Ear Foreign Body Removal

Resident Clinical Pearl (RCP) May 2020

Dr. Sultan Alrobaian (PEM Fellow and Dalhousie PoCUS Fellow, Saint John, NB, Canada)

Reviewed by Dr. David Lewis

Introduction

Most patients with ear Foreign Bodies (FB) are children, adults can also present with ear FB
The most common objects removed include beads, pebbles, tissue paper, small toys, popcorn kernels, and insects
Diagnosis is often delayed because the causative event is usually unobserved or the symptoms are nonspecific
Most of the patients with ear FBs were asymptomatic at presentation, other patients presented with otalgia, bleeding from the ear, otorrhea, tinnitus, hearing loss, a sense of ear fullness or symptoms of otitis media
Successful removal depends on several factors, including location of the foreign body, type of material and patient cooperation
Visualization of a foreign body on otoscopy confirms the diagnosis, the other ear and both nostrils should also be examined closely for additional foreign bodies.

Clinical Anatomy

Equipment

Multiple options exist for removal of external auditory canal foreign bodies
Which piece of equipment to use will be influenced by the type of FB, the shape of the FB, the location of the FB and the cooperativeness of the patient

Timing

The type of foreign body determines the timing for removal
Button batteries, live insects and penetrating foreign bodies warrant urgent removal

Indications for consultation or referral to a specialist

Button battery
Potentially penetrating foreign bodies
Foreign body with evidence of injury to the external ear canal (EAC), tympanic membrane, middle ear, vestibular symptoms or marked pain

Technique

1 – Irrigation

This technique is used for small inorganic objects or insects
Irrigation is often better tolerated than instrumentation and does not require direct visualization
Contraindicated in patients with tympanostomy tubes, perforated tympanic membranes or button battery because the potential for caustic injury.
An angiocatheter or section of tubing from a butterfly syringe
Using body temperature water, retract the pinna, and squirt water superiorly in the external auditory canal, behind the FB

2 – Instrumentation under direct visualization

Instrumentation can be painful and frequently warrants procedural sedation in young children or other uncooperative patients
General anesthesia may be required to ensure safe removal
Restrain if needed for safety

Commonly used pieces of equipment are curettes, alligator forceps, and plain forceps. Other equipment options include using a right angle hook, balloon catheter, such as a Fogarty catheter

Used in conjunction with the operating head of an otoscope
The pinna should be retracted, and the FB visualized
When using forceps, the FB can be grasped and removed

Both curettes and right angle hooks should be gently maneuvered behind the FB and rotated so the end is behind the FB, which can then be pulled out

3 – Suction

This should be performed with a soft suction tipped catheter that has a thumb controlled release valve
Insert the suction against the FB under direct visualization and then activate the suctions and remove the FB

4 – Cyanoacrylate

Apply a small amount of cyanoacrylate or skin glue to the blunt end of a cotton-tipped applicator
Insert it against the FB under direct visualization and hold in place until the glue dries
Slowly and carefully withdraw

5 – Insect removal

The first step is to kill the insect with mineral oil followed by lidocaine
Once the insect is neutralized, it can be removed by any of the above methods

SUMMARY

Foreign bodies of EAC frequently occur in children six years of age and younger
Patients with foreign bodies of the EAC are frequently asymptomatic
Button batteries , penetrating foreign bodies or injury to the EAC should undergo urgent removal by an otolaryngologist.
With adequate illumination, proper equipment, and sufficient personnel, many EAC foreign bodies can be removed

REFERENCES

1.Lotterman S, Sohal M. Ear Foreign Body Removal. [Updated 2019 Jun 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459136 /

2.https://www.uptodate.com

3.Heim S W, Maughan K L. Foreign bodies in the ear, nose, and throat. Am Fam Physician. 2007;76(08):1185–1189. [PubMed] [Google Scholar]

4.Awad AH, ElTaher M. ENT Foreign Bodies: An Experience. Int Arch Otorhinolaryngol. 2018;22(2):146–151. doi:10.1055/s-0037-1603922