Ear Foreign Body Removal


Article Author:
Seth Lotterman


Article Editor:
Maheep Sohal


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
6/5/2019 12:53:51 PM

Introduction

Many physicians who work in acute care settings, especially those who see pediatric patients, will encounter patients who have a foreign body (FB) in the external auditory canal (EAC). Depending on specialty and location of practice, some doctors will encounter this condition more frequently. The goal of this section is to give physicians an understanding of the scope of this condition as well as some methods for managing an FB in the external auditory canal.

While more common in pediatric patients, adults can also present with FB, most commonly an insect, in the external auditory canal. The most commonly removed FB tends to be beads (most common), paper/tissue paper, and popcorn kernels.[1][2] These combined for just over half of the foreign bodies removed in one study.[2] There may also be a slight male predominance, but not all studies have shown this.[2][3] Certain types of FB, such as button batteries, do require urgent removal. However, for most inorganic objects there does not appear to a significant issue with the length of time the FB has been in the external auditory canal before attempted removal.

Anatomy

The external auditory canal, along with the outer layer of the tympanic membrane (TM), is formed from the first branchial cleft. The medial two-thirds are bone covered with stratified squamous epithelial skin, while cartilage makes up the outer third, consisting of both bone and cartilage. The skin lining the cartilaginous portion of the external auditory canal has hairs and modified sweat glands that secrete earwax. Innervation of the external auditory canal is mostly from cranial nerves V3 (mandibular branch) and X. Cranial nerves VII and IX have lesser contributions. The external auditory canal is nearly straight in children, becoming nearly adult size, about 2.5 cm long, at about nine years old. In adults, it becomes more sigmoid shaped with the cartilaginous portion angling posteriorly and superiorly with the bony portion angling anterior inferiorly. As a result, in adults, pulling the helix posterior and superior straightens the external auditory canal and allows for better visualization of the TM. Of significant importance for FB management, the external auditory canal has two natural narrowings. The first point is at the bone and cartilage junction, and the other is just lateral to the TM.[4] Another important anatomic feature of the TM is the potential blind spot in the tympanic sulcus generated as the TM slopes obliquely away from the external auditory canal as it goes inferiorly.

Indications

Indications for this procedure include the presence of an FB in the external auditory canal for removal, the appropriate equipment for removal of an FB in the external auditory canal, and a cooperative patient (or the ability to safely sedate the patient).[5]

Contraindications

Contraindications to the removal of an FB from the external auditory canal are related to the cooperativeness of the patient, location of the FB in the external auditory canal, lack of appropriate tools for removal of the FB, and the type of FB may make methods of removal inappropriate.

An uncooperative patient and the inability to safely sedate an uncooperative patient would be a contraindication to attempting FB removal.

An FB lodged against the TM, or an FB that cannot be grasped easily, such as a hard spherically shaped FB, may require specialized equipment not readily available. Specific methods might also be contraindicated in certain situations. For example, irrigation would be contraindicated with a suspected TM perforation, removal of organic material, or removal of a battery. It may also be contraindicated if the suspected foreign body is made of a spongy material that may swell and enlarge if hydrated.[5]

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.[4]

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. The use of a hemostat, dental pick, skin hooks, fine tissue forceps, and transforming a paper clip into a right angle hook have also been described.[4]

Irrigation is another common option, and this can be performed by attaching an angiocatheter to a 20 mL to 30 mL syringe. Alternatively, modifying a butterfly catheter by cutting off the needle and then attaching the remaining tubing to the syringe.[4] 

Suction is also an option and usually is performed with a soft tip suction catheter.[4]

Another potential method is using cyanoacrylate (superglue) or tissue glue applied to the blunt end of a cotton-tipped applicator and then placed against the FB so the glue adheres to the FB and both the FB and applicator can be pulled out of the external auditory canal together.[4][6]

Personnel

In a cooperative patient, it is possible to remove an FB from the external auditory canal by a single provider. Depending on how cooperative the patient is, one or more assistants may be required to maintain the patient in the proper position and keep the patient still.[5]

Preparation

Evaluation should include noting any injury to the external auditory canal and tympanic membrane (TM) before removal attempts. The patient's hearing should also be assessed, especially if there is suspicion for TM injury/perforation or middle ear injury. Patient positioning is important. Cooperative patients can either sit or lie down with the affected ear turned towards the provider. For younger children, there are several options for positioning. The patient can sit in the parent’s lap with the parent holding the patient’s body with one hand and the other around the head with the head turned. The patient can also lie down, either supine or prone, on the stretcher with their head turned.[7]

Technique

The technique for removal of an FB from the external auditory canal should be based on the initial evaluation of the patient for possible TM injury, the type of FB and location in the external auditory canal, as well as the ability of the patient to cooperate. The appropriate method for removal of the FB should be selected and after positioning the patient as indicated above the FB should be removed. Before beginning the procedure, the physician should determine how many attempts will be made (usually only one or two) and if more than one attempt is planned, what technique should be used for the subsequent attempt. If unsuccessful after one or two attempts, further attempts should be aborted, and the patient should be referred to an ear, nose, and throat (ENT) specialist. Consider examining the contralateral ear and nose for other foreign bodies as well.

Specific Techniques

Manual instrumentation (e.g., forceps, curettes, angle hook)

These are ideally used in conjunction with the operating head of an otoscope, but can also be used with the diagnostic head. 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.[4]

Irrigation

This can be performed with either 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 which will then be washed out of the canal.[4]

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, maintaining suction until the FB is completely out of the external auditory canal.[4]

Cyanoacrylate

Apply a small amount of cyanoacrylate or skin glue to the blunt end of a cotton-tipped applicator. Once the glue is tacky, insert it against the FB under direct visualization and hold in place until the glue dries. Once the FB is secured onto the applicator, it can be removed onto the applicator.[4]

Insect removal

The first step is to kill the insect, which will allow the patient to be more comfortable and allow for removal of the insect after. There are multiple recommended agents for killing the insect. Studies indicate that mineral oil is the most effective, followed by lidocaine.[8] Both can be instilled in the external auditory canal, and once the insect is neutralized, it can be removed by any of the above methods.[4]

Complications

Complications from the placement of an FB into the external auditory canal and attempts at removal of the FB include excoriations and lacerations of the external auditory canal, and as a result, it is important to document a pre-removal and post-removal exam. These typically heal rapidly by keeping the external auditory canal clean and dry. Antibiotic eardrops can be considered as well.[7]

Clinical Significance

Physicians involved in acute patient care can expect to manage patients with an FB in the external auditory canal during the course of their career. As such, it is important to recognize both provider skill and equipment limitations. The type and location of FB in the external auditory canal, along with the ability of the patient to cooperate are the key factors in determining whether an attempt should be made. Referal to a specialist or a location where sedation can be performed is recommended if the FB removal is not practical after the initial evaluation. In general, complications tend to be minor and easily managed.

Enhancing Healthcare Team Outcomes

Successful removal of an ear foreign body often requires the cooperation of the patient and the assistance of family members as well as other medical team members. Patient positioning and a well thought out plan are keys to the success of the procedure. Explaining to patients and family what will happen and gaining their cooperation is important. Involving family members and/or staff members for positioning can be very helpful. Another consideration is the use of medications for anxiolysis or procedural sedation to facilitate patient cooperation. This requires appropriate ancillary staff, such as nursing for intravenous line placement and medication administration and possibly anesthesia or respiratory therapy to assist in airway monitoring. With appropriate team coordination this procedure can be performed safely and rapidly with low risk for complication and minimal stress for the patient. 


  • Image 5775 Not availableImage 5775 Not available
    Contributed by Seth Lotterman, MD
Attributed To: Contributed by Seth Lotterman, MD

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Ear Foreign Body Removal - Questions

Take a quiz of the questions on this article.

Take Quiz
Which of the following foreign bodies should not be removed with irrigation from the ear?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is the best initial method of removing a foreign body from a child's ear?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 7-year old child is brought in by the mother with a 2-day history of a foul-smelling discharge from the left ear. The mother denies any past medical history or any trauma. The child has been complaining of ear pain but has no fever or signs of an upper respiratory tract infection. Otoscope exam is difficult because the child is in pain and extremely irritable. There is a yellowish discharge that has a foul smell. What is the most likely diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old male presents with a live insect in his ear canal. Which of the following is most likely to kill the insect the fastest?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 3-year-old female presents with a small bead in her ear canal. The parents don’t remember her playing with any beads, but she does have an older sibling and are unsure when the bead was placed in her ear. Which of the following is true regarding removal of the bead?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 5-year-old boy is brought in after the eraser on a pencil broke off in his ear canal. Using a right angle hook the eraser is successfully removed, but on assessment afterward, a superficial, small laceration is noted in the ear canal. Which is the best method of management of the excoriation?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Ear Foreign Body Removal - References

References

Pediatric external auditory canal foreign bodies: a review of 698 cases., Schulze SL,Kerschner J,Beste D,, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, 2002 Jul     [PubMed]
Critical ENT skills and procedures in the emergency department., Falcon-Chevere JL,Giraldez L,Rivera-Rivera JO,Suero-Salvador T,, Emergency medicine clinics of North America, 2013 Feb     [PubMed]
Foreign body removal from the external auditory canal in a pediatric emergency department., Marin JR,Trainor JL,, Pediatric emergency care, 2006 Sep     [PubMed]
Chemical immobilization and killing of intra-aural roaches: an in vitro comparative study., Leffler S,Cheney P,Tandberg D,, Annals of emergency medicine, 1993 Dec     [PubMed]
Thompson SK,Wein RO,Dutcher PO, External auditory canal foreign body removal: management practices and outcomes. The Laryngoscope. 2003 Nov     [PubMed]
Friedman EM, VIDEOS IN CLINICAL MEDICINE. Removal of Foreign Bodies from the Ear and Nose. The New England journal of medicine. 2016 Feb 18     [PubMed]
Benger JR,Davies PH, A useful form of glue ear. Journal of accident & emergency medicine. 2000 Mar     [PubMed]
Davies PH,Benger JR, Foreign bodies in the nose and ear: a review of techniques for removal in the emergency department. Journal of accident & emergency medicine. 2000 Mar     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Pediatrics-Medical Student. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Pediatrics-Medical Student, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Pediatrics-Medical Student, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Pediatrics-Medical Student. When it is time for the Pediatrics-Medical Student board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Pediatrics-Medical Student.