Overview
Foreign bodies of the ear, which are relatively common in emergency medicine, are seen most often, but not exclusively, in children. A study by Morris et al using NHS England hospital data showed that between 2010 and 2016, children accounted for 85.9% of the 17,325 foreign bodies removed from the auditory canal. [1]
Various objects may be found in the ear, including toys, beads, stones, folded paper, and biologic materials such as insects or seeds.
In a study of pediatric patients, Xiao et al, using the National Electronic Injury Surveillance System, reported that in the United States, ear foreign bodies resulted in an estimated 446,819 emergency department visits over a 10-year span. The mean patient age was 7.2 years, and females made up the majority of cases (55.6%). Jewelry (most commonly, embedded earrings and beads) was the most common type of foreign object found, being responsible for 55.5% of emergency department visits. Other objects included the following [2] :
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Paper products - 7.1% of visits
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Pens and pencils - 4.1% of visits
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Desk supplies (erasers) - 3.7% of visits
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BBs or pellets - 3.5% of visits
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Earplugs and earphones - 3% of visits
A literature review by White et al on external auditory canal foreign bodies in pediatric patients found that the success rate for removal was greater for otolaryngologists managing a foreign body for which no previous removal attempt had been made than for otolaryngologists treating a foreign body that had already undergone a removal attempt by another health-care provider (92.9% vs 64.1%, respectively). The investigators suggested that this difference may be because, following a previous removal attempt, patients become less cooperative or complications, such as canal edema and bleeding, occur. In comparing foreign body removal by otolaryngologists to that by emergency departments and primary care physicians, the success rate was lowest for emergency departments, at 64.0%. [3]
In contrast, a retrospective study by Gupta et al of management of ear, nose, and throat foreign bodies in an Australian tertiary care hospital found a high rate of success in the removal of these foreign bodies by the emergency department staff. According to the report, the emergency department staff attempted foreign body removal in 89% of cases (the remaining cases having been referred to the otolaryngology team), with successful removal achieved in 78% of cases. This included removal in 86% of nasal cases, 72% of aural cases, and 67% of throat cases, with no major complications occurring. [4]
Clinical Presentation
History
See the list below:
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Most adults are able to tell the examiner that there is something in their ear, but this is not always true. For example, an older adult with a hearing aid may lose a button battery or hearing aid in their canal and not realize it.
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Children, depending on age, may be able to indicate that they have a foreign body, or they may present with complaints of ear pain or discharge.
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Patients may be in significant discomfort and complain of nausea or vomiting if a live insect is in the ear canal.
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Patients may present with hearing loss or sense of fullness.
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Rarely, hiccups or persistent cough may be the presenting complaint.
Physical
The physical examination is the main diagnostic tool.
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Physical findings vary according to object and length of time it has been in the ear.
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An inanimate object that has been in the ear a very short time typically presents with no abnormal finding other than the object itself seen on direct visualization or otoscopic examination.
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Pain or bleeding may occur with objects that abrade the ear canal or rupture the tympanic membrane or from the patient's attempts to remove the object.
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Hearing loss may be noted.
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With delayed presentation, erythema and swelling of the canal and a foul-smelling discharge may be present.
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Insects may injure the canal or tympanic membrane by scratching or stinging.
Causes
In some cases, a patient, caretaker, or sibling intentionally places an object in the ear canal and is unable to remove it. In other instances, insects may crawl or fly into the ear. Patients who have increased cerumen production are at higher risk for manipulation of the ear canal (thus traumatizing it) or inserting objects, in order to remove the cerumen.
A study by Celenk et al suggested that children with attention deficit hyperactivity disorder (ADHD) may be more inclined than other children to self-insert foreign bodies into the nose and ears. The study compared 60 pediatric patients with nasal or aural foreign bodies with 50 controls, with test scores indicating the presence of ADHD being significantly higher among the foreign-body patients aged 5-9 years than among the control subjects. [5]
A German study, by Schuldt et al, found a high prevalence of hyperkinetic disorders (14.1%), congenital malformations (50.8%), and psychological development disorders (52.7%) in children suffering from aural or nasal foreign bodies. [6]
A Japanese study, by Oya et al, found that the number of pediatric patients with aural or nasal foreign bodies tended to be higher during intervals of rainy weather, suggesting that this phenomenon results from children spending more time indoors on rainy days, with greater opportunity to put a small toy in their ear or nose. [7]
Differential Diagnosis
Abrasions to ear canal
Hematoma
Otitis media
Tumor
Cholesteatoma
Tympanic membrane perforation
Workup
No specific laboratory or radiologic studies are recommended. The physical examination is the main diagnostic tool.
Use an otoscope while retracting the pinna in a posterosuperior direction. A head mirror with a strong light source, operating otoscope, or operating microscope also may be used. Refractory objects may require extraction by an ear, nose, and throat (ENT) specialist.
Treatment & Management
No specific prehospital treatment exists other than transport to a hospital. Occasionally, treating significant pain or nausea may be necessary.
Patients in extreme distress secondary to an insect in the ear require prompt attention. The insect should be killed prior to removal, using mineral oil or lidocaine (2%). EMLA cream has also been reported as being effective to kill the insect as well as provide local anaesthesia. [8]
Methods of removal
Irrigation is the simplest method of foreign body removal, provided the tympanic membrane is not perforated. [9, 10] It can be accomplished using lukewarm water or saline for irrigation, with employment of a 20 or 50 cc syringe that has a 14- to 16-gauge plastic catheter attached. An electric ear syringe, available in some areas, may be very helpful for irrigation. [11] Use of the commercial product Waterpik is not recommended because the high pressure it generates may perforate the tympanic membrane. Irrigation with water is contraindicated for soft objects, organic matter, or seeds, which may swell if exposed to water.
Wearing a headlamp allows the practitioner to have both hands free. Suction is sometimes a useful means of foreign body removal. [9] Suction the ear with a small catheter held in contact with the object. It is helpful to trim the catheter at an angle to better conform to a rounded object. Using direct visualization and with the patient holding still, the object may be grasped with alligator forceps. It is sometimes possible to place a right-angled hook behind the object to pull it out. A hook can be formed with a 25-gauge needle to snag and remove a large, soft object such as a pencil eraser.
The bent end of a paperclip (one that has been unfolded and has the tip of the paperclip bent at a right angle) may also be used. The bent end is inserted in a parallel path past the foreign object and then rotated. The object is then withdrawn from the canal. Holding the paper clip with forceps adds stability.
Cyanoacrylate adhesive may be placed on the wooden end of a Q-tip and inserted to make good contact with the object. The Q-tip must remain on the object for at least 60 seconds to ensure that it has adhered before everything is removed as a unit.
Avoid any interventions that push the object in deeper.
The physician may need to sedate the patient to attempt removal of the object. Use mild sedation following a procedural sedation protocol.
See Ear Foreign Body Removal Procedures for more information.
Special instances
Cyanoacrylate adhesives (eg, Superglue) may be removed manually within 24-48 hours once desquamation occurs. Acetone or hydrogen peroxide may also be used to dissolve the bond to the skin. Insert cotton balls saturated with acetone into the external auditory canal and wait 10 minutes before removal. If adhesive touches the tympanic membrane, remove it carefully and refer the patient to an ENT specialist.
Remove batteries immediately to prevent corrosion or burns. Do not crush the battery during removal.
Consultations
Consult an ENT specialist if the object cannot easily be removed and consider an urgent consult if tympanic membrane (TM) perforation is suspected. (TM perforation may be considered if vertigo, nausea, or hearing loss is present.)
Medications
After the foreign body is removed, inspect the external canal. For most foreign bodies, no medications are needed. However, if infection or abrasion is evident, fill the ear canal 5 times/day for 5-7 days with a combination antibiotic and steroid otic suspension (eg, Cortisporin or Cipro HC).
