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EAR FOREIGN BODIES

Overview
Seen most commonly in the pediatric population, though occasionally in adults, patients can present with self-admission/sibling story, witnessed placement, unilateral foul-smelling otorrhea, and ear pain. In most adults and older cooperative children, ear canal foreign bodies can be removed at bedside with the use of an otic speculum, headlight, loupes, and otologic instruments. If an ear microscope is available, this should be used preferentially over loupes and a headlight as this may reduce the risk of inadvertent trauma to the ear canal and tympanic membrane. If the patient is not tolerant of bedside instrumentation, sedation in the emergency department or evaluation in the operating room may be necessary, especially if several failed attempts have been made. Rocks, popcorn kernels, and other small smooth round objects may be difficult to retrieve without inadvertantly pushing the object medially. In these cases, it is often best to carefully advance a small microhook just beyond the object to pull it out. In some cases, having an extra set of hands to help retract the tragus and gently apply posterior pinna traction can allow for improved visualization and bimanual removal of the foreign body. After removal, if ear canal skin or tympanic membrane are irritated, antibiotic/steroid drops or steroid drops alone can be helpful. In patients exhibit tympanic membrane trauma such as perforation, a follow-up with audiogram is pertinent to assess for hearing loss.

Key Supplies for Ear Foreign Body Removal

  • Otoscope, Loupes and headlight

  • Ear Microscope if available

  • Right angle hook

  • Loop curette

  • Alligator or cups forceps

  • 5 or 7 Baron suction


Management

  • Imaging is not generally indicated unless middle ear trauma suspected

  • Visualize item with otoscope, develop plan for which tool would best remove it

    • Right angle useful for objects with sharp edges, soft objects that you can hook, or smooth round objects

    • Alligator forceps or microcups are useful for flatter objects that can be grasped

    • If live insect is seen in canal, consider killing the insect prior to removal by filling ear canal with mineral oil

  • Review plan thoroughly with patient and family prior to procedure

  • Visualize well with speculum, headlight, and loupes, or preferably ear microscope if available

  • Locate gap where instrument (loop/right angle) can be passed just distal to object without ear canal trauma, or where object can be grasped

  • Remove atraumatically and efficiently since children will not always permit multiple attempts at bedside; have a low threshold for removal in the operating room for challenging cases

  • After removal, complete an otologic exam to assess for injury to tympanic membrane and ear canal

  • If tympanic membrane rupture

    • Consider otic antibiotic drops

    • Audiogram

    • ENT Follow up

  • Consider antibiotic/steroid otic drops (i.e Ciprodex) if significant canal laceration or edema

  • Follow up with primary care is reasonable unless significant canal laceration or concern of other injuries

Example Procedure Note
After discussion of risks and benefits, written consent was obtained. The patient was restrained by the mother and visualization of the ___ ear canal was obtained with the ear microscope and ear speculum. The foreign body was visualized in the mid canal. A right-angle hook was carefully inserted just deep to the object and was used to remove the foreign body atraumatically. Following removal, the ear was inspected and seen to be mildly edematous without any lacerations or tympanic membrane injury. The patient tolerated the procedure well.

 

References

  1. Friedman EM. VIDEOS IN CLINICAL MEDICINE. Removal of Foreign Bodies from the Ear and Nose. N Engl J Med. 2016;374(7):e7. doi:10.1056/NEJMvcm1207469

  2. Lotterman S, Sohal M. Ear Foreign Body Removal. In: StatPearls. Treasure Island (FL): StatPearls Publishing; March 25, 2020.