Don’t Be Tone Deaf—Removal of Aural Foreign Bodies

“Aural foreign bodies can present in all ages, but they are most common in children under the age of eight…”

CASE

An otherwise healthy 3-year-old boy presented to the emergency department, accompanied by his father, for concern of aural foreign body.  The patient was playing outside near his family’s gravel driveway and the father witnessed him place a pebble in his ear. The patient denied pain. Vital signs were within normal limits. On examination, the patient was well appearing. On otoscopic exam, a small pebble was noted in the external auditory canal of the right ear. There was some slight surrounding erythema. The tympanic membrane (TM) was intact. The left ear, nares, and throat were unremarkable and without additional foreign bodies. There were no signs of trauma to the head. Neurologic exam was intact.

 

DIAGNOSIS

Aural foreign body (FB)

 

DISCUSSION

Presentation & Exam

Aural foreign bodies can present in all ages, but they are most common in children under the age of eight. Sometimes, the placement is witnessed by an adult. Other times, it is noted by chance at a child’s annual well visit. Children old enough to express themselves may tell adults about the FB or report pain. However, other presentations include tugging at the ear, irritability, decreased hearing, otorrhea, otitis, or chronic coughing or hiccups. The foreign bodies are most commonly beads, plastic toys, pebbles, insects, paper, popcorn kernels, other food or organic/plant materials, and button batteries, amongst other items. It is important to examine the contralateral ear, as well as the nares and oropharynx for other potential foreign bodies. On exam, the position of the object in relation to the TM should be noted, as should any signs of trauma, excoriations, or lacerations. Ulceration, swelling, or dark otorrhea may indicate a caustic FB, such as a battery. Penetrating foreign bodies may be associated with classic signs of basilar skull fracture, including raccoon eyes or Battle’s sign. Organic materials such as beans, rice, or other foods, can absorb moisture and swell over time, creating a more stubborn obstruction.

 

ED Management

Objects that require urgent removal are button batteries, insects, penetrating foreign bodies, and foreign bodies associated with a perforated TM. For button batteries and penetrating foreign bodies, immediate otolaryngologist (ENT) consultation is advised. For other types of “difficult” foreign bodies, immediate or expedited referral to ENT is recommended. This includes foreign bodies that already have associated trauma to the canal, objects pressed against the TM, objects with sharp edges such as glass, objects that are tightly wedged in the ear canal, and any object that the ED clinician has failed to remove. Aside from insects, button batteries, and penetrating foreign bodies, most aural FBs can otherwise be referred for expedient outpatient ENT follow up if they are unable to be safely removed in the ED. For these patients, provide otic antibiotic drops to avoid otitis externa until the patient can see ENT for definitive management.


A variety of techniques for foreign body removal exist, and supplies available will vary between practice environments. The first attempt at removal is the most likely to be successful, and each subsequent attempt can cause pain and potentially damage to the ear. Set up and proper positioning is key. Certain shapes, textures, or types of objects may be more amenable to certain methods of removal than others. If the FB is an insect, euthanize it prior to removal with mineral oil, 1% lidocaine, or ethanol.

Figure 1: Instruments commonly used for removal of aural foreign body.

From left to right: L-shaped hook, Rosen needle, wax curette, ring curette, crocodile forceps, Frazier catheters of varying sizes, sucker connecter with finger hole, and refashioned hypodermic needle.

Taken from “Aural foreign body removal: there is no one-size-fits-all method” [3]

Setup

  • The parent holds the child to their chest, with the child’s head resting against the chest and his/her legs around the parent’s waist.

  • The parent should wrap his/her arms around the child, both to support the child’s body and head and to draw his/her head tightly into the parent’s chest.

  • Additional staff may be needed to immobilize the child’s arms.

  • Consider intranasal midazolam for anxiolysis.

  • If a child remains difficult to immobilize, his or her head movement risks damage to the structures of the ear. In this instance, conscious sedation or general anesthesia may be necessary.

Removal Techniques

  • Manual Instrumentation

    • Use alligator forceps, L shaped hooks, or a variety of available curettes (see Figure 1).

  • Lasso Technique

    • Create a lasso by tying a loop of non-absorbable suture to a ring curette. Loop the lasso around the FB and tighten the loop to remove the FB (see Figure 2).

    • Good for FBs without surrounding space in which to maneuver a removal device, or FBs that are too smooth to grasp with removal device.

Figure 2: Lasso technique for foreign body removal

Taken from “Aural foreign body removal: there is no one-size-fits-all method” [3]

  • Skin Glue

    • Apply Dermabond to the wooden end of a long, cotton-tipped applicator.

    • Place Dermabond end against FB. Let dry for 30 seconds.

    • Be mindful to not get Dermabond elsewhere in the ear, especially on the TM.

    • Good for FBs without surrounding space in which to maneuver a removal device, or FBs that are too smooth to grasp with removal device.

  • Irrigation

    • Use warmed (body temperature) water. Use an angiocath to flush out or float the object.

    • Do not use for button batteries, organic objects that could expand when wet, or with a perforated TM.

  • Suction

    • Employ low continuous suction with Schuknecht or Frazier catheter (see Figure 1)

    • Good for insects, tissue paper, cotton.

After successful removal, re-inspect the ear canal for signs of damage and to ensure the entire FB has been removed.

CASE RESOLUTION

The pebble in the patient’s external auditory canal was small and was not wedged tightly. Thus, warmed sterile water was used to float the foreign body to the level of the tragus, where it was digitally removed. On repeat examination, the canal and TM were intact. There were no lacerations or abrasions. The patient was discharged.


TAKE-AWAYS

  • Aural foreign bodies present predominantly in children and range from beads to organic objects to insects.

  • Batteries and penetrating foreign bodies require ENT consultation.

  • Insects must be removed immediately, as must any FB involving a perforated TM.

  • Many techniques for removal exist, and choice of technique should be tailored to the type and position of the FB.

  • Many types of FBs can be safely discharged with close ENT follow-up and removal in the outpatient setting, if emergency department removal is unsuccessful.

Author: Alexandra Pusateri, MD, is a current second-year resident at Brown Emergency Medicine Residency.

Faculty Reviewer: Michelle Myles, MD, is an assistant professor and clinician educator at Brown Emergency Medicine.

REFERENCES

 Ansley JF, Cunningham MJ. Treatment of Aural Foreign Bodies in Children. Pediatrics. 1998;101(4):638-641. doi:https://doi.org/10.1542/peds.101.4.638

Singh GB, Sidhu TS, Sharma A, Dhawan Ru, Jha SK, Singh N. Management of aural foreign body: an evaluative study in 738 consecutive cases. American Journal of Otolaryngology. 2007;28(2):87-90. doi:https://doi.org/10.1016/j.amjoto.2006.06.018

Ng TT. Aural foreign body removal: there is no one-size-fits-all method. Open Access Emergency Medicine. 2018;Volume 10:177-182. doi:https://doi.org/10.2147/oaem.s17885

Thabet MH, Basha WM, Askar S. Button Battery Foreign Bodies in Children: Hazards, Management, and Recommendations. BioMed Research International. 2013;2013:1-7. doi:https://doi.org/10.1155/2013/846091

Heim SW, Maughan KL. Foreign bodies in the ear, nose, and throat. Am Fam Physician. 2007;76(8):1185-1189.

ENT, Fast Track, Pediatrics, ProceduresAlexandra Pusateripediatric EM, fast track, proceduresComment