Nasal foreign bodies usually are more of an annoyance than a threat to life. Most of them are inserted by toddlers or preschoolers themselves. Occasionally, a piece of tissue placed in the nose to stop a nosebleed inadvertently stays in place for days to weeks. The classic finding of an intranasal foreign body is persistent, unilateral, purulent nasal discharge that may be tinged with blood. Foul odor is a common finding. Occasionally, nasal foreign bodies have dislodged posteriorly and have been aspirated, either spontaneously or during an attempt at removal. Although the diagnosis should be readily apparent, copious or dried secretions can obscure the foreign body. Alternatively, the foreign object may be misinterpreted as a nasal polyp.

Removal of most nasal foreign bodies is accomplished readily in the office without use of general anesthesia. Sedation may be required but usually is not necessary.

Soft or irregularly shaped objects that can be grasped easily by forceps are best removed in this way. Retrieval of a round, hard object, such as a bead, is accomplished best by inserting an ear curet past the foreign body and then applying gentle forward pressure.

Aspiration of foreign material into the larynx and trachea can be lethal, and aspiration of foreign bodies into the upper airway is estimated to be the second leading cause of accidental death in the home among children younger than 5 years of age. In most cases, the diagnosis is evident immediately. Sometimes, however, a child may aspirate while alone or asleep, and sudden unexpected death or sudden onset of severe respiratory distress may occur. Although the aspirated material usually is a piece of food or candy, various other objects have been recovered from the larynx and trachea. The plastic cap of a water pistol, a fragment of a balloon, and a piece of bubble gum are examples of objects that have been recovered at autopsy.

Very small foreign objects in the trachea generally are not life-threatening. Although one would imagine that such objects would be either coughed out promptly or aspirated more deeply, this is not always the case; foreign bodies may remain in the trachea for days or even weeks, often becoming embedded in granulation tissue. Although the predominant clinical feature is inspiratory stridor, associated expiratory wheezing is present in approximately 25% to 50% of cases. Cases have been misdiagnosed as croup or tumors. Eggshells, plastic toys or parts of toys, and watermelon seeds are examples of objects that have remained in the trachea for extended periods.

Signs and symptoms of an upper airway foreign body may be mimicked by an esophageal foreign body that is pressing on the posterior trachea. Remarkably, in some cases, esophageal foreign bodies cause stridor or wheezing without pain and without difficulty in swallowing.

Most patients with acute life-threatening upper airway obstruction caused by a foreign body are treated in the field, usually by someone who is not a physician. By the very nature of the condition, few patients requiring urgent treatment reach the hospital before intervention occurs. Consequently, most physicians have had little direct personal experience in treating patients with life-threatening upper airway foreign bodies. Obviously, controlled studies in humans cannot be performed. Available data are from anecdotal case reports, studies in anesthetized animals (some of which had an endotracheal tube in place during the experiment), mechanical models, and theoretic considerations.

Maneuvers used in treating acute, severe upper airway foreign bodies include (a) abdominal thrust (Heimlich maneuver) for patients older than 1 year of age, (b) back blows and chest thrusts for patients younger than 1 year of age, and (c) finger sweeps of the oropharynx.

To perform the abdominal thrust with the victim sitting or standing, the rescuer stands behind the patient with his or her arms wrapped around the victim’s abdomen and one fist grabbed by the other hand, slightly above the navel and well below the xiphoid process. The rescuer then forces the fist into the abdomen with a quick upward thrust. If the patient is supine, the rescuer places the heel of one hand, with the other hand on top, on the abdomen in the location described and exerts a sudden upward pressure in the midline. Back blows are applied with the heel of the hand high between the scapulae. Chest thrusts are similar to external cardiac compressions, delivered quickly in a series of four thrusts.

The Heimlich maneuver is potentially dangerous to abdominal viscera, especially the liver in infants, and back blows can drive the foreign body further into the airway. As a compromise, the former is used for patients older than 1 year of age and the latter for infants younger than 1 year old.

Recommendations for emergency management of an upper airway foreign body are as follows: If the victim can speak, breathe, or cough, all interfering maneuvers are unnecessary and dangerous. The patient should be permitted to try to clear the obstructing object by spontaneous cough while preparations are made for emergency transportation to the nearest medical facility.