The management of foreign bodies located in the external auditory canal can be nuanced, and for some medical professionals, may be intimidating if not performed frequently. This activity reviews the anatomy of the external auditory canal, the technique for removing external auditory canal foreign bodies. It highlights the interprofessional team's role in ensuring patient comfort and appropriate positioning during the removal of the foreign body.
Identify potential contraindications to the removal of a foreign object from the external auditory canal.
Summarize objects that require emergent removal from the external auditory canal.
Describe the techniques used for the removal of foreign bodies from the external auditory canal.
Outline the importance of collaboration and coordination amongst the interprofessional team to facilitate safe ear foreign body removal to minimize complications and improve patient outcomes.
Many physicians who work in acute care settings, especially those who see pediatric patients, will encounter patients with a foreign body in the external auditory canal (EAC). Depending on the specialty and location of practice, some doctors will encounter this condition more frequently. This section aims to give physicians an understanding of the scope of this condition and some methods for managing a foreign body in the external auditory canal.
While more common in pediatric patients, adults can also present with a foreign body, ranging from insects to hearing air pieces, in the external auditory canal. The most commonly removed foreign bodies include beads (most common), paper/tissue paper, and popcorn kernels. These combine to account for just over half of the foreign bodies removed in one study. There may also be a slight male predominance, but not all studies have shown this. Certain types of foreign bodies, such as button batteries, do require urgent removal. However, for most inorganic objects, there does not appear to a significant issue with the length of time the foreign body has been in the external auditory canal before attempted removal, though in prolonged retention of foreign bodies, there can be significant swelling of the EAC, which may increase patient discomfort upon attempted removal.
Anatomy and Physiology
The external auditory canal and the outer layer of the tympanic membrane form from the first branchial cleft. The medial two-thirds are bone covered with stratified squamous epithelial skin, while cartilage makes up the outer third. The skin lining the cartilaginous portion of the external auditory canal has hairs and modified sweat glands that secrete cerumen (earwax). Innervation of the external auditory canal is mostly from cranial nerves V3 (mandibular branch) and X. Cranial nerves VII and IX have lesser contributions. The external auditory canal is nearly straight in children, becoming adult-sized, approximately 2.5 cm long, at about nine years old. It becomes more sigmoid in adults with the cartilaginous portion angling posteriorly and superiorly with the bony portion angling anterior inferiorly. As a result, in adults, pulling the helix posterior and superior straightens the external auditory canal and allows for better visualization of the tympanic membrane. Of significant importance for foreign body management, the external auditory canal has two natural narrowings. The first narrowing is at the bony-cartilaginous junction, and the other is just lateral to the tympanic membrane. Another important anatomic feature of the tympanic membrane is the potential blind spot in the tympanic sulcus generated as the tympanic membrane slopes obliquely away from the external auditory canal as it goes inferiorly.
Indications for this procedure include the presence of a foreign body in the external auditory canal, the appropriate equipment for removing a foreign body in the external auditory canal, and a cooperative patient (or the ability to sedate or restrain the patient safely).
Contraindications to removing a foreign body from the external auditory canal are related to the patient's cooperativeness, location of the object in the external auditory canal, lack of appropriate tools for removing the foreign body, and the type of foreign body may make methods of removal inappropriate.
An uncooperative patient and the inability to safely sedate an uncooperative patient are contraindications to attempting foreign body removal.
A foreign body lodged against the tympanic membrane, or a foreign body that cannot be grasped easily, such as a hard spherically shaped object, may require specialized equipment not readily available. Specific methods might also be contraindicated in certain situations. For example, irrigation would be contraindicated with a suspected tympanic membrane perforation, removal of organic material, or removal of a battery. It may also be contraindicated if the suspected foreign body is made of a spongy material that may swell and enlarge if hydrated.
Multiple options exist for the removal of external auditory canal foreign bodies. Which piece of equipment to use will be influenced by the type and shape of the foreign body, its location, and the patient's cooperativeness.
Commonly used equipment include alligator forceps, cup forceps, right-angle hook, balloon catheters, such as a Fogarty catheter, or Rosen needle. The use of fine, sharper instruments is greatly facilitated by binocular microscopy.
Irrigation is another common option, and this can be performed by attaching an angiocatheter to a 20 mL to 30 mL syringe. Alternatively, modifying a butterfly catheter by cutting off the needle and then attaching the remaining tubing to the syringe. Great care must be taken with blind irrigation as an unknown tympanic membrane perforation may exist. Some authors advise against the irrigation of the EAC unless the tympanic membrane can be visualized to ensure it is intact.
Suction is also an option and usually is performed with a Frazier suction under microscopic guidance.
Another potential method uses cyanoacrylate (superglue) or tissue glue applied to the blunt end of a cotton-tipped applicator and then placed against the foreign body, so the glue adheres to it, and both the foreign body and applicator can be removed from the external auditory canal together.
In a cooperative patient, it is possible to remove a foreign body from the external auditory canal by a single provider. Depending on how cooperative the patient is, one or more assistants may be required to maintain the patient in the proper position and keep the patient still. This is especially common in pediatric patients.
Evaluation should include noting any injury to the external auditory canal and tympanic membrane before removal attempts. The patient's hearing should also be assessed, especially if there is suspicion for tympanic membrane injury/perforation or middle ear injury once the foreign body is removed. If the patient complains of hearing loss before the foreign body is removed, audiometry or tuning fork testing should be used to ensure an appropriate conductive loss is demonstrated. If the hearing loss is greater than expected, or a sensorineural hearing loss is encountered, the patient should be urgently referred to an otolaryngologist for evaluation and removal, likely in the operating room.
Patient positioning is important. Cooperative patients can either sit or lie down with the affected ear turned towards the provider. For younger children, there are several options for positioning. The patient can sit in the parent’s lap with the parent holding the patient’s body with one hand and the other around the head with the head turned. The patient can also lie down, either supine or prone, on the stretcher with their head turned.
Before beginning the procedure, the physician should determine how many attempts will be made (usually only one or two) and, if planning more than one attempt, what technique should be used for the subsequent attempt. If unsuccessful after one or two attempts, further attempts should be aborted, and the patient should be referred to an ear, nose, and throat (ENT) specialist. Consider examining the contralateral ear and nose for other foreign bodies as well, particularly in children.
These are typically used in conjunction with the operating head of an otoscope but can also be used with the diagnostic head. Binocular microscopy is ideal, though it may not be available in all settings. The pinna should be retracted, and the object in the ear canal visualized. When using forceps, the foreign body can be grasped and removed. Both curettes and right-angle hooks should be gently maneuvered behind the foreign body and rotated, so the end is behind it, which can then be pulled out.
This can be performed with either an angiocatheter or a section of tubing from a butterfly syringe. Using body temperature water, retract the pinna, and squirt water superiorly in the external auditory canal, behind the foreign body, which will then be washed out of the canal.
This should be performed with a suction tipped catheter with a thumb-controlled release valve, such as a Frazier tip. Insert the suction against the foreign body under direct visualization, activate the suctions, remove the object, and maintain suction until the foreign body is completely out of the external auditory canal.
Apply a small amount of cyanoacrylate or skin glue to the blunt end of a cotton-tipped applicator. Once the glue is tacky, insert it against the foreign body under direct visualization and hold it in place until the glue dries. Once the object is secured onto the applicator, it can be removed by removing the applicator.
The first step is to kill the insect, allowing the patient to be more comfortable and allow for the removal of the insect. There are multiple recommended agents for killing the insect. Studies indicate that mineral oil is the most effective, followed by lidocaine. Both can be instilled in the external auditory canal, and once the insect is neutralized, it can be removed by any of the above methods. In practice, lidocaine offers the advantage of anesthetizing the EAC as the insect struggles, potentially scratching the EAC and causing pain.
The most common complications from foreign bodies in the external auditory canal and attempts to remove them include excoriations and lacerations of the external auditory canal. As a result, it is important to document a pre-removal and post-removal exam, noting the presence of any pre-removal injuries. These typically heal rapidly by keeping the external auditory canal clean and dry. Antibiotic eardrops can be considered as well. Much rarer and much more serious foreign body removal complications include tympanic membrane perforation or ossicular chain damage. These are potentially devastating and should be avoided at all costs. If the physician is unable to, or uncomfortable with, removing EAC foreign bodies, then the patient should be referred to an otolaryngologist.
Physicians involved in acute patient care can expect to manage patients with a foreign body in the external auditory canal during their careers. As such, it is important to recognize both provider skill and equipment limitations. The type and location of the object in the external auditory canal, along with the patient's ability to cooperate, are the key factors in determining whether an attempt should be made. Referral to a specialist or a location where sedation can be performed is recommended if the removal is not practical after the initial evaluation. In general, complications tend to be minor and easily managed.
Enhancing Healthcare Team Outcomes
Successful removal of an ear foreign body requires a cooperative patient and may require the assistance of family members as well as other medical team members. Patient positioning and a well thought out plan are keys to the success of the procedure. Explaining to patients and family what will happen and gaining their cooperation is important. Involving family members and/or staff members for positioning can be very helpful. Another consideration is the use of medications for anxiolysis or procedural sedation to facilitate patient cooperation. This requires appropriate ancillary staff, such as nursing for intravenous line placement and medication administration and possibly anesthesia or respiratory therapy to assist in airway monitoring. With appropriate team coordination, this procedure can be performed safely and rapidly with low risk for complication and minimal stress for the patient. All members of the interprofessional team, most notably clinicians (including PAs and NPs) and nurses, should be able to identify the problem, assist experienced hands in foreign body removal, or know when to refer the patient in more complicated cases. This will result in better patient outcomes. [Level 5]
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Contributed by Seth Lotterman, MD
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