We report a 6 year old female child, who presented with history of right sided recurrent headache for four months. On diagnostic nasal endoscopy, a metallic foreign body was seen impacted between superior turbinate, middle turbinate and nasal septum which was removed using pediatric nasal endoscope. Following removal, the symptom of unilateral headache subsided. Possibility of a foreign body should always be ruled out while evaluating a child with recurrent, unilateral headache.

Key words: Foreign body, Nose, Secondary headache, Unilateral headache.

A 6-year old girl was referred from a general practitioner with complain of right sided recurrent headache since four months. She had no similar complain before that. Her visual acuity and CNS examination was normal. On anterior rhinoscopic examination, scanty, blood stained mucopus was seen in right nasal cavity. Roentogram of the skull demonstrated presence of a metallic foreign body in right nasal cavity. Endoscopic examination was suggestive of presence of some impacted, metallic foreign body in right nasal cavity, between superior turbinate, middle turbinate and nasal septum. There was no nasal septal deviation. Foreign body (rusted metallic screw) was then removed under general anesthesia using pediatric 0 degree nasal endoscope. After removal of foreign body, patient was relieved of headache. Retrospectively patient gave history that she had accidently introduced foreign body (screw) in her right nostril while playing but she did not tell to any one at that time due to fear and later on she forgot the incidence. Patient is on regular follow up since one year and is well.

Fig. 1 X-ray AP and lateral view of Skull demonstrating the foreign body (metallic screw).

In this patient, even though, the foreign body was there in the nasal cavity for four months and was causing recurrent headache, yet it remained undiagnosed due to its unexpected presentation.

The mechanism involved in headache due to foreign body in nose can be explained by the fact that pressure exerted on sensory nerves of adjacent lateral wall, can produce pain [1]. This concept was first elaborated by Sluder, and the resultant condition has been called ‘The anterior ethmoidal nerve syndrome’ [2]. In addition to their direct neurological effects, reflex changes perhaps may result from septal deformities, which affect nasopulmonary and nasal reflexes.

Mcauliffe, et al. studied the sensitivity of the nasal cavities and the paranasal sinuses using mainly faradic stimulation and found that the lateral wall of the nasal cavity was much more sensitive than the septum [3]. Clinical studies show that the very severely impacted nasal septum can exert pressure on the more sensitive structure of the lateral nasal wall and cause referred trigeminal pain and chronic headache [4].

Thus, when a pediatric patient presents with such a history, appropriate radiological evaluation should be carried out and thorough nasal endoscopic examination has to be performed to reach the correct diagnosis and appropriate management of patient.

Contributors: AJ: managed the case, reviewed the literature and wrote the paper; MS: collected data; SJ: critically reviewed. All authors helped in writing the manuscript.

Funding: None.

Competing interests: None stated.

1. David B. The nasal septum. In: Ian SM, Bull TR, editors. Scott-Brown’s Otolaryngology. 6th ed. Oxford: Butterworth – Heinemann publishers and distributers: 1997. P. 4:11.

2. Shalom, AS. The anterior ethmoid nerve syndrome. J Laryngol Otol. 1963;77:315.

3. McAuliffe GW, Goodell H, Wolff HG. Experimental studies on headache: Pain from the nasal and paranasal structures. Research publication of the association for Research into Nervous and Mental Diseases. 1943;23:185-206.