Ear Foreign Body Removal Procedures
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The removal of foreign bodies from the ear is a common procedure in the emergency department. [1] Children older than 9 months often present with foreign bodies in the ear; at this age, the pincer grasp is fully developed, which enables children to maneuver tiny objects.
See Foreign Bodies: Curious Findings, a Critical Images slideshow, to help identify various foreign objects and determine appropriate interventions and treatment options.
In adults, insects (eg, cockroaches, moths, flies, household ants) are the foreign bodies most commonly found in the ear. Rarely, other objects have been reported (eg, teeth, hardened concrete sediments, illicit drugs, plant material). [2] , [3] , [4] Some persons from Mexico and Central America reportedly insert leaves and other plant material into their ears as a form of native remedy. [5] Also, some adults with psychiatric disorders present to the emergency department with foreign bodies lodged in their ears as a form of self-mutilation called ear stuffing. [6]
In children, the range of foreign bodies is extensive. Food particles (eg, candy, vegetable matter, beans, chewing gum) and other organic material (eg, leaves, flowers, cotton pieces) are commonly encountered. [7] Inorganic objects such as small toys, beads, pencil erasers, and rocks are also common.
The ear is composed of external, middle (tympanic) (malleus, incus, and stapes), and inner (labyrinth) (semicircular canals, vestibule, cochlea) portions. The auricle and external acoustic meatus (or external auditory canal) compose the external ear. The external ear functions to collect and amplify sound, which then gets transmitted to the middle ear. The tympanic cavity (middle ear) extends from the tympanic membrane to the oval window and contains the bony conduction elements of the malleus, incus, and stapes. The primary functionality of the middle ear is that of bony conduction of sound via transference of sound waves in the air collected by the auricle to the fluid of the inner ear. The inner ear, also called the labyrinthine cavity, is essentially formed of the membranous labyrinth encased in the bony osseus labyrinth. The labyrinthine cavity functions to conduct sound to the central nervous system as well as to assist in balance.
For more information about the relevant anatomy, see Ear Anatomy.
The prompt removal of foreign bodies from the ear is indicated whenever a well-visualized foreign body is identified in the external auditory canal and an uncomplicated first attempt is anticipated.
See the list below:
The presence of a tympanic membrane (TM) perforation, contact of a foreign body with the tympanic membrane, or incomplete visualization of the auditory canal are indications for urgent-emergent ENT consultation for removal by operative microscope and speculum.
If button batteries or hearing aid batteries are involved, emergent ENT consultation is always warranted because time-sensitive liquefaction necrosis may lead to subsequent tympanic membrane perforation and further complications. In fact, irrigation should never be attempted in such cases, as it accelerates the necrotic process. [8] , [9]
See the list below:
Local anesthesia is invasive and is not generally used for uncomplicated ear foreign body removal because of the complex innervations of the external ear canal.
Procedural sedation is sometimes necessary for a patient who is unable to cooperate with the removal procedure. For more information, see Procedural Sedation.
The equipment required depends on the removal method. Typical equipment includes the following (see video below):
Otoscope with removable lens
Microscopic otoscope
Nasal speculum
Headlamp
Bayonet forceps
Alligator forceps
Syringe
Angiocatheter, 20 gauge (ga)
Emesis basin
Soft-tipped suction catheter and suction equipment
Magnet for metallic foreign bodies
A patient’s external auditory canal is easily visualized in both seated and lateral decubitus positions; cooperative patients can choose whichever position is more comfortable. In adults and young children, gently retract the pinna superiorly and posteriorly to straighten the ear canal for optimal visualization (see video below). In infants, the pinna may have to be gently retracted posteriorly or even downward for optimal view of the external auditory canal.
Techniques appropriate for the removal of ear foreign bodies include mechanical extraction, irrigation, and suction. Practitioners should allow the nature of the foreign body to guide the choice of technique. Irrigation is contraindicated for organic matter that may swell through osmosis and enlarge within the auditory canal. Insects, organic matter, and objects with the potential to become friable and break into smaller evasive pieces are often better extracted with suction than with forceps. Live insects in the ear canal should be immobilized before removal is attempted. [7] Mineral oil, microscope oil, and viscous lidocaine have all been used successfully for this purpose. [10, 11]
Position the patient comfortably. Briefly repeat the ear examination while observing the location and depth of the foreign body. Move the otoscope lens to one side and carefully introduce bayonet forceps or alligator forceps through the otoscope lens. Advance the forceps incrementally through the external auditory canal until the foreign body is grasped. Gently withdraw the forceps, with attached foreign body, from the auditory canal. Always check for complete removal of the foreign body, perforation of the tympanic membrane, and abrasions of the auditory canal. See video below.
To irrigate, first attach a 20-ga angiocatheter to a 60-mL syringe. Warming the irrigation fluid (water or normal saline) greatly enhances patient comfort. Position the patient comfortably and drape the area to keep the patient dry. Position an emesis basin under the affected ear to collect irrigation runoff. Place the flexible angiocatheter tip gently in the external auditory canal. Advancing the tip too far risks damage to the tympanic membrane. With the angiocatheter tip held gently in position, slowly inject irrigation fluid until the foreign body washes out. Always conduct a postprocedural ear examination to confirm complete removal of the foreign body and to check for complications. See video below.
Connect the soft-tipped suction catheter to low wall suction and position the patient comfortably. Visualize the foreign body with the otoscope. Maintain the position of the otoscope while retracting its lens to one side. Introduce the catheter through the otoscope and gently advance it incrementally until the foreign body is contacted. Gently withdraw the suction catheter tip and attached foreign body from the external auditory canal. Repeat a postprocedural ear examination to confirm complete removal of the foreign body and to check for complications. See video below.
Abandon attempts to retrieve a foreign body if complications arise. If the object migrates farther into the canal or if bleeding, edema, or increasing pain develops, consult an ENT specialist. Repeated attempts to remove a foreign body from the ear may result in infection, perforation, or other morbidity. [12, 13, 14]
See the list below:
Consider that an underlying illness may have prompted the patient to insert a foreign body into the ear to relieve discomfort such as pain or pruritus. [15]
Perform a thorough head, ears, eyes, nose, and throat (HEENT) examination in all patients, since throat pain can refer to the ears.
Always examine the opposite ear and both nares for additional foreign bodies.
Always examine the external auditory canal after the removal of a foreign body to identify preexisting or iatrogenic tympanic membrane perforations or abrasions.
Acetone has been used successfully to remove chewing gum, Styrofoam, and superglue from the ear canal. [16, 17, 18]
Ethyl chloride has been used to remove Styrofoam beads from the ear canal. [19]
See the list below:
Reported acute complications of ear foreign body removal include canal abrasions, bleeding, infection, and perforation of the tympanic membrane. [7] Presentation of these complications may be delayed. Retained foreign body particles may cause subsequent formation of granulomas. [20]
For the uncomplicated removal of foreign bodies from the ear, neither prophylactic antibiotics nor routine ENT follow-up is indicated. [21]
Not all complications are immediately evident. Ensure that the patient or caregiver understands that further treatment is warranted if pain, redness, fever, or discharge develops.
Overview
What is the prevalence of ear foreign body removal?
What is the anatomy of ear relevant to foreign body removal?
What are indications for ear foreign body removal procedures?
What are contraindications for ear foreign body removal procedures?
What is the role of anesthesia in the removal of ear foreign bodies?
What equipment is needed to perform removal of ear foreign bodies?
How is the patient positioned for removal of ear foreign bodies?
Which removal techniques are used for ear foreign bodies?
What is the role of mechanical extraction in the removal of ear foreign bodies?
What is the role of irrigation in the removal of ear foreign bodies?
What is the role of suction in the removal of ear foreign bodies?
What are treatment pearls for the removal of ear foreign bodies?
What are the possible complications of foreign body removal from the ear?
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Bressler K, Shelton C. Ear foreign-body removal: a review of 98 consecutive cases. Laryngoscope. 1993 Apr. 103(4 Pt 1):367-70. [Medline].
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McRae D, Premachandra DJ, Gatland DJ. Button batteries in the ear, nose and cervical esophagus: a destructive foreign body. J Otolaryngol. 1989 Oct. 18(6):317-9.
Antonelli PJ, Ahmadi A, Prevatt A. Insecticidal activity of common reagents for insect foreign bodies of the ear. Laryngoscope. 2001 Jan. 111(1):15-20.
Leffler S, Cheney P, Tandberg D. Chemical immobilization and killing of intra-aural roaches: an in-vitro comparative study. Ann Emerg Med. 1993 Dec. 22(12):1795-8.
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].
Thompson SK, Wein RO, Dutcher PO. External auditory canal foreign body removal: management practices and outcomes. Laryngoscope. 2003 Nov. 113(11):1912-5.
Dwivedi RC, Dwivedi RC, Bhatia N, Rhys-Evans PH. Low-cost dual-action aural foreign-body extractor. Laryngoscope. 2009 Feb. 119(2):351-4. [Medline].
Das SK. Aetiological evaluation of foreign bodies in the ear and nose. J Laryngol Otol. 1984 Oct. 98(10):989-91. [Medline].
Abadir WF, Nakhla V, Chong P. Removal of superglue from the external ear using acetone: case report and literature review. J Laryngol Otol. 1995 Dec. 109(12):1219-21. [Medline].
Chisholm EJ, Barber-Craig H, Farrell R. Chewing gum removal from the ear using acetone. J Laryngol Otol. 2003 Apr. 117(4):325.
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].
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].
Jahn AF, Hawke M. Foreign body granulomas of the ear. J Otolaryngol. 1976 Jun. 5(3):221-6.
Ansley JF, Cunningham MJ. Treatment of aural foreign bodies in children. Pediatrics. Apr 1998. 101(4 Pt 1):638-41.
Angela On-Kee Kwong, MD Attending Physician, Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center
Disclosure: Nothing to disclose.
Jennifer M Provataris, MD Clinical Instructor, Attending Physician, Department of Emergency Medicine, Jacobi Medical Center and North Central Bronx Hospital
Jennifer M Provataris, MD is a member of the following medical societies: Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.
Prajoy P Kadkade, MD Assistant Professor of Otolaryngology, Albert Einstein College of Medicine; Attending Physician, Department of Otolaryngology and Communicative Disorders, Director of Otolaryngology, North Shore University Hospital, North Shore-Long Island Jewish Hospital System
Prajoy P Kadkade, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, Medical Society of the State of New York
Disclosure: Nothing to disclose.
The author thanks Dr. Melissa Harper and Dr. Linda Liu for their wonderful patience and winning attitude in participating with this chapter, as well as Dr. Jennifer Provataris, for her infinite encouragement, tireless diligence, wisdom, and creativity in producing this chapter.
Medscape Drugs & Diseases also thanks Hamid R Djalilian, MD, Associate Professor of Otolaryngology, Director of Neurotology and Skull Base Surgery, University of California Irvine Medical Center, for assistance with the video contribution to this article.
Ear Foreign Body Removal Procedures
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