ultimately granulation tissue is formed, and there may be ulceration of the
mucosa, and occasionally necrosis of bone or cartilage.
A general anaesthetic will be required in the following circumstances if the
patient is uncooperative or very apprehensive.
The parent must be supervised their child to prevent the incidence of
foreign bodies. They must be avoided of the material that can be foreign bodies.

CHAPTER V

Conclusion

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Have been reported, female, 4 year old, she was be diagnosed as foreign body in
the left nose, and it can be evacuated..

REFERENCES

1. Buccino,K. Foreign Body, Nose . Available in :

www.emedicinehealth.com/foreign_body_nose/article-em.htm

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2. Lee KJ. The Nose and Paranasal Sinuses. In: Essential Otolaryngology Head &
Neck Surgery 8th ed. McGraw-Hill Medical Publishing Division, New York 2003:
682-695.
3. Simpson, J.F. Nasal and Paranasal sinuses disease. In Synopsis of Otolaringology.
Bristol: John Wright and Sons LTD 1967 : 175-176
4. Gray RF. Diseases of the nose and paranasal sinuses In: Synopsis of
Otolaryngology 5th ed. Butterworth Heineman ltd. Oxford 1992: 219-233.
5. Ransome, J. Foreign bodies in the nose. Available in :
www.Famona.sezampro.rs/medifiles/OTOHNS/SCOTT/scott617.pdf

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