Ear, Nose & Throat
A 7 year old boy is brought to the Emergency Department by his grandparents. They tell you he has placed a small beetle he found in the garden into his left ear. Using an otoscope you can see the insect moving near the tympanic membrane. What is your immediate management in this situation?
Answer:
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. Insects should be killed prior to removal, using mineral oil or lidocaine 2%.Foreign Body in Ear
Ear, Nose & Throat
Last Updated: 12th February 2021
Foreign bodies of the ear, which are relatively common in emergency medicine, are seen most often, but not exclusively, in children. 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. Various objects may be found in the ear, including toys, beads, stones, folded paper, and biological materials such as insects, food or seeds.
Clinical Features
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 realise it. 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. Patients may be in significant discomfort and complain of nausea or vomiting if a live insect is in the ear canal. Patients may present with hearing loss or sense of fullness.
Physical findings vary according to object and length of time it has been in the ear. 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 visualisation or otoscopic examination. 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. Hearing loss may be noted. With delayed presentation, erythema and swelling of the canal and a foul-smelling discharge may be present. Insects may injure the canal or tympanic membrane by scratching or stinging.
Methods of Removal
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. Insects should be killed prior to removal, using mineral oil or lidocaine 2%.
- Mechanical Extraction
- Forceps removal to grasp the object
- Hook removal to slide a hook behind the object and pull
- N.B. Avoid any interventions that push the object in deeper
- Irrigation
- N.B. Irrigation with water is contraindicated for soft objects, organic matter, or seeds, which may swell if exposed to water, and also if the tympanic membrane is perforated.
- Suction
- N.B. 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.
Indications for ENT referral
- The presence of a tympanic membrane (TM) perforation, contact of a foreign body with the tympanic membrane, or incomplete visualisation 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.
- Abandon attempts to retrieve a foreign body if complications arise. If the object migrates farther into the canal or if bleeding, oedema, 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.
Complications
- Canal abrasions
- Bleeding
- Infection
- Perforation of the tympanic membrane
- Retained foreign body with granuloma formation
Report A Problem
Is there something wrong with this question? Let us know and we’ll fix it as soon as possible.
Loading Form...
- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
