Doctor123.org

Foreign Body, Ear, Emergency Medicine

Basics

Description

- Foreign bodies (FBs) lodged in the external auditory canal - The external auditory canal: - Cartilaginous and bony passage lined with periosteum and skin - The periosteum is extremely sensitive, making removal a painful procedure: - In small children general anesthesia may be required to remove the object - FBs usually impact at the junction of the inner end of the cartilaginous portion of the canal or at the isthmus - Innervated by the facial, glossopharyngeal, vagus nerves

- Otitis externa - Malocclusion from erosion into the temporomandibular joint - Parapharyngeal abscess - Mastoiditis - Meningitis - Brain abscess - Insects may injure the tympanic membrane or canal by stinging, biting, or scratching - Button batteries can cause significant destruction due to the strong electrical currents and pressure necrosis - Typically, the most damage is caused by negative side of the battery - Damage to the facial nerve and ossicles have been reported

- Children: - Stones - Small beads - Paper - Toys - Seeds and popcorn kernels - Beans and other food and organic materials - Button batteries: - Higher risk for necrosis than other FBs

- Prepare the equipment and the patient: - Strong light source - Otoscope or operating microscope - Achieve proper head immobilization - Retract the pinna of the ear in a posterosuperior direction to straighten the canal

- Procedural sedation: - Indicated for children and uncooperative adults - Use before attempts, as unsuccessful efforts may produce bleeding, edema, or injury to the tympanic membrane - Ketamine for children - Benzodiazepines for older patients - Consider fentanyl if analgesia is indicated during removal

- Options for removal: - Water irrigation: - Perform careful visualization - Place an Angiocath catheter adjacent to, or preferably distal to, the FB - Inject warm water or sterile saline through catheter via a syringe - Backwash the FB out - Never attempt removal by irrigation when the FB is a button battery

- Use of instruments to dislodge the FB: - Alligator forceps removal - Cupped forceps: Numbers 3, 5, and 7 suction tips, preferably with Frazier suction cups - Cerumen loops - Right-angle blunt hooks

- Cyanoacrylate glue on the tip of a blunt probe: - Place on the FB for 10 sec, and then pull - May contaminate the ear with glue, and this technique has been associated with tympanic membrane rupture

- Acetone: - Used to dissolve Styrofoam FBs or loosen superglue

- Polished or smooth object extraction: - Visualize - Direct suction - Blunt right-angled probe: Pass beyond the FB; rotate 90 °; remove it with the FB - Fogarty catheter - Cyanoacrylate glue

  • Foreign bodies (FBs) lodged in the external auditory canal
  • The external auditory canal:Cartilaginous and bony passage lined with periosteum and skinThe periosteum is extremely sensitive, making removal a painful procedure:In small children general anesthesia may be required to remove the objectFBs usually impact at the junction of the inner end of the cartilaginous portion of the canal or at the isthmusInnervated by the facial, glossopharyngeal, vagus nerves
  • Inanimate foreign objects are often associated with delayed presentations:Children often delay reporting because of fear of punishmentOften the FB is an incidental finding in children during an ear exam
  • Physical findings may change due to length of time the object is in the canal
  • Children with cerumen impaction or those with pica are predisposed
  • The location is often the right ear, due to the predominance of right handedness
  • Children and psychiatric patients may insert anything sufficiently small to enter the external auditory canal.
  • Ear FBs are most common in children <8 yr
  • Complications:Canal laceration:Usually caused by repeated attempts to remove a nongraspable objectPerforation of tympanic membrane:More likely to result from removal procedure than the FBOtitis externaMalocclusion from erosion into the temporomandibular jointParapharyngeal abscessMastoiditisMeningitisBrain abscessInsects may injure the tympanic membrane or canal by stinging, biting, or scratchingButton batteries can cause significant destruction due to the strong electrical currents and pressure necrosisTypically, the most damage is caused by negative side of the batteryDamage to the facial nerve and ossicles have been reported
  • Symptoms usually resolve within a few days after FB removal

Etiology

  • Children:StonesSmall beadsPaperToysSeeds and popcorn kernelsBeans and other food and organic materialsButton batteries:Higher risk for necrosis than other FBs
  • Competent adults:Cotton-swab tipsEarplugsInsects:Cockroach most common in USHidden illicit drugs

Diagnosis

Signs and Symptoms

  • Decreased hearing
  • Excessive crying in infants
  • Unilateral ear pain
  • Fullness
  • Loud noises
  • Buzzing sound (with live insects)
  • Nausea
  • Dizziness
  • Ipsilateral tearing
  • Purulent discharge from the external ear
  • Itching
  • Bleeding

History

  • Travel or camping history or poor living conditions suggests insects in the external ear canal
  • Inquire about previous attempts to remove the FB and any trauma associated with these attempts

Physical Exam

Otoscopic exam should be performed before and after removal of the FB:

  • Identify type of FB to determine removal procedure:Button batteryLive insectVegetableInanimate objectSizeRisk of swelling when exposed to water
  • Perform a bilateral exam; especially important in children and psychiatric patients, and prevent overlooking a quiescent FB in the contralateral ear
  • Attempt to visualize tympanic membrane to assess for rupture
  • Assess for otitis externa
  • Assess for retained fragments after the removal
  • Always exam the nonaffected ear and nostrils for additional FBs
  • Significant pain, vertigo, or ataxia, nsytagmus, hearing loss, otorrhea, or facial nerve paralysis are concerning signs and an otolaryngologist consultation should be considered

Essential Workup

Careful otoscopic exam:

  • Minimize pain
  • Gain the patients trust
  • Identify the FB before attempting removal

Diagnosis Tests & Interpretation

Lab

None indicated

Imaging

CT scan if infectious or erosive sequelae are suspected

Diagnostic Procedures/Surgery

Otomicroscope:

  • May be used when standard ED techniques fail or the equipment is available to emergency medical staff

Differential Diagnosis

  • Cerumen impaction
  • Granuloma
  • Hematoma
  • Injury
  • Otitis externa
  • Perforated tympanic membrane
  • Residual otitis externa after self-extraction of the FB
  • Tumor

Treatment

Pre-Hospital

  • Cautions:Severe ear pain, sensation of movement, and loud, buzzing sound:Typical signs of a live insect in external auditory canalInstill warm lidocaine or mineral oil into affected ear to kill insect
  • Controversies:Attempts at removal in the field are not indicated:Lack of appropriate equipmentPrior failed attempts may make future attempts more difficult

Initial Stabilization/Therapy

For a patient in distress because of a live insect:

  • Drown or immobilize insect before any removal attempts
  • Instill warm solution into the external auditory canal:2% lidocaine solutionEtherAlcoholMineral oil
  • Cold fluids should not be used so as to avoid a caloric response

Ed Treatment/Procedures

  • Prepare the equipment and the patient:Strong light sourceOtoscope or operating microscopeAchieve proper head immobilizationRetract the pinna of the ear in a posterosuperior direction to straighten the canal
  • Analgesia:Lidocaine instillation for topical anesthesia:Liquid 1-2% solution is preferred to viscous lidocaine.Lidocaine injection of the 4 quadrants of the canal using a tuberculin syringe through the otoscope1-2% lidocaine, with or without epinephrine
  • Procedural sedation:Indicated for children and uncooperative adultsUse before attempts, as unsuccessful efforts may produce bleeding, edema, or injury to the tympanic membraneKetamine for childrenBenzodiazepines for older patientsConsider fentanyl if analgesia is indicated during removal
  • Options for removal:Water irrigation:Perform careful visualizationPlace an Angiocath catheter adjacent to, or preferably distal to, the FBInject warm water or sterile saline through catheter via a syringeBackwash the FB outNever attempt removal by irrigation when the FB is a button batteryUse of instruments to dislodge the FB:Alligator forceps removalCupped forceps: Numbers 3, 5, and 7 suction tips, preferably with Frazier suction cupsCerumen loopsRight-angle blunt hooksSuction catheters:Best used for small objectsFogarty catheter:Carefully pass beyond the FB and inflate and withdraw; this approach puts the tympanic membrane at particular risk of inadvertent injuryCyanoacrylate glue on the tip of a blunt probe:Place on the FB for 10 sec, and then pullMay contaminate the ear with glue, and this technique has been associated with tympanic membrane ruptureAcetone:Used to dissolve Styrofoam FBs or loosen superglueOtomicroscopy:Usually performed in the OR although reports of use in the ED have been positive
  • Vegetable matter:Avoid irrigation of FBs that will swell when exposed to waterAttempt removal with instrumentForceps usually work with graspable objectsBe certain to delineate clearly between FB and inflamed external auditory canal tissue
  • Nonvegetable inanimate FB removal:If easily grasped, attempt removal with forcepsIf not accessible, attempt removal with irrigation
  • Polished or smooth object extraction:VisualizeDirect suctionBlunt right-angled probe: Pass beyond the FB; rotate 90 °; remove it with the FBFogarty catheterCyanoacrylate glue
  • Insect removal:Kill insect by rapidly instilling alcohol, 2% lidocaine (Xylocaine), or mineral oil into the earOnce killed, remove with forceps or by irrigationRe-examine to ensure that all insect parts are removed
  • Sharp objects:Remove with operating microscopeConsider otolaryngologic referral if there is evidence of trauma or if patient is uncooperative

Medication

First Line

  • Fentanyl: 1 μg/kg IV
  • Ketamine: 1-2 mg/kg IV or 4 mg/kg IM
  • Midazolam: 1 mg IV slowly q2-3min up to 5 mg (peds: 6 mo-5 yr, 0.05-0.1 mg/kg, titrate to max. of 0.6 mg/kg; 6-12 yr, 0.025-0.05 mg/kg, titrate to max. of 0.4 mg/kg)

Second Line

  • Cortisporin otic: 4 gtt in ear QID
  • Amoxicillin: 500 mg PO (peds: 80-90 mg/kg/24 h) PO TID for 7-10 days.
  • Augmentin: 875 mg (peds: 90 mg/kg/24 h) PO BID for 7-10 days.
  • Fill ear canal 5 — per day with a combination of antibiotic and steroid otic solution for 5-7 days if there is suspected infection or abrasion

Follow-Up

Disposition

Admission Criteria

Hospital admission if the FB is a button battery that cannot be removed

Discharge Criteria

  • FB removed
  • Inability to remove a FB that will not cause rapid tissue necrosis
  • Oral antibiotics (amoxicillin or Augmentin) should be initiated in cases with tympanic membrane perforation

Issues for Referral

Follow-up with ENT specialist as an outpatient:

  • Inability to remove a FB
  • Immunocompromised patients with signs of otitis externa

Follow-Up Recommendations

  • Patient should be instructed not to place any objects in ear
  • A short course of analgesics after traumatic FB removal
  • Otitis externa:Topical antimicrobial such as Cortisporin suspension
  • Immunocompromised patients may require oral antibiotics
  • Perforated tympanic membrane:Prophylaxis with antibioticsFollow-up with ENT specialist
  • Avoid submersion in water until follow-up if trauma or infection present

Pearls and Pitfalls

  • Use procedural sedation with uncooperative patients or when a difficult removal is anticipated
  • Irrigation in patients with button batteries in the ear should never be performed as the electrical current or battery contents can cause liquefaction tissue necrosis.

Additional Reading

  • Brown L, Denmark TK, Wittlake WA, et al. Procedural sedation use in the ED: Management of pediatric ear and nose foreign bodies. Am J Emerg Med. 2004;22:310-314.
  • Cederberg CA, Kerschner JE. Otomicroscope in the emergency department management of pediatric ear foreign bodies. Int J Pediatr Otorhinolaryngol. 2009;73:589-591.
  • Dance D, Riley M, Ludemann P. Removal of ear canal foreign bodies in children: What can go wrong and when to refer. BCMJ. 2009;51:20-24.
  • Davies PH, Benger JR. Foreign bodies in the nose and ear: A review of techniques for removal in the emergency department. J Accid Emerg Med. 2000;17:91-94.
  • Erkalp K, KalekoÄŸlu Erkalp N, Ozdemir H. Acute otalgia during sleep (live insect in the ear): A case report. Agri. 2009;21:36-38.
  • Heim SW, Maughan KL. Foreign bodies in the ear, nose, and throat. Am Fam Physician. 2007;76:1185-1189.
  • Kumar S, Kumar M, Lesser T, et al. Foreign bodies in the ear: A simple technique for removal analysed in vitro. Emerg Med J. 2005;22:266-268.

See Also (Topic, Algorithm, Electronic Media Element)

  • Tympanic Membrane Perforation
  • Procedural Sedation

Codes

ICD9

931 Foreign body in ear

ICD10

  • T16.1XXA Foreign body in right ear, initial encounter
  • T16.2XXA Foreign body in left ear, initial encounter
  • T16.9XXA Foreign body in ear, unspecified ear, initial encounter

SNOMED

  • 75441006 foreign body in ear (disorder)
  • 32874004 Foreign body in auditory canal (disorder)