Ear Foreign Body Removal Procedures

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.

Relevant Anatomy

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

  Equipment display.

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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]}

Mechanical extraction

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.

Irrigation

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.

Suction

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.