3.05 Foreign Body in Ear
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 grasing 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.
Table of Contents
from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES ©
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Craig Feied, MD
Mark Smith, MD
Jon Handler, MD
Michael Gillam, MD
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