Objective To evaluate the use, success rate and time in the paediatric emergency department when employing the kissing technique to remove nasal foreign bodies from children.
Methods The present work was a retrospective case note review for children attending with a nasal foreign body over a 15-month period.
Results In all, 116 children had a confirmed nasal foreign body and 84 were treated by the kissing technique with a success rate of 48.8%. This group had lower rates of instrumentation (20.2% vs 53.1%) and general anaesthesia (11.9% vs 18.8%). The average time saved per patient who had the kissing technique attempted in the paediatric emergency department was 30.6 min.
Conclusion The kissing technique should be employed as a preferred technique to remove nasal foreign bodies in children.
- Paediatric emergency med
- nasal foreign bodies in children: kissing it better
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‘Nasal foreign body’ is a common presentation in paediatric emergency care. Removal is important, as (1) damage can occur to the nasal cavity and surrounding structures and (2) there is potential for dislodgement into the airway. Invasive methods of removal are usually used, such as suction or instrumentation (microsuction/Jobson Horne probe). However these methods can lead to an uncooperative and fearful child, which can hinder removal1 2 and increase the need for general anaesthesia.1
The kissing technique was first described by Ctibor in 1965.3 The manoeuvre is performed by the parent under instruction from a member of staff. The parent puts their mouth over the child's (giving a ‘big kiss’) and occludes the unaffected nostril with one finger. The parent then exhales into the child's mouth, generating positive pressures, similar to that of nose blowing.3 4 The kissing technique is not distressing for the child,2 3 is straightforward to perform and does not involve topical anaesthesia.
There are few studies that compare techniques for nasal foreign body removal, and the largest previous case series for the kissing technique only included 31 patients. During the introduction of the kissing technique in a large emergency department (ED) the opportunity for an observational study arose, as some staff had been trained to use this method and some had not.
A retrospective analysis was conducted for all children presenting with a confirmed nasal foreign body to the Paediatric Emergency Department of the Leicester Royal Infirmary, Leicester, UK over a 15-month period from 1 January 2008 to 31 March 2009. Patients were identified by searching for ‘ENT FB in nostril’ on the Emergency Department Information System (EDIS). Patients aged <16 years with a confirmed foreign body were included.
The case notes of all patients were reviewed. Data extracted was whether or not the kissing technique was used, the successful method used to remove the foreign body and the time spent in the ED. Patient demographics and type of foreign body present were also recorded.
During the study period some of the staff in the ED had been trained and routinely used the technique, whereas others were not trained in the technique, allowing us to compare different methods. The training of staff was carried out opportunistically (when the consultant was present to teach) however no formal randomisation was carried out. Children had the kissing technique performed if the triage nurse on duty had been trained to explain the manoeuvre to the parents. The technique was not used if the child could cooperate sufficiently to strongly blow his or her own nose.
A total of 116 patients were eligible for analysis, and 84 children (72.4%) underwent the kissing technique versus 32 children (27.6%) who did not. The kissing technique was successful in 41 cases (48.8%) with most (73.2%) of the successes happening on the first attempt. This is summarised as a cohort diagram in figure 1. This method was explained by the paediatric emergency department triage nurse in 82.1% cases (with an ED doctor giving instructions for the rest). No parent declined to attempt the manoeuvre.
The patient demographics are shown in table 1. Both groups had similar ages and involved foreign bodies more commonly in the right nostril. The oldest child in the series was 8 years old. Those who underwent the kissing technique were predominantly girls (63.1%), but with the opposite gender ratio (female 31.2%) in the group where the technique was not attempted.
The kissing technique group had lower rates of instrumentation (20.2% vs 53.1%, χ2 p=0.0005) general anaesthesia (11.9% vs 18.8%, χ2 p=NS) when compared to those where the technique was not attempted (table 2). There was no post procedure epistaxis seen in either group.
The kissing technique group spent an average time of 67.7 min in the department versus an average of 98.3 min for the non-kissing technique group. The average time saved per patient who had the kissing technique attempted was 30.6 min.
Published data on the kissing technique is limited to small case series of between 8 and 31 patients,2 3 5 with no randomised control trials or meta-analyses. This retrospective study is the largest to date and illustrates some important points. Firstly, the technique can be instigated by the paediatric emergency department triage nurse, with a good chance of success (one-half of patients). Secondly, it reduces the need for more invasive and distressing techniques such as instrumentation, and one-third fewer patients are admitted for general anaesthesia. Thirdly, success of the kissing technique means that the patient can be discharged from the ED within minutes of arrival, so that for every 10 children who have the technique 5.1 patient hours of ED time are saved, which will help to improve waiting times and overall flow of patients through the department.
The method seemed acceptable to parents, as no parent declined to attempt the manoeuvre. We did not formally evaluate the child's view, but anecdotally children actually find the method fun as it is made part of a ‘game’—there is a lot more giggling and a lot less screaming compared with the conventional methods! The gender difference between the groups is difficult to explain—it is not clear if this is a statistical quirk, or due to some sort of selection bias. As no parent declined to attempt the manoeuvre there was unlikely to be bias from parent/child preferences, and it also seems unlikely that the triage nurse would be more reluctant to suggest the technique for boys. So this difference seems most likely to be a statistical quirk.
This study is retrospective, with all the associated limitations. However given the simplicity, lack of harm and evident success of this technique, a randomised study is unlikely to be ethical.
Our practice now is to employ the kissing technique as the preferred technique to remove nasal foreign bodies in children.
Competing interests None.
Provenance and peer review Not commissioned; not externally peer reviewed.
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