18 m/o with ear pain
Patient will present as → an 18-month-old with ear pain and otorrhea. Otoscopic examination reveals a small insect impacted in the ear canal, which is still moving. The tympanic membrane appears intact.
A foreign body in the ear is any object that gets stuck in the ear canal. This can include anything from small objects like beads and toys to insects and food particles
- Patients may be asymptomatic or present with otalgia, hearing loss, bleeding, and discharge from the ear
The two emergencies
- BUTTON BATTERY = EMERGENT REMOVAL. Do not irrigate. Do not delay. A battery in contact with moist tissue generates hydroxide ions and causes an alkaline (liquefactive) burn within about 2 hours, and the injury keeps progressing even after the battery is out. Result: canal necrosis, tympanic membrane perforation, ossicular destruction, facial nerve injury. Irrigating makes it worse — water completes the circuit and accelerates the burn. The same rule applies to a nasal button battery (septal perforation) and an esophageal one
- Live insect: KILL IT FIRST. Instill mineral oil, lidocaine, or alcohol to drown the insect before you try to remove it. A live insect thrashing against the tympanic membrane causes severe pain and can perforate it
Diagnosis is made by history and physical exam, with visualization of the foreign body
- Foreign bodies can sometimes be difficult to visualize, so a normal-appearing exam does not exclude their presence
- Always examine the other ear and the nose — children who put things in one orifice put things in others
Removal should be attempted under direct visualization using warm irrigation with a syringe or instruments like an alligator forceps or a right-angle hook
- Insects must be immobilized prior to removal ⇒ Drown insects with mineral oil or viscous lidocaine before attempting removal
- Irrigation of the external ear can be uncomfortable for a child. Aggressive flushing can cause perforation of the tympanic membrane, so caution is advised while irrigating
- After each flush, it is prudent to recheck the external canal for retained foreign body fragments, which can occur with an insect
- After irrigation, if the child is uncomfortable, consider treating with topical pain agents such as benzocaine-anti-pyrene
- Do NOT irrigate: a button battery, organic/vegetable matter (beans, seeds — they SWELL when wet), or any ear with a suspected tympanic membrane perforation
- Refer to ENT for a smooth round non-graspable object, an object touching the tympanic membrane, an uncooperative child, or after 2 failed attempts — every failed attempt traumatizes the canal, causes bleeding, and makes the next attempt harder. Procedural sedation or the operating room may be needed
Question 1 |
A 4 year-old boy presents with pain and irritation of his left ear. Otoscopic examination reveals an insect in the left auditory canal. The tympanic membrane is not completely visualized. Which of the following is the most appropriate initial step before the insect is removed?
Instillation of carbamide peroxide (Debrox) drops Hint: Carbamide peroxide is a cerumen softener for wax impaction. It does not immobilize an insect and is not used for foreign-body removal. | |
Irrigation with room-temperature saline Hint: Irrigation is avoided for organic foreign bodies such as insects, beans, or seeds, which can swell with water, and it should never be done when the tympanic membrane cannot be confirmed intact. | |
Instillation of 2% lidocaine solution Hint: Lidocaine does immobilize insects, but it should not be used when a tympanic membrane perforation cannot be excluded (here the TM is not fully visualized), because it can reach the middle ear and cause severe vertigo. | |
Polymyxin B drops delivered by ear wick Hint: Polymyxin B delivered by a wick treats otitis externa with canal edema. It has no role in foreign-body removal. | |
Instillation of mineral oil |
Question 1 Explanation:
A live insect in the ear canal should be killed or immobilized before removal, and the agent chosen depends on whether the tympanic membrane is known to be intact. Mineral oil fills the canal and immobilizes the insect, which is then removed with suction or forceps under direct visualization. It is safe even if the tympanic membrane turns out to be perforated.
Lidocaine also immobilizes insects, but because the tympanic membrane is not completely visualized here, a perforation cannot be ruled out, and lidocaine reaching the middle ear can cause a profound vestibular response with severe vertigo. Irrigation is avoided for organic foreign bodies, which can swell with water.
Lidocaine also immobilizes insects, but because the tympanic membrane is not completely visualized here, a perforation cannot be ruled out, and lidocaine reaching the middle ear can cause a profound vestibular response with severe vertigo. Irrigation is avoided for organic foreign bodies, which can swell with water.
Question 2 |
A frantic mother of a 2-year-old toddler reports her child put a small bead in his ear during playtime. She tried to remove it herself but was unsuccessful.Which of the following factors in this scenario most significantly increases the risk of complications?
The child is under 3 years old Hint: Young children are a common age group, but the act of tampering itself creates the most substantial risk. | |
The foreign object is an organic material (bead) Hint: While some objects (button batteries, insects) have risks unique to their type, the attempted removal is the more important concern. | |
The mother attempted to remove the object | |
Foreign body has been present for less than 24 hours Hint: Longer durations can increase otitis externa risks, but the immediate concern is damage from extraction efforts. | |
The child is uncooperative for an ear exam Hint: This makes management more challenging, but extraction without appropriate visualization creates greater potential harm. |
Question 2 Explanation:
Unskilled attempts at foreign body removal are the primary risk factor for complications. This can introduce the object further into the ear canal and cause trauma to delicate structures, creating the potential for ear canal laceration, perforation of the tympanic membrane, or middle ear damage.
There are 2 questions to complete.
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