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
- Inanimate foreign objects are often associated with delayed presentations:
- Children often delay reporting because of fear of punishment
- Often 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 object
- Perforation of tympanic membrane:
- More likely to result from removal procedure than the FB
- 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
- Symptoms usually resolve within a few days after FB removal
Etiology
- 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
- Competent adults:
- Cotton-swab tips
- Earplugs
- Insects:
- Cockroach most common in US
- Hidden 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 battery
- Live insect
- Vegetable
- Inanimate object
- Size
- Risk 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 canal
- Instill warm lidocaine or mineral oil into affected ear to kill insect
- Controversies:
- Attempts at removal in the field are not indicated:
- Lack of appropriate equipment
- Prior 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 solution
- Ether
- Alcohol
- Mineral 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 source
- Otoscope or operating microscope
- Achieve proper head immobilization
- Retract 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 otoscope
- 1-2% lidocaine, with or without epinephrine
- 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
- Suction catheters:
- Best used for small objects
- Fogarty catheter:
- Carefully pass beyond the FB and inflate and withdraw; this approach puts the tympanic membrane at particular risk of inadvertent injury
- 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
- Otomicroscopy:
- 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 water
- Attempt removal with instrument
- Forceps usually work with graspable objects
- Be certain to delineate clearly between FB and inflamed external auditory canal tissue
- Nonvegetable inanimate FB removal:
- If easily grasped, attempt removal with forceps
- If not accessible, attempt removal with irrigation
- 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
- Insect removal:
- Kill insect by rapidly instilling alcohol, 2% lidocaine (Xylocaine), or mineral oil into the ear
- Once killed, remove with forceps or by irrigation
- Re-examine to ensure that all insect parts are removed
- Sharp objects:
- Remove with operating microscope
- Consider 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 antibiotics
- Follow-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)