Otolaryngology

Foreign Body in Ear: Insects, Solid Objects, Cerumen

Insects and Bugs

Pathophysiology

1. Insect flies/crawls into external canal(s), often during sleep

Diagnostics

1. History/Symptoms
   • Most patients are asymptomatic
   • Patients often very anxious/agitated
   • Patients (may) complain of noise (frequently know something is in ear)
   • Bleeding from ear
   • Ear may be
     • Red
     • Swollen
   • Sense of ear fullness
   • Drainage from ear
2. Physical Exam/Signs
   • Direct visualization of insect or parts in external canal

Treatment

1. Suffocate insect by instilling
   • 1% lidocaine, auralgan, or mineral oil into external auditory canal; live insect may crawl out
2. Preferred
   • If insect or parts still visible
     • Irrigate (View image) (View image) using syringe and warm tap water
3. Alternate
   • Remove with alligator forceps under direct visualization
     • Insect may fragment and may require irrigation to remove small pieces
4. Intra-aural insect
   • Frazier suction device can be utilized

Disposition

1. Re-examine canal and TM after FB removal: If both intact, no further follow-up
2. Topical antibiotic (e.g., cortisporin otic suspension) if evidence of minor trauma/abrasions
3. ENT follow-up if evidence of more severe trauma or TM perforation ; or if unable to remove foreign matter

Solid Object

Pathophysiology

1. Usually self-inflicted, may be accidental

Diagnostics

1. History/Symptoms
   • May be asymptomatic
   • Decreased hearing
   • Patients aware of foreign body insertion
   • Earache
   • Ear discharge
   • Aural fullness
2. Physical Exam/Signs
   • Direct visualization with ophthalmoscope
   • Foreign body may be incidental finding during routine otoscopic exam

Treatment

1. Children or uncooperative adults may require local anesthesia
   • Infiltration around external auditory canal or four-quadrant local block
   • In severe cases consider conscious sedation
2. Attempt removal with fine forceps, small right angle hook, or cerumen spoon
3. Suction may be useful for soft material, cerumen, vegetable matter, etc.
4. Hard or smooth objects
   • If available a special speculum with soft, flanged tip fitted with suction port (Schuchardt foreign body remover); consider careful use of a drop of super-glue on a probe, which is held on object; quick bonding may allow extraction of attached foreign body
5. Flushing (View image) (View image) with warm water may facilitate
   • DO NOT use if material might swell when moistened
6. Cyanoacrylate
   • Apply small amount or skin to the cotton end of a cotton-tipped applicator
   • May help remove some of the cotton in order to diminish the size of time and improve visualization
     • Prior to application of the adhesive and insertion into the external auditory canal (EAC)
   • Once glue is tacky, insert the applicator into the EAC, place sticky end to FB
     • Holding in place until glue dries
     • Once secured, it can be removed with applicator
   • Be sure not to touch skin of EAC while inserting cotton-tipped applicator
     • As it adheres to EAC rather than FB, will cause injury and edema

Disposition

1. Topical antibiotics after removal only if evidence of inflammation or trauma (auditory canal lacerations, abrasions, bleeding)
   • Remember to check tetanus status if canal abraded/lacerated
2. Foreign body traversing TM should be removed by ENT in OR
3. Caution: In children check nose and other ear for foreign bodies

Cerumen

Pathophysiology

1. Normal physiologic process
2. May become impacted secondary to patient’s use of cotton swabs

Diagnostics

1. History/Symptoms
   • Conductive hearing loss
   • May cause vertigo
   • Ear fullness
   • Pruritus
   • Dizziness
   • Tinnitus
   • Earache
2. Physical Exam/Signs
   • External canal obstructed by cerumen on ophthalmoscope visualization

Treatment

1. Cerumenolytics
   • Cerumenex
   • Carbamide peroxide
     • Common cerumenolytic prescribed
     • 5-10 drops BID for up to 4 days
   • Contraindications
     • Perforated tympanic membrane
     • History of ear surgery
       • Including tympanostomy tube placement
2. Suction/irrigation (View image) (View image) often may be used to clear with no instrumentation, irrigation
   • Room temp or warm water (consider a 50:50 mix of hydrogen peroxide and water)
   • 20 mL syringe
   • Angiocath
   • Butterfly with needle and wings cut off
   • Water-Pick-type device
3. Manual removal (final method recommended by American Academy of Otolaryngology-Head and Neck Surgery)
   • Cerumen spoons
     • Soft plastic loops or smooth metal loops; use to gently remove cerumen
4. AVOID curettes with sharp cutting edges (look similar to cerumen spoons/loops)

Disposition

1. Consider recommending routine use of Cerumenex, etc. in cases with recurring problems
2. Topical antibiotics (cortisporin , etc.) should be used in those with inflammation or minor trauma from impaction/removal
3. Warn against cotton swab use

References

1. Awad AH, ElTaher M. ENT Foreign Bodies: An Experience. Int Arch Otorhinolaryngol. Apr 2018; 22(2):146–151.
2. Aliem. Trick of the Trade: Insect removal from the ear. Available at: https://www.aliem.com/trick-of-trade-insect-removal-from-the-ear/. [Accessed May 2022]
3. Ear Foreign Body Removal. StatPearls [Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK459136/. [Accessed May 2022]

1. Singh, Ajaydeep, MD