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\begin{document}

\title{Intranasal foreign bodies: A 10-year analysis of a large cohort, in a
tertiary medical center}



\author[1]{Ofir Zavdy}%
\author[1]{Igor Vainer}%
\author[1]{Nataly London}%
\author[1]{Tomer Menzely}%
\author[1]{Roy Hod}%
\author[1]{Eyal Raveh}%
\author[1]{Dror Gilony}%
\affil[1]{Rabin Medical Center}%


\vspace{-1em}



  
  \date{May 24, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
Objective: To describe the occurrence, clinical presentation and
management, of pediatric nasal foreign bodies, and to assess various
risk factors for complications. Methods: A retrospective analysis of a
computerized patient directory of 562 children admitted to the emergency
department (ED) in a tertiary pediatric hospital during a 10-year period
(Jan 2010-Dec 2019), with a witnessed NFB upon physical examination.
Results: Upon admittance to the ED, most of the children (82\%) were
asymptomatic. Among the symptomatic children (18\%), the primary
symptoms were nasal discharge (10\%), epistaxis (8\%) and pain (4\%).
Younger children (under age 4 years) were more likely to insert organic
materials, compared to older children. Younger children were also
admitted sooner to the ED and were more likely to present with nasal
discharge. The overall complication rate was 5\%. None of the children
had aspirated the NFB. Complications included infection (2\%), necrosis
(0.7\%), septal perforation (0.5\%), deep mucosal laceration (1.5\%) and
loss of NFB (1.9\%). Significantly higher rates of symptoms and
complications were associated with button batteries. Increased risk for
complications were observed according to NFB-type, multiple attempts to
remove NFB, posterior insertion of NFB and left-side insertion.
Conclusions: NFB in children are common. Mostly, patients are
asymptomatic, therefore a high index of suspicion is required, for quick
diagnosis and safe removal, without complications.%
\end{abstract}%



\sloppy


\textbf{Intranasal foreign bodies: A 10-year analysis of a large cohort,
in a tertiary medical center}

\textbf{ABSTRACT}

\textbf{Objectives:~} To describe the occurrence, clinical presentation
and management, of pediatric nasal foreign bodies, and to assess various
risk factors for complications.

\textbf{Design:~} A retrospective analysis of a computerized patient
directory of 562 children admitted to the emergency department during a
10-year period, with a nasal foreign body.

\textbf{Settings:} A tertiary pediatric hospital.

\textbf{Results:} Upon admittance, most of the children (82\%) were
asymptomatic. Among the symptomatic children (18\%), the primary
symptoms were nasal discharge (10\%), epistaxis (8\%) and pain (4\%).
Younger children (under 4 years) were more likely to insert organic
materials, compared to older children. Younger children were also
admitted sooner to the emergency department and were more likely to
present with nasal discharge. The overall complication rate was 5\%.
None of the children had aspirated the foreign body. Complications
included infection (2\%), necrosis (0.7\%), septal perforation (0.5\%),
deep mucosal laceration (1.5\%) and loss of foreign body (1.9\%).
Significantly higher rates of symptoms and complications were associated
with button batteries. Increased risk for complications were observed
according to type of foreign body, multiple attempts to remove it,
posterior insertion and left-side insertion.

\textbf{Conclusions:~} Nasal foreign bodies in children are common.
Mostly, patients are asymptomatic, therefore a high index of suspicion
is required, for quick diagnosis and safe removal, without
complications.

\textbf{KEYWORDS}

Foreign nasal bodies, batteries, epistaxis, organic, complications.

\textbf{Key points}

\begin{itemize}
\tightlist
\item
  Nasal foreign bodies are a common problem in children.
\item
  Children under 4 years insert mostly food items into the nasal cavity,
  contrary to older children who insert toys and batteries
\item
  No major complication was reported in our cohort of 10-years in a
  pediatric tertiary medical center.
\item
  Batteries and magnets cause significant mucosal damage, that often
  requires recurrent surgical debridement and long follow up periods in
  the clinic.
\item
  Excellent teamwork and cooperation between pediatric ED physicians and
  otolaryngologists is imperative for optimal diagnosis and treatment.
\end{itemize}

\textbf{Level of evidence:} 4



\textbf{Data availability statements:}

The data that support the findings of this study are available from the
corresponding author upon reasonable request.

\textbf{Conflict of interest and financial disclosure:}

The authors have no funding, financial relationships, or conflicts of
interest to disclose\textbf{.}



\textbf{INTRODUCTION}

Foreign bodies (FB) of the upper aerodigestive tract are among the most
common emergencies for otolaryngologists, especially regarding pediatric
patients. FB have been reported as the reason for admission of 10-30\%
of all patients to otolaryngology emergency departments (ED); of which,
nasal FBs (NFB) represent 20-30\%\textsuperscript{1-2}.

The most common anatomical site for NFB is below the inferior
turbinate\textsuperscript{3}. Only small fractions, approximately 30\%
of NFB, are radiopaque. Therefore, NFB are not usually seen in plain
radiographs performed in the ED setting\textsuperscript{4}. Most
patients with NFB are successfully managed in the ED by
pediatricians\textsuperscript{5}. Only a small fraction requires
assistance of otolaryngologists, usually due to more posterior
positioning of the NFB inside the nasal cavity or to lack of patients'
cooperation, which sometimes necessitates anesthesia\textsuperscript{6}.
Overall complication rates for NFB removal, as reported in the
literature, are estimated between 5-22\%\textsuperscript{7-8}.

\textbf{OBJECTIVES}

The aim of our study was to review the demographic and medical
characteristics, treatment modalities and outcomes of all the patients
with NFB in a tertiary pediatric medical center. We sought to analyze
potential risk factors associated with adverse effects and unfavorable
results.



\textbf{METHODS}

\textbf{Design and Settings}

After receiving institutional review board approval, we reviewed all the
electronic database charts of pediatric patients, under age 18 years,
who were admitted to the ED with a diagnosis of NFB during 2010-2019.

\textbf{Data Collection and Main Outcomes}

The data collected included demographic characteristics and medical
history, presenting symptoms in the ED and information related to NFB
upon physical examination. Outcome measures included treatment
modalities and outcomes, including complications. A posterior nasal
location was defined as an NFB that was visible with fiber-optic nasal
examination, and not with anterior rhinoscopy.

\textbf{Statistical analysis}

All statistical analyses were performed using IBM SPSS Statistics for
Windows, Version 25.0 (IBM Corp, Armonk, NY, USA). A p-value cut-off
point of 0.05 at 95\% confidence interval (CI) was used to determine
statistical significance. A univariate analysis was conducted using the
Pearson chi-square test and independent-samples t-test to compare
various descriptive variables with outcome measures. Post-hoc
multivariate logistic regression analysis was used to assess the outcome
measures according to the risk factors examined in the prediction model.

\textbf{Reporting guidelines:}

von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP.
The Strengthening the Reporting of Observational Studies in Epidemiology
(STROBE) Statement: guidelines for reporting observational studies. Ann
Intern Med. 2007;147(8):573-577.

\textbf{RESULTS}

Patient Characteristics and Symptoms

During 2010-2019, a total of 847 children with suspected NFB were
admitted to the ED at our medical center. On physical examination, a NFB
was found in 562 (66\%); these represented the study cohort. Sixty
percent of the patients were recorded as arriving within 24 hours
following the insertion, 7.5\% within one week, and 5\% after more than
one week. For 27\% of the patients, the time of arrival to the ED was
unknown. Most of the children (82\%) were asymptomatic upon arrival to
the ED, i.e. without any signs of nasal blockage or infection, such as
fever, foul odor, rhinorrhea, epistaxis or pain. The most common cause
for ED admittance among asymptomatic patients was a witnessed NFB
insertion (38\%), followed by self-reported insertion by the child
(26\%). The remaining asymptomatic patients (18\%) were referred to the
ED by a caregiver (either a kindergarten teacher or a family doctor),
after the NFB was seen in the nose (usually with no knowledge of the
time of insertion). Among the symptomatic children (18\%), the primary
symptoms were nasal discharge (10\%), followed by epistaxis (8\%) and
pain (4\%). Fever was noted in only 2\% of the patients, and nasal
blockage in 1.5\%. All the children were hemodynamically and respiratory
stable upon arrival; none of them demonstrated respiratory symptoms.

NFB were recorded as inserted to the right nostril in 56\% and to the
left in 25\% (p\textless{}0.05), while in 19\% of the children, the side
of insertion was not mentioned. Five percent of the patients had
comorbidities (asthma, allergy, cardiac abnormalities, developmental
delay and psychiatric disorders). Sixty-seven percent of the patients
(377 patients) were referred to examination by otolaryngologists during
the ED visit after first being treated by ED pediatricians. For 18\% (68
patients), this was after failure to remove the NFB on the first
attempt. Twenty-six patients (4.5\%) required general anesthesia for NFB
removal, which was always performed by otolaryngologists in the
operating room . None of the patients required ventilatory or pressure
support, nor the need for transfer to the intensive care unit following
the removal of the NFB. This suggests that none of the children had
aspirated the NFB. The overnight hospitalization rate was 5\%. The
recurrence rate, i.e., more than a single episode of NFB, was 2\%.
Characteristics of the cohort are presented in table 1.

Complications

Complications included infection (3.5\%), necrosis (0.7\%), septal
perforation (0.5\%), deep mucosal laceration (1.5\%) and the loss of NFB
during removal (1.2\%). The overall complication rate was 5\%. In
multivariate analysis, increased risk for complications was associated
with NFB-type (OR=6.5, p=0.01), multiple attempts to remove NFB (OR=6.4,
p=0.01), posterior insertion of NFB (OR= 2.4, p=0.02) and left side
insertion (OR=1.8, p=0.02). Characteristics of the cohort are presented
in table 2.

Subgroup Analysis According to Age

The younger age-group, age \textless{}4 years, comprised 328 patients,
representing 58\% of the cohort. The older age-group,
age\emph{\textgreater{}} 4 years, comprised 237 patients, representing
42\% of the cohort. No differences were found between these age-groups
in the male-to-female ratio; or in the proportions with comorbidities,
anterior versus posterior insertions, right-side versus left-side
insertions, or treatment with antibiotics (Table 3). A statistically
significant difference was found between the groups in the nature of the
NFB. In children under age 4 years, 39\% of NFB were organic, compared
to only 19\% in older children (OR=2.75, p\textless{}0.001). Younger
patients were also more likely to insert NFB into the right nostril
(OR=1.43, p=0.04). In older children, magnets and buttons were more
common (OR=3.3, p=0.03), as well as non-organic substances, although not
significant., as were magnets and buttons, Older patients were admitted
earlier to the ED, within the first 24 hours (OR=1.9, p=0.03). Other
differences, without statistical significance, were observed between the
age groups (Table 3 and Figure 1). Younger compared to older children
were more likely to present with nasal discharge (14\% vs 8\%) and were
less likely to undergo general anesthesia (2.8\% vs 5.5\%).
Characteristics of the patients according to age group are presented in
table 3 and in figure 1.

Subgroup Analysis of Outcomes According to NFB

Batteries and magnets were significantly more hazardous than all other
NFB. Epistaxis and nasal discharge were significantly more common in
children who inserted batteries and magnets than other NFB (OR= 14.3 and
10.4 for epistaxis and discharge, respectively, compared to other NFB).
The risk for nasal discharge was significantly higher in non-organic
than in organic NFB (OR=1.86, p=0.02).



\textbf{DISCUSSION}

Most patients with NFB are aged nine months to six years, and older
children with mental illnesses\textsuperscript{7,9}. Most NFB are
non-organic, including beads, toys, batteries and
magnets\textsuperscript{10}. Seventy-five percent of NFB are
asymptomatic. Chronic nasal discharge with foul smell is the most common
presenting symptom, while epistaxis, nasal blockage, high fever and
swelling of the face are less common presenting
symptoms\textsuperscript{11}. A long-standing NFB may result in the
formation of granulation tissue and rhinoliths\textsuperscript{12}. NFB
removal more than 72 hours following insertion was assessed as four
times more likely to fail and become complicated, compared to early
removal\textsuperscript{13}.

Our 10-year cohort comprised 562 children who attended the ED with a
documented NFB upon physical examination. There was a slight
predisposition of female to male ratio of 1.2, as was shown in previous
studies. Most of the patients (85\%) were aged 2-5 years. A possible
explanation for the high incidence rates among 2-year-olds is the
development of the pincer grasp milestone\textsuperscript{14}.
Right-side insertion was more common (56\%), presumably due to
right-handed predominance in the population\textsuperscript{15}. In
accordance with the literature\textsuperscript{16}, most of the NFB were
nonorganic (65\%). Organic NFB accounted for 30\%, and 5\% were
batteries and magnets. Most patients who presented with NFB were
asymptomatic (82\%), regardless of age and gender, as reported in
previous studies\textsuperscript{17}.

Characteristics and Outcomes According to Age Groups

Age was the prognostic factor examined that most strongly associated
with presenting symptoms, the type of NFB material, failure rates, the
use of general anesthesia and overall complications. In children under
age 4 years, 39\% of NFB were organic, compared to only 19\% in older
children (OR=2.64, p\textless{}0.05). This difference may be partially
explained by lesser exposure of younger children to small nonorganic
toys, beads and batteries due to safety reasons. In contrast, organic
materials (seeds, fruits, etc.) are more commonly within toddlers'
reach. For 70\% of older patients, medical attention was sought within
the first 24 hours, compared to only 55\% of younger patients (OR=1.9,
p=0.03). Older children can better express themselves to their parents
and are more capable of conveying discomfort due to NFB. In our cohort,
younger patients were more prone to insert NFB into the right nostril
(OR=1.43, p=0.04). Insertion of NFB to the ipsilateral rather than the
contralateral side presumably requires less coordination abilities, and
is thus easier for younger children. The overall complication rate did
not differ according to the duration of NFB in the nasal cavity (data
not presented). Nasal discharge, which was the most common presenting
symptom, was more common in younger than older patients (14\% vs. 8\%),
although the difference was not statistically significant. This is
especially important for the general practitioner who may encounter a
child with a unilateral nasal discharge. In younger patients who are not
always able to express their complaints, a chronic unilateral nasal
discharge can be a crucial diagnostic sign. Notably, nasal blockage and
fever were both rare in our cohort. In younger children, the nasal
cavity is anatomically smaller, which increases the challenge of
removing NFB in the first attempt. In our cohort, failed attempts were
more common among younger patients (11\% vs 7.5\%). Older children, on
the other hand, are more difficult to hold while they resist physical
examination, which lower the likelihood of safe removal in the ED. Among
our older patients, the risk for removal under general anesthesia was
higher (5.5\% vs 2.8\%), as was the overall rate of complications (5.5\%
vs. 4.6\%). Although these age-related differences were not
statistically significant, a trend was demonstrated.

Removal of NFB

NFB can be removed by various means, including exertion of positive
oronasal pressure\textsuperscript{18} and the use of various medical
instruments, such as suction, forceps, hooks and a Fogarty
catheter\textsuperscript{19}. Kadish et
al.\textsuperscript{20}previously published successful NFB extraction
rates of 98\% among pediatricians. Removal failure was defined in our
study as an attempt to extract the NFB, which ultimately required
further intervention (by a second physician, usually an
otolaryngologist, or by general anesthesia). All 26 patients who
required anesthesia were examined primarily by an otolaryngologist
(either as a first or a second attempt). Altogether, 69\% of the
patients were seen by otolaryngologists. The failure rate among
otolaryngologists was 6.7\%. Pediatricians in the ED treated 172
children without referral to an otolaryngologist. The failure rate among
pediatricians was 24\% (p=0.01). Nonetheless, complicated NFB (28
patients, 5\%) were always seen by otolaryngologists; this demonstrates
proper clinical assessment and referral by ED pediatricians. X-ray
radiographs were rarely (1\%) used in our cohort.

Complications

Several risk factors were associated with increased risk for
complications (NFB-type, multiple attempts to remove NFB, posterior
insertion of NFB and left-side insertion). These risk factors, when
presenting, should alert clinicians in their assessment and management
of patients with a NFB, and should be considered in the treatment plan
regarding preparation for removal. The complications found in our study
are presented in table 2. The overall complication rate was 5\%, which
concurs with other reports\textsuperscript{8,11,13}. The loss of NFB
during a failed attempt can potentially compromise the airway. In 11
(2\%) of our patients, the objects were ingested following a failed
attempt. Among these, eight occurred after attempts by primary
pediatricians, and three after attempts by an otolaryngologist. None of
these patients exhibited signs of dyspnea or dysphagia, suggesting that
none of the children had aspirated the NFB.

Nasal insertion of batteries and magnets poses a particularly high risk.
In our cohort, perforation or significant mucosal lacerations occurred
in 13 (2.2\%) patients, among whom nine were a direct result of
batteries and magnets. The risks for nasal perforation in children who
inserted magnets and batteries were extremely high (OR=22 and OR=8.4,
respectively, p\textless{}0.001). Mucosal necrosis was observed almost
entirely in patients with nasal batteries (OR=38, p\textless{}0.001).
All children who inserted nasal batteries or magnets were treated with
systemic antibiotics, on admission or discharge, compared to those who
inserted all other materials (OR=7.9, p\textless{}0.05). One patient
exhibited necrosis of the middle turbinate within 3 hours after the
insertion of a button battery. Two patients underwent surgical
debridement one month after the incident and one patient had
intermittent epistaxis due to septal perforation and had to undergo
septo-rhinoplasty surgery years later. The overall risk for
complications was significantly higher among patients with inserted
batteries or magnets than with all other materials (organic and
nonorganic), OR=12.3, p\textless{}0.001. This is consistent with
previous studies\textsuperscript{21-22}. Small magnets are most commonly
found in the nasal cavity of female teenagers, as they are usually a
part of jewelry hinged to the ala nasi. Damage to the nose can result
from decubitus, leading to ulcers and perforations\textsuperscript{23}.
Button batteries have positively and negatively charged poles, on either
side. When a negatively charged pole adheres to the nasal septum, the
chemical reaction that results in electrolysis can cause rapid septal
perforation in up to 4 hours\textsuperscript{24-25}. To this date,
follow-up publications that assess long-term nasal damage are lacking.

Limitations

This study is a retrospective analysis, with data limited to the
computerized patients' files. Most of the patients had no follow-up
after the initial ED admission, thus long-term complications are rarely
documented.

Conclusions

To the best of our knowledge, this study represents one of the largest
pediatric cohorts of NFB. Most patients with NFB are asymptomatic; thus,
a high index of suspicion of the possibility of a foreign body is
important. Button batteries and magnets in the nasal cavity are
extremely hazardous and can cause rapid tissue damage to the nasal
mucosa. Posterior location of NFB, left-sided insertion, multiple
failures of removal and older age were found to be associated with the
need of general anesthesia, and with consequent infections and
complications. With regards to previous publications, it is worth
mentioning that none of the patients in our cohort present with any
major complications, including respiratory distress nor signs of sepsis
or hemodynamic instability. This is in contrary to other reports.
Although aspiration of the NFB is a potential life-threatening
complication, we did not have such cases in our cohort. We believe that
our favorable results represent the outstanding cooperation between
pediatric ED physicians and otolaryngologists in our medical center.
Excellent teamwork is crucial for treating all patients, especially
children with NFB.

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\textbf{Table 1}

\textbf{Characteristics of children who presented with nasal foreign
bodies (N=562)}\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
\textbf{Variable}\strut
\end{minipage} & \begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
\textbf{Number (\%) or mean}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textbf{Boys}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
248 (44.1\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textbf{Age, years (mean)}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
4.1\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textbf{Asymptomatic presentation}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
460 (81.9\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textbf{Comorbidities}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
30 (5\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Asthma\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
16 (2.7\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Congenital anomalies\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
9 (1.5\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Allergies\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
18 (2.8\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Psychiatric\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
5 (0.8\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textbf{Treated by otolaryngologists}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
360 (64\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textbf{NFB type}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Organic\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
170 (30\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Nonorganic\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
368 (65\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Batteries and magnets\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
30 (5\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textbf{Symptoms} Nasal discharge Epistaxis Pain\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
45 (8\%) 48 (8.5\%) 24 (4\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textbf{Failure rate (Multiple removal attempts)}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
68 (12\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textbf{X-ray demonstrating NFB}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
6 (1\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textbf{Hospitalization}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
28 (5\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textbf{Recurrence (\textgreater{}1 episode of NFB)}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
11 (2\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textbf{General anesthesia}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
26 (4.5\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textbf{Antibiotics} \textbf{Topical} \textbf{Systemic}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
58 (10\%) 34 (6\%) 27 (4.8\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textbf{Complications} Infection Necrosis Septal perforation Deep
mucosal laceration Loss of NFB\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
28 (5\%) 19 (3.5\%) 4 (0.7\%) 3 (0.5\%) 9 (1.5\%) 11 (1.9\%)\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}



\textbf{Table 2.}

\textbf{Factors that were associated with increased risk of
complications}\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\textbf{Factor} & \textbf{OR, P value} & \textbf{Comparison
group}\tabularnewline
\midrule
\endhead
\textbf{NFB type (batteries and magnets)} & OR= 6.5, P=0.01 & All other
NFB together\tabularnewline
\textbf{More than one removal attempt} & OR= 6.4, P=0.01 & Removal in
the first attempt\tabularnewline
\textbf{Posterior insertion of NFB} & OR= 2.4, P=0.02 & Anterior
insertion\tabularnewline
\textbf{Left-side insertion of NFB} & OR= 1.8, P=0.02 & Right-side
insertion\tabularnewline
\bottomrule
\end{longtable}

\emph{}

\emph{Table 3.}

\textbf{Statistically-significant characteristics of children who
presented with nasal foreign bodies according to age}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{Age \textless{}4 years}\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{Age \emph{\textgreater{}}4 years}\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{P value}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Right-side insertion}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
60\%\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
50\%\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
P=0.04\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Organic NFB}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
39\%\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
19\%\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
P\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Batteries and magnets}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.5\%\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
6.5\%\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
P=0.03\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Time from insertion until arrival to ED}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Less than 24 hours\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
55\%\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
70\%\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
P=0.03\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Less than one week\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
10\%\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
7\%\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
More than one week\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
35\%\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
23\%\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}



\textbf{Legends to figures.}

\textbf{Figure 1} : Patients Data

\textbf{Figure 1: Patient Data}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

