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ENT: Foreign Bodies, Ear

Peds Ear | Peds Foreign Body

ENT: Foreign Bodies, Ear

See also Adult Ear

Background

  1. Definition
    • Foreign object such as insect, organic, or inorganic matter in external auditory canal
  2. General Information
    • Relatively common foreign body complaints in primary care offices, urgent care, and emergency room settings
    • May be asymptomatic or an incidental finding
  3. Epidemiology
    • Incidence/Prevalence
      • Most often presents in children between 9 months (pincer grasp develops) and 8 yrs
      • Most common foreign body
        • Beads
        • Plastic toys
        • Pebbles
        • Popcorn kernels
    • Morbidity/Mortality
      • Complications of placement and removal of foreign body can include
        • Canal Laceration
        • Pressure or liquefactive necrosis (disc batteries)
        • Otitis Externa
        • Tympanic membrane perforation
        • Hearing Loss
        • Canal wall hematoma

Pathophysiology

  1. Pathology of Disease
    • External auditory canal comprised of cartilaginous portion and bony portion
    • Inner 2/3 is very sensitive bony portion lined with thin vascular skin and periosteum
      • Extremely sensitive, removal of the foreign body will be painful
    • Outer 1/3 is a cartilaginous portion
    • Cartilaginous/ bony junction is point of narrowing
    • Abrasion of the ear canal may lead to bleeding & pain
    • Tympanic membrane may rupture
    • Canal erythema, swelling & foul smelling discharge may be late occurrences
  2. Etiology
    • Younger children more likely to have objects such as beads, toys, pebbles, beans, seeds, or popcorn kernels as foreign body
      • 75% of pts were younger than 8 yo
    • Older children (>10 years) through adults more likely to have insects
      • Most commonly cockroaches, as foreign body
    • Seeds, nuts, plastic toys, and beads are most common objects
  3. Risk Factors
    • Reasons for foreign body placement likely multifactorial
    • Coexisting ear pathology such as acute otitis media, otitis externa, cerumen impaction, or middle ear effusion
    • Curiosity or fun-making
    • Developmental delay
    • Behavioral Disorder such as ADHD
    • Mental Illness

Diagnostics

  1. History/Symptoms
    • Asymptomatic or incidental examination finding
    • Pain in affected ear
    • Noise or “drumming” in ear associated with insect foreign body
    • Hearing loss
    • Sensation of ear fullness
    • Unilateral otorrhea
    • Bleeding
    • Self-reported by patient or parent
  2. Physical Examination/Signs
    • Otorrhea of affected side may be present
    • Direct visualization w/ an otoscope may reveal full view of foreign body
    • Exam should include careful inspection of contralateral ear and nares for other foreign bodies
    • Hearing evaluation pre and post-extraction with tuning fork or audiogram may be indicated if reported hearing loss
    • Pneumatic otoscopy could be considered to confirm intact tympanic membrane if low risk of pushing object further into ear canal
    • Examination of canal both pre and post-extraction to document any lacerations, hematoma, bleeding, infection, tissue necrosis, or remaining foreign body
  3. Diagnostic Testing
    • Otoscopic visualization

Differential Diagnosis

  1. Tumor or mass
  2. Cerumen
  3. Otomycosis and exostosis may be some considerations
  4. Congenital Cholesteatoma
  5. Acute otitis media

Therapeutics

  1. Acute Treatment
    • With exception of disc batteries, most ear foreign bodies not an emergency and can await specialty consultation if indicated
    • Primary treatment is removal of foreign body using variety of possible techniques
      • First, irrigate w/ water
      • Primary insturements used
        • Forceps
        • Cerumen loop
        • Right-angle ball hook
        • Suction catheter
    • Careful consideration should be given to
      • Clinician dexterity and experience
      • Adequate visualization
      • Adequate support staff
      • Safety and comfort of patient and clinician
      • Availability of appropriate instruments
    • Children should be appropriately restrained, either in supine position or in adult’s lap
  2. Removal Techniques
    • Irrigation
      • Attempt to confirm an intact tympanic membrane with pneumatic otoscopy prior to irrigation
      • Contraindications
      • Organic matter (such as dried fruit, cotton, beans, peas, and popcorn kernels), due to their hydroscopic properties and propensity to swell when exposed to liquids
        • Disc batteries should never be irrigated due to risk of liquefactive necrosis
        • Perforation of tympanic membrane
        • Commercial irrigators, or a 60 mL syringe with 14- or 16-gauge angiocath, with warm water or saline solution may be used
        • Direct the stream superiorly (never directly at the tympanic membrane) past the object if possible
      • Styrofoam foreign body
        • Dissolve with aqueous Acetone soln
    • Suction
      • Best for spherical or non-graspable objects not tightly lodged in the canal
      • Warn patient of noise due to suction device
      • Instruments include Frazer tip suction or Schuknecht foreign body remover
      • Risk of pushing the object further into the canal with the suction device
    • Instrumentation
      • Graspable objects with irregular contours that are easily visualized, consider
      • Alligator or Hartman forceps
      • Cerumen loop
      • Right angle ball hook
      • For smooth or spherical non-graspable objects, a right angle ball hook can be passed behind to foreign body and then used to dislodge or pull the object out of the canal
      • Use caution due to risk of perforation of the tympanic membrane
    • Cyanoacrylate Glue
      • Tissue glue or superglue may be applied to end of cotton swab and then glued to foreign body
        • Allow glue to set for 30-60 seconds
        • Requires cooperative patient, thus may be contraindicated in young children
        • Glue on ear canal can be dissolved with acetone if tympanic membrane intact
      • Ear hair or tortuous anatomy may complicate procedure
        • Risk of pushing the object further into ear
    • Operative Removal and Specialty Consultation
      • Younger children at higher risk of
        • Requiring anesthesia for extraction, and
        • Failure of removal with direct visualization
      • Success rates of extraction higher with Otolaryngology consultation and otomicroscopy versus direct visualization
        • Some providers may have upright operating microscope availability in their clinic for purposes such as colposcopy
        • Removal with microscopy preferred due to binocular vision and magnification power
      • Indications for referral to Otolaryngologist may include some of the following
        • Age < 4 years
        • Operator inexperience, uncooperative patient, poor visualization of object, lack of staff or tools, etc.
        • Foreign body in canal >24 hours
        • Existing complications such as perforated tympanic membrane or tissue necrosis
        • Disc batteries (urgent referral highly recommended)
        • Multiple prior attempts
        • Objects near tympanic membrane or deep in bony canal
        • Sharp objects that may cause perforation or laceration during removal
      • Insect removal
        • Kill insect by introducing alcohol, 2% lidocaine (Xylocaine), or mineral oil into the ear canal
          • Should be done before removal attempt
          • avoid if there is perforation of the tympanic membrane
    • Special Considerations
      • Live insects can be killed by submerging in mineral oil (microscope oil) or lidocaine prior to extraction attempts
      • Case reports of using acetone and other organic solvents to dissolve Styrofoam, glue, and gum

Follow Up

  1. Uncomplicated extractions generally do not require further follow up
  2. Early follow up with primary care provider or otolaryngologist may be appropriate if extraction complicated by
    • Canal laceration
    • Tympanic membrane perforation
    • Canal wall hematoma, or
    • Otitis externa
  3. Otitis externa and tympanic membrane perforation should be treated appropriately
  4. Indications for referral
    • Need for sedation
    • Trauma to
      • Canal or tympanic membrane trauma
    • Nongraspable foreign body
      • Tightly wedged, or
      • Touching tympanic membrane
    • Sharp foreign body
    • Removal attempts unsuccessful
      • After the first attempt, the next attempts are more likely to fail
      • Otolaryngology referral
        • Obtained for patients requiring sedation or anesthesia

Prognosis

  1. Good, overall
  2. Chance of successful extraction diminishes with each attempt, while rate of complications increases with each attempt

Prevention

  1. Mostly non preventable
  2. Discourage children from putting anything in the ear

References

  1. 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;17(2):91-4.
  2. Schulze SL, Kerschner J, Beste D. Pediatric external auditory canal foreign bodies: a review of 698 cases. Otolaryngol Head Neck Surg. 2002;127(1):73-8.
  3. Dimuzio J, Deschler DG. Emergency department management of foreign bodies of the external ear canal in children. Otol Neurotol. 2002;23(4):473-5.
  4. Bressler K, Shelton C. Ear foreign-body removal: a review of 98 consecutive cases. Laryngoscope. 1993;103(4 Pt 1):367-70.
  5. Heim SW, Maughan KL. Foreign bodies in the ear, nose, and throat. Am Fam Physician. 2007;76(8):1185-9.
  6. Chinski A, Foltran, F, Gregori, D. et al. Foreign bodies in the ears in children: the experience of the Buenos Aires pediatric ORL clinic. The Turkish Journal of Pediatrics. 2011; 53(4): 425-29.
  7. Chai CK, Tang IP, Tan TY, et al. A Review of Ear, Nose, And Throat Foreign Bodies In Sarawak General Hospital. A Five Year Experience. Med J Malaysia; 2012; 67(1): 17-20.
  8. Ansley JF, Cunningham MJ. Treatment of aural foreign bodies in children. Pediatrics. 1998;101(4 Pt 1):638-41.
  9. Brown JC, Rizvi S, Klein EJ, Bittner R. Hydroscopic properties of organic objects that may present as aural foreign bodies. J Clin Med Res. 2010;2(4):172-6.
  10. Capo JM, Lucente FE. Alkaline battery foreign bodies of the ear and nose. Arch Otolaryngol Head Neck Surg. 1986;112(5):562-3.
  11. Kadish H. Ear and nose foreign bodies: "It is all about the tools''. Clin Pediatr (Phila). 2005;44(8):665-70.
  12. Pride H, Schwab R. A new technique for removing foreign bodies of the external auditory canal. Pediatr Emerg Care. 1989;5(2):135-6.
  13. Hanson RM, Stephens M. Cyanoacrylate-assisted foreign body removal from the ear and nose in children. J Paediatr Child Health. 1994;30(1):77-8.
  14. Mclaughlin R, Ullah R, Heylings D. Comparative prospective study of foreign body removal from external auditory canals of cadavers with right angle hook or cyanoacrylate glue. Emerg Med J. 2002;19(1):43-5.
  15. Antonelli PJ, Ahmadi A, Prevatt A. Insecticidal activity of common reagents for insect foreign bodies of the ear. Laryngoscope. 2001;111(1):15-20.
  16. Parajuli R. Foreign bodies in the ear, nose and throat: an experience in a tertiary care hospital in central Nepal. Int Arch Otorhinolaryngol. 2015 Apr;19(2):121-3. doi: 10.1055/s-0034-1397336. Epub 2014 Dec 30.
  17. Thompson SK, Wein RO, Dutcher PO. External auditory canal foreign body removal: management practices and outcomes. Laryngoscope. 2003;113:1912-5.
  18. White SJ, Broner S. The use of acetone to dissolve a Styrofoam impaction of the ear. Ann Emerg Med. 1994;23:580-2.
  19. Foreign Bodies in the Ear, Nose, and Throat STEVEN W. HEIM, MD, MSPH, AND KAREN L. MAUGHAN, MD Am Fam Physician. 2007;76(8):1185-1189.https://www.aafp.org/pubs/afp/issues/2007/1015/p1185.html

Contributors

  1. Kyle Mouery, MD
  2. Mari Ricker, MD
  3. Ausi, Michael, MD, MPH

Updated/Reviewed: May 2023