Ear Foreign Body Removal in Emergency Medicine
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Foreign bodies of the ear are relatively common in emergency medicine. They are seen most often but not exclusively in children.
Various objects may be found, including toys, beads, stones, folded paper, and biologic materials such as insects or seeds.
A study by Svider et al using the National Electronic Injury Surveillance System estimated that from 2008 to 2012, there were 280,939 emergency department visits in the United States for aural foreign bodies, with children aged 2-8 years being the most frequent patients. Jewelry accounted for the greatest percentage of foreign objects found in the ear (39.4%), being the most frequently encountered foreign bodies in the 2- to 8-year-old group. In adults, cotton swabs/first-aid products were the most commonly found objects. Hearing aids and other ear-specific accessories were also frequently encountered in adults. [1]
A retrospective study by Gupta et al of management of ear, nose, and throat foreign bodies in an Australian tertiary care hospital found a high rate of success in the removal of these foreign bodies by the emergency department staff. According to the report, the emergency department staff attempted foreign body removal in 89% of cases (the remaining cases having been referred to the otolaryngology team), with successful removal achieved in 78% of cases. This included removal in 86% of nasal cases, 72% of aural cases, and 67% of throat cases, with no major complications occurring. [2]
See the list below:
Most adults are able to tell the examiner that there is something in their ear, but this is not always true. For example, an older adult with a hearing aid may lose a button battery or hearing aid in their canal and not realize it.
Children, depending on age, may be able to indicate that they have a foreign body, or they may present with complaints of ear pain or discharge.
Patients may be in significant discomfort and complain of nausea or vomiting if a live insect is in the ear canal.
Patients may present with hearing loss or sense of fullness.
The physical examination is the main diagnostic tool.
Physical findings vary according to object and length of time it has been in the ear.
An inanimate object that has been in the ear a very short time typically presents with no abnormal finding other than the object itself seen on direct visualization or otoscopic examination.
Pain or bleeding may occur with objects that abrade the ear canal or rupture the tympanic membrane or from the patient’s attempts to remove the object.
Hearing loss may be noted.
With delayed presentation, erythema and swelling of the canal and a foul-smelling discharge may be present.
Insects may injure the canal or tympanic membrane by scratching or stinging.
In some cases, a patient, caretaker, or sibling intentionally places an object in the ear canal and is unable to remove it. In other instances, insects may crawl or fly into the ear.
A study by Celenk et al suggested that children with attention deficit hyperactivity disorder (ADHD) may be more inclined than other children to self-insert foreign bodies into the nose and ears. The study compared 60 pediatric patients with nasal or aural foreign bodies with 50 controls, with test scores indicating the presence of ADHD being significantly higher among the foreign-body patients aged 5-9 years than among the control subjects. [3]
Abrasions to ear canal
Hematoma
Tumor
Tympanic membrane perforation
No specific laboratory or radiologic studies are recommended. The physical examination is the main diagnostic tool.
Use an otoscope while retracting the pinna in a posterosuperior direction. A head mirror with a strong light source, operating otoscope, or operating microscope also may be used. Refractory objects may require extraction by an ear, nose, and throat (ENT) specialist.
No specific prehospital treatment exists other than transport to a hospital. Occasionally, treating significant pain or nausea may be necessary.
Patients in extreme distress secondary to an insect in the ear require prompt attention. The insect should be killed prior to removal, using mineral oil or lidocaine (2%). EMLA cream has also been reported as being effective to kill the insect as well as provide local anaesthesia. [4]
Irrigation is the simplest method of foreign body removal, provided the tympanic membrane is not perforated. [5] An electric ear syringe, available in some areas, may be very helpful for irrigation. [6] Use of the commercial product Waterpik is not recommended because the high pressure it generates may perforate the tympanic membrane. Irrigation with water is contraindicated for soft objects, organic matter, or seeds, which may swell if exposed to water.
Suction is sometimes a useful means of foreign body removal. [5] Suction the ear with a small catheter held in contact with the object. Grasp the object with alligator forceps. Place a right-angled hook behind the object and pull it out. Form a hook with a 25-gauge needle to snag and remove a large, soft object such as a pencil eraser.
Using the bent end of a paperclip (one that has been unfolded and has the tip of the paperclip bent at a right angle) may also be used. The bent end is inserted in a parallel path past the foreign object and then rotated. The object is then withdrawn from the canal. Holding the paper clip with forceps adds stability.
Avoid any interventions that push the object in deeper.
The physician may need to sedate the patient to attempt removal of the object. Use mild sedation following a procedural sedation protocol.
See Ear Foreign Body Removal Procedures for more information.
Cyanoacrylate adhesives (eg, Superglue) may be removed manually within 24-48 hours once desquamation occurs. If adhesive touches the tympanic membrane, remove it carefully, and refer the patient to an ENT specialist.
Remove batteries immediately to prevent corrosion or burns. Do not crush battery during removal.
Consult an ENT specialist if the object cannot be removed or if tympanic membrane perforation is suspected.
For excellent patient education resources, visit eMedicineHealth’s Ear, Nose, and Throat Center. Also, see eMedicineHealth’s patient education article Foreign Body, Ear.
After the foreign body is removed, inspect the external canal. For most foreign bodies, no medications are needed. However, if infection or abrasion is evident, fill the ear canal 5 times/day for 5-7 days with a combination antibiotic and steroid otic suspension (eg, Cortisporin or Cipro HC).
Svider PF, Vong A, Sheyn A, et al. What are we putting in our ears? A consumer product analysis of aural foreign bodies. Laryngoscope. 2015 Mar. 125(3):709-14. [Medline].
Gupta R, Nyakunu RP, Kippax JR. Is the emergency department management of ENT foreign bodies successful? A tertiary care hospital experience in Australia. Ear Nose Throat J. 2016 Mar. 95 (3):113-6. [Medline].
Celenk F, Gokcen C, Celenk N, et al. Association between the self-insertion of nasal and aural foreign bodies and attention-deficit/hyperactivity disorder in children. Int J Pediatr Otorhinolaryngol. 2013 Aug. 77(8):1291-4. [Medline].
Erkalp K, Kalekoglu Erkalp N, Ozdemir H. Acute otalgia during sleep (live insect in the ear): a case report. Agri. 2009 Jan. 21(1):36-8. [Medline].
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 Mar. 17(2):91-4. [Medline].
Jones I, Moulton C. Use of an electric ear syringe in the emergency department. J Accid Emerg Med. 1998 Sep. 15(5):327-8. [Medline].
Backous DD, Minor LB, Niparko JK. Trauma to the external auditory canal and temporal bone. Otolaryngol Clin North Am. 1996 Oct. 29(5):853-66. [Medline].
Balbani AP, Sanchez TG, Butugan O, et al. Ear and nose foreign body removal in children. Int J Pediatr Otorhinolaryngol. 1998 Nov 15. 46(1-2):37-42. [Medline].
Goldman SA, Ankerstjerne JK, Welker KB, Chen DA. Fatal meningitis and brain abscess resulting from foreign body-induced otomastoiditis. Otolaryngol Head Neck Surg. 1998 Jan. 118(1):6-8. [Medline].
Hof JR, Kremer B, Manni JJ. Mould constituents in the middle ear, a hearing-aid complication. J Laryngol Otol. 2000 Jan. 114(1):50-2. [Medline].
Jones RL, Chavda SV, Pahor AL. Parapharyngeal abscess secondary to an external auditory meatus foreign body. J Laryngol Otol. 1997 Nov. 111(11):1086-7. [Medline].
Peacock WF. Otolaryngologic emergencies. In: Tintinalli JE, et al, eds. Emergency Medicine: A Comprehensive Study Guide. 4th ed. McGraw Hill Text; 1996:1068-81.
Pfaff JA, Moore GP. Eye, ear, nose, and throat. Emerg Med Clin North Am. 1997 May. 15(2):327-40. [Medline].
Pons PT. Foreign bodies. Rosen P, et al, eds. Emergency Medicine: Concepts and Clinical Practice. Mosby-Year Book Inc; 1992. 319-337.
Schulze SL, Kerschner J, Beste D. Pediatric external auditory canal foreign bodies: a review of 698 cases. Otolaryngol Head Neck Surg. 2002 Jul. 127(1):73-8. [Medline].
Strachan DR, Kenny H, Hope GA. The hearing-aid battery: a hazard to elderly patients. Age Ageing. 1994 Sep. 23(5):425-6. [Medline].
White SJ, Broner S. The use of acetone to dissolve a Styrofoam impaction of the ear. Ann Emerg Med. 1994 Mar. 23(3):580-2. [Medline].
Robin Mantooth, MD, FACEP Assistant Medical Director, Department of Emergency Medicine, Norman Regional Health System; Adjunct Clinical Assistant Professor of Family Medicine, Oklahoma State University; Consulting Staff, Department of Emergency Medicine, Integris Southwest Medical Center, Oklahoma University Medical Center, Integris Canadian Valley Health Center, Saint Anthony Hospital, Commanche County Medical Center, Claremore Medical Center, and Oklahoma Heart Hospital
Robin Mantooth, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Christian Medical and Dental Associations
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Edmond A Hooker, II, MD, DrPH, FAAEM Associate Professor, Department of Health Services Administration, Xavier University, Cincinnati, Ohio; Assistant Professor, Department of Emergency Medicine, University of Cincinnati College of Medicine
Edmond A Hooker, II, MD, DrPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Public Health Association, Society for Academic Emergency Medicine, Southern Medical Association
Disclosure: Nothing to disclose.
Mark W Fourre, MD Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine; Program Director, Department of Emergency Medicine, Maine Medical Center
Disclosure: Nothing to disclose.
Ear Foreign Body Removal in Emergency Medicine
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