Ann-Marie was a 3 1/2-year-old whom I was seeing in the office for the very first time. Ann and her family had recently moved to Southern California from out-of-state, and, although she has been very healthy, mom felt it was important to get established with a doctor near their new home.
As is the case with all new patients I started taking the history from the beginning, asking about the pregnancy and delivery which were normal and uneventful. Ann’s growth, development and past medical history were completely normal as well. The child was all dressed up for her doctor visit, and sat patiently looking through a book as mom and I talked. A bit shy, she always looked at her mother with a coquettish glance before answering my questions somewhat reluctantly. It was noticeable that before speaking she would sniffle and rub her nose. There was a small amount of yellow drainage in the right nostril.
In anticipation of any anxiety that Ann might have I had her sit in mom’s lap while I examined her. As I scooted my chair next to them, and I got near to Ann, it hit me like a blast of hot air. I knew what the diagnosis was.
Continuing with the physical exam, I questioned mom about the sniffles and nasal discharge. “Oh, she’s done that off and on for the past few months,” she said, as if resigned to the problem. “Her doctor in Texas gave us three different antibiotics, but they didn’t seem to make a bit of difference. We figured it was allergies, and hoped it might clear up when we moved to California.”
As I expected, Ann’s exam was essentially normal, and yet, not completely normal. The striking element was a distinct and putrid odor noticed the minute I got near the child. There was no mistaking what it was from.
Mom had a peculiar look on her face when I asked if Ann had a habit or history of putting things in her nose. She thought for a moment, then shook her head in a slow and pensive way before looking up and saying, “You know, before falling asleep Ann sucks her thumb while holding teddy bear in the same hand…and often times she does stick the index finger in her nose. I haven’t made a big deal out of it because it only happens at the brink of falling asleep.” Then she asked incredulously, “Why, do you think she could have something in her nose?”
I told her that I was not a betting person. However, this was one bet that I was sure of—the history, exam and above all, the putrid odor made too compelling a case for a nasal foreign body. There was one sure way to find out! Ann was a very cooperative patient, lying motionless on the examining table. She was perfectly still as I inserted a plastic speculum inside the right nostril to better visualize the anatomy.
Mom literally let out a loud shriek when I pulled out a good three inches of nasty looking, spongy foam-like material from Ann’s nose. It didn’t seem to end. Mom looked a bit pale, rubbed her forehead and said, “I think I’m gonna get sick…What was that?…Where did it come from?”
Before long we determined that the teddy bear Ann took to bed was frayed and worn. It had a couple of areas where his stuffing tried to escape. Before washing him, Ann’s mom would “suture” his little tears. But the remedy would never quite make it to the next washing. It was the stuffing from the teddy bear that the child was packing in her nose.
I put Ann on a short course of antibiotics, even though the removal of the foreign body was probably sufficient treatment. There was concern because the packing had been full of pus and blood—it had obviously been there for some time. I was also worried that she might have developed a secondary infection. While talking to mom, she stopped in mid-sentence with a stunned look on her face. “Oh, my gosh,” she uttered. “Could this have been there the entire two-to-three months? I feel like a terrible mom?” The realization had just hit.
I reassured her that she had done everything she was told to do. She had gone to the doctor’s office three times for the same problem. There was nothing she could have done differently. Ann’s case was very typical of a nasal foreign body in a child.
Young children have a unique fascination with their noses and with their ears as well. For some unexplainable reason they have an overwhelming urge to put things in their noses, aside from the usual fingers. I have removed food, crayons, pieces of erasers, a plastic propeller from a toy, beans, beads and stones…to name a few. Most of the time, when the toddlers realize what they have done, they will tell the parent. Or the parent will see them do it but not be able to intervene in time. In these cases, they are usually brought into the office so that the “treasure” packed into the proboscis can be removed. Beans in the nose are a bit more challenging. They absorb water and can swell tremendously in size, making it difficult to remove.
Ann’s case represents a more difficult patient. Foam, spongy material, or wads of paper that have been packed in the nose as part of a habit may go unnoticed for some time. A clue for this might be a unilateral nasal discharge or obstruction that does not respond to conventional therapies. Most colds or respiratory infections will involve both sides of the nose. The real tip-off, however, is the foul and putrid odor that is so characteristic of a nasal foreign body. It is said that an experienced doctor can walk into a room, take a couple of whiffs, and make a diagnosis. I must say that I have experienced this on more than one occasion and agree; there is nothing quite like this odor.
Ann responded quite nicely and all of her symptoms cleared up. The teddy bear was put into “early retirement." Mom said that it was time anyway. The material had become so frayed and worn that it was like cheesecloth and beyond any further repair. Ann was fine with this decision, and the toy now holds a place of honor on top of the dresser.
When I saw Ann a few weeks later, mom told me that she and her husband could not believe how good the toddler was doing. They had become so accustomed to the sniffles and odor that it was only when the packing was removed that they could appreciate the impact it had made on all of their lives.