External auditory canal foreign bodies are most commonly seen in children under 7. Children with conditions that cause irritation of the ear such as otitis media or cerumen impaction are at higher risk. Additional risk factors include pica and ADHD. Most often, the foreign body is on the right side due to the handedness of the child. The most common foreign bodies found in the external auditory canal include beads, pebbles, pieces of paper, toys, popcorn kernels and insects.

Frequently, foreign bodies of the external auditory canal are asymptomatic and found during routine otoscopy. However, they may cause impaired hearing, pain, purulent or bloody drainage from the ear or chronic cough/hiccups (which is rare).

Timing of removal is dependent upon the type of foreign body

Button batteries should be removed immediately, as the electrical current from the battery can cause destruction of the ear canal skin, tympanic membrane, facial nerve and ossicles. They also cause local pressure necrosis.

Insects should be removed urgently because they can cause damage to the tympanic membrane and middle ear as the insects move in the canal.

Foreign bodies that can penetrate the tympanic membrane and cause damage to middle ear structures should also be evaluated immediately. Such foreign bodies include cotton applicator tips, pencil points, hair pins. A patient with a penetrating foreign body who exhibits vertigo, ataxia, facial nerve damage, or hearing impairment should be urgently evaluated by an otolaryngologist.

Referral to a subspecialist such as an ENT depends upon the type of foreign body, tools available, type of assistance available and behavior of the child. Patients with button batteries, penetrating foreign bodies or foreign bodies with evidence of injury to the ear canal, tympanic membrane or middle ear should be seen by an otolaryngologist. Foreign bodies that may require ENT referral include glass or other sharp edged foreign bodies, hard spherical foreign bodies that are wedged in the canal and foreign bodies touching the tympanic membrane as these have been shown to be difficult to remove without the help of a sub specialist.

Techniques for removal

Irrigation

Can be used for small, inorganic items. Contraindicated in patients with PE tubes or with perforated tympanic membranes. Should not be used to remove vegetable matter or button batteries. Organic matter may swell with water, which leads to further obstruction. Using water with button batteries increases risk of chemical injury.

  • The patient should be in the supine position with affected ear up. Irrigate with body temperature water until foreign body is expelled. May still require instrumentation to grasp the foreign body if it reaches the auditory meatus but is not expelled.

Instrumentation

Commonly used instruments for foreign body removal include an ear speculum, forceps, or curettes. The use of instrumentation can be painful and may be difficult in patients who are unable to remain still for the procedure.

  • soft objects with irregular edges typically can be grasped with forceps
  • round objects are often removed by extending an instrument such as a curette beyond the object then slowly withdrawing it from the ear canal

Special consideration: Insects

Live insects should be killed with mineral oil or 1% lidocaine prior to removal to prevent insect movement during removal. Mineral oil is preferred because though both kill the insect, lidocaine may cause it to writhe and squirm which is, needless to say, uncomfortable for the patient.

Complications

Common complications include laceration or abrasion of the ear canal, which occurs in up to 50% of patients. Additionally, patients are at risk for tympanic membrane perforation and middle ear damage during removal.

A study by Thompson, Wein and Dutcher in 2003 looked at patients presenting to an emergency department over a 3 year period with a chief complaint of external auditory canal foreign body. Of the 162 patients seen with this chief complaint, about 33% required ENT referral, 81% of them after unsuccessful removal attempt in the ED. They found that ED removal was successful for irregularly shaped, soft objects with easily graspable parts such as paper, small toys and insects. Firm, smooth and round objects such as beads, beans, stones and popcorn kernels were more likely to require ENT referral. A wide variety of removal techniques were used in the ED including irrigation, forceps, suction and curette. Overall complication rate was about 1% with 2 patients developing tympanic membrane perforation after multiple attempts at foreign body removal ultimately requiring removal by an ENT (Thompson, Wein, Dutcher 2003).

Another study by Marin and Trainor examined the medical records of patients presenting to a pediatric emergency department with a chief complaint of “foreign body in the ear” between November 1998 and October 2003. In this study, there were 254 foreign body removal attempts in 250 children over 5 years. About 80% of foreign bodies were successfully removed in the ED using a variety of different techniques. Twenty percent of cases were referred to ENT, and 6% required removal in the OR. Complications included canal bleeding and/or laceration in 29 patients. One patient developed a perforation of the tympanic membrane with ossicle damage. Risk of complications increased as number of attempts at removal increased as well as the number of instruments used for removal increased (Marin, Trainor 2003).

References

Isaacson A, Aderonke O. Diagnosis and management of foreign bodies of the outer ear. In: UpToDate, Stack A, Wiley J (Ed), UpToDate, Waltham, MA. (Accessed on January 13, 2017.)

Marin J, Trainor J. Foreign Body Removal from the External Auditory Canal in a Pediatric Emergency Department. Pediatric Emergency Care 2006;22(9):630-634.

Thompson SK, Wein RO, Dutcher PO. External Auditory Canal Foreign Body Removal: Management Practices and Outcomes. Laryngoscope 2003;113:1912-1915.