In Otorhinolaryngology (ORL) practice, we commonly received cases of foreign bodies in the nose. Among these referrals, the pediatric group is the most common, others could involve the mentally challenged patients. These foreign bodies may vary from different materials and consistencies and removal them requires good clinical experience as well as proper clinical instruments and cooperative clinical staff and the patient. On rare occasion, penetrating foreign body at the nasal bridge was presented to us; and, we are reporting a case of penetrating fishhook at the nasal bridge and its management.
Foreign bodies, Penetrating, Nasal bridge, Fishhook
Nasal foreign bodies (NFB) are a common presentation to the general healthcare provider or the Otorhinolaryngology (ORL) clinic. Nasal foreign bodies can either inorganic or organic. Inorganic materials such as plastic or metal, and organic foreign bodies may include food, rubber, wood, and sponges. Jewelry beads are the most common seen NFB . Objects that can cause permanent damage are such as batteries and magnets that require emergency removal. Commonly the NFB was found inserted into the nasal cavity, however, rarely we encountered penetration nasal foreign body.
During the Covid-19 lockdown period, school-age children in our country were not able to attend to school and there were not allowed to participate in any outdoor activities. Therefore, daily activities are limited to home compound. Due to curiosity, many instruments or tools that are deemed harmful were used as playing tools. As in our patient, he was playing with a fishing rod with a fishhook attached, which accidentally penetrated the nasal bridge. The purpose of this report is to share our experience in managing penetrating fishhook injury over nasal bridge.
A 6-year-old child presented to our emergency and trauma department with a fishhook penetrated over his nasal bridge (Figure 1). The history from the caretaker revealed that the incident occurred when the patient was playing a fishing rod with his brother at home, and accidently swung the fish rod with the fishhook attached to the patient face, and; subsequently the fishhook entangled over his nasal bridge. Post-trauma he developed pain and bleeding over nasal bridge. Fishing wire was cut, and he was brought to the hospital. On examination the child was hemodynamically stable, and he was in calm condition. The fishhook was penetrating from the right medial canthus and exited via the contralateral side at the level of the nasal bridge. No active bleeding noted over the wound. There was no injury to the eyes and the nasolacrimal ducts were spared. Facial X-ray was done showed the fishhook only involved the superficial subcutaneous tissue and no deeper structure involvement (Figure 2).
Figure 1: The fishhook was penetrating at the level of the nasal bridge from the right medial canthus (A) and exited via the contralateral side (B). View Figure 1
Figure 2: The lateral (A) and anteroposterior (B) view facial X-rays showed the fishhook only involved the superficial subcutaneous tissue and no deeper structure involvement. View Figure 2
The methods of the fishhook removal were thoroughly discussed among the family members, and they opted for removal under sedation using intravenous ketamine. Under a sterile environment and the child was well sedated, a wire cutter was used to cut the proximal end of the fishhook (Figure 3), then entangled hook was gently pulled at the sharp tip with a needle holder. Hemostasis was secured. He was on close observation until he was fully conscious and stable. The patient was a given tetanus toxoid injection, oral antibiotics, analgesia and antibiotic ointment for local application. The patient was reviewed after 7 days with the well-healed scar and there were further complications.
Figure 3: A) The fishhook was cut at the proximal end and removed by pulling the sharp distal end; B) Wire-cutter used for cutting the fishhook. View Figure 3
A fishhook is a curved, sharp instrument placed on a lure or line to catch fish. Some fishhook has a barb near the tip that keeps the fish on the hook, and there is also barbless fishhook, which may reduce the chance of a fishhook injury (Figure 4). Fishhook over nose bridge is an extremely rare foreign body, and in this anatomical region, the vital structures, i.e. the eyes, nasolacrimal ducts, angular vessels might involve which could lead to complication intra- and post-operatively, and fortunately, as in our case, these structures were not involved. However, it was a barbed fishhook that causing the injury which removal of it was challenging.
Figure 4: A) Barbed fishhook; B) Non-barbed fishhook. View Figure 4
In Malaysia NFB are common problems in the pediatric age group, and the most frequent age group was 3 years (48.83%) followed by 2 years (18.6%) and the least frequent 7 to 9 years (2.33%), and; in general which most patients were under 5 years of age [2-5]. NFB could be easily removed; however, multiple unsuccessful attempts at removal may cause stress and further trauma to the patient, and thus, hampering further attempts . The factors associated with the success of foreign body removal, depending on the duration of foreign body residence, their characteristics (size, shape and texture), patient cooperation during the procedure, foreign body visualization and its location with the surrounding structures, equipment and the operator's skill . As for our patient, improper technique to attempt to remove the fishhook by pulling it will cause severe pain, extensive tissue damage or severe bleeding. Further injury to nearby structure such as the eyes or bone might occur and cause significant morbidity to the patient. Thus, appropriate sedation is required to prevent the child from struggling during removal of the fishhook. By cutting the proximal end near to the eye and removing it by pulling the sharp end of the hook was less traumatic and minimize the complication. Local compression using adrenaline gauze can help to secure bleeding. As fishhook is a heavily contaminated object, tetanus toxoid and antibiotics are to be prescribed to reduce the risk of infection.
Penetrating foreign body at the nasal bridge is rare, and managing such case required consideration of several factors, including the types of material involved, the extent of the injury, steadiness state of the patient and the skillful physicians. During removal, it should be properly planned and done under sterile and well-equipped environment to prevent further injury and complication to the patient.