Foreign bodies in the ear and nose
One or two good attempts, then ENT. Button batteries are an emergency. Try the "parent's kiss" for the nose.
A 3-year-old pushed something into her right nostril this morning. Her mother saw a shiny silver disc. The child is calm, breathing normally.
A 5-year-old has a smelly yellow discharge from one nostril for 3 weeks, treated twice with antibiotics.
Why is the first an emergency, and what does the second probably have?
- Button battery or magnetsEmergency: remove within hours. They burn and perforate.
- Live insect in the earKill it with mineral oil or lidocaine first, then remove.
- Nose: try the parent's kiss firstSeal the other nostril, parent blows once into the mouth.
- Calm child, good light, right toolOne good attempt. Don't keep trying.
- Ear: forceps for soft objects, hook for round onesDon't push it further.
- IrrigationNot for batteries, vegetable matter, or a perforated drum.
- Check the other ear and nostrilChildren often put in more than one.
- Button battery or magnets
- Failed attempt
- Child won't cooperate
- Bleeding or damage to the drum
- Possible inhalation (cough, wheeze, choking)
- Object deep or impacted
- Button battery
- Second object
- Inhaled or swallowed foreign body
- Damage to the eardrum
- Nasal foreign body as the cause of one-sided discharge
| Button battery | Same-day ENT removal, no irrigation |
| Parent's kiss | Seal the other nostril, one short sharp breath into the mouth |
| Attempts | Stop after one or two failed attempts and refer to ENT |
| Insect | Instil mineral oil or 2% lidocaine first |
| One-sided smelly nasal discharge in a child | Foreign body until proven otherwise |
| Possible inhalation | Cough, wheeze, choking episode: chest X-ray and ENT |
Check every dose against a current drug reference and your hospital protocol.
On this page
Why some are emergencies
- Button batteries leak current and alkali, burning through tissue within hours: septal perforation in the nose, canal and drum damage in the ear.
- Magnets on each side of the septum crush it.
- Vegetable matter (seeds, beans) swells with water.
- Inhalation of a nasal object during removal attempts.
Assessment
- What is it, when, which side? Any choking, coughing or wheeze since?
- Look with good light and an otoscope or head torch.
- Check both ears and both nostrils.
- Don't keep trying if the child is distressed: one good attempt with the right tool, then ENT.
Technique by object
- Urgent ENT
- no water
- Hook or loop behind it, or suction
- not forceps
Crocodile forceps
Parent's kiss first
Mineral oil or lidocaine first, then remove
The parent's kiss
- ExplainTell the child it's a "big kiss".
- PositionChild on the parent's lap.
- SealParent closes the clear nostril with a finger.
- BlowParent seals their mouth over the child's mouth and gives one short, sharp breath.
- CheckThe object often shoots out. Can repeat a few times.
Removing ear foreign bodies
- Soft objects (cotton, paper): crocodile forceps under direct vision.
- Round objects (beads): a wax hook or loop passed behind the object, or suction.
- Insects: fill the canal with mineral oil or lidocaine to kill it, then remove or irrigate.
- Irrigation with body-temperature water is useful for small non-vegetable objects, but never for batteries, vegetable matter, or a perforated drum.
- After removal, check the canal and drum for damage.
One-sided nasal discharge in a child
A child with one-sided, smelly, sometimes blood-stained nasal discharge for days or weeks has a foreign body until proven otherwise. Look carefully; antibiotics won't cure it.
Common mistakes
- Delaying a button battery removal.
- Using forceps on a round bead (pushes it deeper).
- Irrigating a battery, a seed or a perforated ear.
- Repeated attempts on a screaming child.
- Missing a second object.
- Giving antibiotics for one-sided nasal discharge without looking.
Frequently asked questions
Why is a button battery in the nose or ear an emergency?
It releases current and alkali that burn tissue within hours, causing perforation. It must be removed the same day.
What is the parent's kiss technique?
The parent seals the clear nostril and gives one short, sharp breath into the child's mouth, pushing the object out of the nose.
How do you remove an insect from the ear?
Kill it first with mineral oil or lidocaine drops, then remove it with forceps, suction or gentle irrigation.
What does one-sided smelly nasal discharge in a child mean?
A nasal foreign body until proven otherwise.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A child has a button battery in the nostril. What is the management?
Answer: Same-day removal by ENT. Button batteries cause tissue necrosis and perforation.
- Review next week: Too late.
- Nasal irrigation: No water.
- Wait for it to come out: Causes burns within hours.
- Decongestant and review: No.
2. Which is the first technique for a bead in a child's nose?
Answer: Parent's kiss. Parent seals the other nostril and blows into the child's mouth.
- Irrigation: Not for the nose.
- Crocodile forceps: Pushes round objects deeper.
- General anaesthetic: Not first.
- Suction under pressure: Not first.
3. A child has foul one-sided nasal discharge for weeks. What is the most likely cause?
Answer: Nasal foreign body. Unilateral smelly discharge in a child is a foreign body until proven otherwise.
- Sinusitis: Usually bilateral.
- Adenoids: Bilateral.
- CSF leak: No smell.
- Allergic rhinitis: Clear and bilateral.
4. A 2-year-old swallowed a coin-sized button battery 1 hour ago. X-ray shows it in the oesophagus with a double-ring (halo) sign. What is needed?
Answer: Urgent endoscopic removal. Button batteries lodged in the oesophagus cause rapid liquefactive necrosis (electrolysis) within 2 hours — perforation, tracheo-oesophageal fistula, aortic fistula. X-ray halo/double-ring sign distinguishes from coins. Emergency endoscopic removal; honey or sucralfate before removal may reduce injury (if ≥ 1 year, ingestion < 12 h). Batteries beyond the oesophagus usually pass but magnets (multiple) need removal.
- Observe and wait for passage: Oesophageal burns develop within hours.
- Induce vomiting: Inducing vomiting is unsafe.
- Repeat X-ray in 1 week: Waiting a week risks perforation.
5. A 3-year-old pushed a small shiny round button battery into her right nostril 1 hour ago. She is comfortable. What is the urgency of removal?
Answer: Emergency removal. Button batteries generate an electrical current and alkaline (caustic) burns in moist tissues, causing necrosis and septal perforation within hours. In the oesophagus they can cause fatal erosion into major vessels. Nasal and ear button batteries need emergency removal; a swallowed button battery needs urgent X-ray and, if in the oesophagus, immediate endoscopic removal.
- Routine clinic next week: Button batteries cause necrosis within hours.
- Remove if symptoms develop: Waiting for symptoms is unsafe: a button battery starts causing chemical necrosis of the septum within an hour or two, before any symptoms appear.
- Wait for it to be sneezed out: Unsafe; it must be removed now.
6. On otoscopy of a normal right tympanic membrane, where is the cone of light seen?
Answer: Anteroinferior quadrant. The tympanic membrane is oval, pearly grey, set obliquely, and concave laterally, with the umbo at the tip of the malleus handle. The light reflex (cone of light) extends anteroinferiorly from the umbo. The small pars flaccida (above the lateral process of the malleus, between the malleolar folds) is the site of attic retraction pockets and cholesteatoma; the larger pars tensa forms the rest. The posterosuperior quadrant is related to the long process of the incus and chorda tympani, and myringotomy is done in the anteroinferior or posteroinferior quadrant to avoid ossicles.
- Posterosuperior quadrant: Ossicles lie behind this area.
- Pars flaccida: Site of attic cholesteatoma.
- Posteroinferior quadrant: Not where the light reflex lies.
- Over the umbo: The cone starts at the umbo but points anteroinferiorly.
7. The tympanic membrane develops from which germ layers?
Answer: Ectoderm, mesoderm and endoderm. The tympanic membrane forms where the first pharyngeal cleft meets the first pharyngeal pouch, with mesoderm in between. Its outer layer is skin from the cleft (ectoderm), its middle fibrous layer is mesoderm, and its inner mucosal layer is from the pouch (endoderm). The first cleft forms the external acoustic meatus, and the first pouch forms the middle ear cavity and auditory tube.
- Ectoderm only: Ectoderm forms only the outer layer.
- Endoderm only: Endoderm forms only the inner layer.
- Mesoderm and endoderm only: The outer layer is ectoderm, so all three are needed.
- Neural crest only: Neural crest forms the ossicles, not the membrane layers.
References and dose sources
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.