3.05 Foreign Body in Ear

agk’s Library of Common Simple Emergencies

Presentation

Sometimes a young child admits to putting something like a bead or a bean in his ear, or an adult witnesses the act. Sometimes the history is hidden and the child simply presents with a purulent discharge, pain, bleeding or hearing loss. Most dramatically, a patient arrives at the emergency department panic-stricken because he feels and hears a bug crawling around in his ear.

What to do:

• If there is a live insect in the patient’s ear, simply fill the canal with mineral oil (e.g., microscope immersion oil). Lay the patient on his side and drop the oil down the canal while pulling on the pinna to remove air bubbles. This will suffocate the intruder, so it can be removed using one of the techniques below. The least invasive methods should be tried first.
• Water irrigation is often effective for safely removing a foreign body that is not tightly wedged in the ear canal. This can be accomplished with an irrigation syringe, Water Pik, or a standard syringe and scalp vein needle catheter cut short (see above). Tap water or normal saline at body temperature can be used to flush out the foreign body by directing the stream along the wall of the ear canal and around the object, thereby flushing it out.
• If the object is light and moves easily, attempt to suction it out with a standard metal suction tip or specialized flexible tip, whichever can make a vacuum seal on the foreign body.
• If a hard or spherical foreign body remains in the ear canal, and the patient is able to hold still, you can attempt to roll it out with a right-angle hook, ear curette or wire loop. Stabilize the patient’s head and fix your hand against it, holding the instrument loosely between your fingers to reduce the risk of injury should the patient move suddenly. Under direct visualizaton through an ear speculum, slide the tip of the right-angle hook, ear curette or wire loop behind the object (rotate the hook to catch) and then roll or slide the foreign body out of the ear.
• Alligator forceps are best for grasping soft objects like cotton or paper. The wooden shaft of a long cotton swab can be armed with one drop of cyanoacrylate (Super Glue) to adhere to a smooth, clean, dry foreign body. Touch it to the foreign body, hold for ten seconds, then pull. Try not to glue the stick to the wall of the ear canal, but if you do, be thankful for cerumen (above).

What not to do:

• Do not use a rigid instrument to remove an object from an uncooperative patient’s ear. An unexpected movement might lead to a serious injury of the middle ear.
• Do not attempt to remove a large bug or insect without killing it first. They tend to be wily, evasive little creatures well equipped for fighting in tunnels. In the heat of battle, the patient can become terrorized by the noise and pain and the instrument that you are using is likely to damage the ear canal.
• Do not attempt to irrigate a tightly wedged bean or seed from an ear canal. The water may cause the bean to swell.
• Do not attempt to remove a large or hard object with bayonet or similar forceps. The bony canal will slowly close the forceps as they are advanced and the object will be pushed farther into the canal. Alligator forceps are designed for the canal, but even they will push a large, hard foreign body farther into the ear.

Discussion

The cutaneous lining of the bony canal of the ear is very sensitive and is not much affected by topical anesthetics. If your patient is an uncooperative child, you might make one cautious attempt at removal under conscious sedation (see below) with firm head restraint, but your most prudent strategy is to schedule elective removal under general anesthesia by a specialist.

Irrigation techniques and the use of the ear curette can also be effective in removing excess cerumen from an ear canal (see above). Whenever an instrument is used in an ear canal it is a good idea to warn the patient or parents beforehand that there may be a small amount of bleeding.

There should be no delay in removing an external auditory canal foreign body when there is an obvious infection or when the foreign body is a disk batters. On contact with most tissue, this type of alkaline battery is capable of producing a liquefactive necrosis extending into deep tissues. After removal, the canal should be irrigated to remove alkalai residue. Styrofoam beads can be instantly dissolved by spraying them with a small amount of ethyl chloride. Lidocaine has been shown to make cockroaches exit the ear canal, but this may be unpleasant for the patient. On telephone consultation, patients can be instructed to use cooking or baby oil to kill an intra-aural insect, which can then be removed in a subsequent office visit.

Complications of foreign body removal include trauma to the skin of the canal, canal hematoma, otitis externa, tympanic membrane perforations, ossicular dislocations and facial nerve palsy.

References:

• Bressler K, Shelton C: Ear foreign-body removal: a review of 98 consecutive cases. Laryngoscope 1993;103:367-370.
• O’Toole K, Paris PM, Stewart RD, Martinez R: Removing cockroaches from the auditory canal: controlled trial. N Eng J Med 1985;312:1197.
• Leffler S, Cherney P, Tandberg D: Chemical immobilization and killing of intra-aural roaches. An in-vitro comparative study. Ann Emerg Med 1993;22:1795-1798.
• Brunskill AJ, Satterwaite K: Foreign bodies. Ann Emerg Med 1994;24:757.
• Skinner DW, Chui P: The hazard of button-sized batteries as foreign bodies in the nose and ear. J Laryngol Otol 1986;100:1315- 1319.

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