Foreign Bodies of the External Auditory Canal

Introduction

The acute event resulting from entrapment of a foreign body in the ear canal will bring most patients to the attention of a physician, physician’s assistant, or nurse practitioner. Patients may be treated in a variety of settings including an emergency room, clinic, or office. It is important to note that different age- and gender-specific patterns emerge in describing the specific types of foreign bodies found within the external auditory canal. A recent review of the National Electronic Injury Surveillance System (NEISS), a database that tracks injuries caused by consumer products, revealed that children between the ages of 2 and 8 were the most common age group affected. Jewelry was by far the most common foreign body seen in the young population, with beads and earrings being the most frequently identified types. Among adults and senior citizens, the most common offenders were cotton swabs and first aid supplies. After ear cleaning, a person may realize that the cotton tip is no longer attached to the end of the applicator. Senior citizens are also uniquely vulnerable to the accidental insertion of disk batteries owing to altered cognition, reduced tactile sensation, and the more frequent use of hearing aids.

Adolescents and/or adults may become immediately aware that an object that they were using to clean or manipulate the ear has become dislodged and remains in the external auditory canal. The most common inorganic object creating this problem, as already stated, is the end of a cotton-tipped applicator. Similarly, other materials (e.g., facial tissue and paper) can be rolled in an elongated fashion and used to either probe, clean, or pack the ear. Institutionalized adults and children may use these materials instead of cotton-tipped applicators, medical packing, or earplugs. In this population, if drainage, infection, or odor has not developed, such material may be found only on routine physical examination.

Along with using instrumentation to clean their ears, adults also place objects in the ear canal for protection, including devices to minimize water exposure because of recurrent otitis externa or perforation of the tympanic membrane. Materials used for hearing protection can become lodged or break off and remain in the external canal. Examples of such products include silicone putty used for sound or water protection and Silastic occlusive plugs or foam inserts for sound protection. Again, patients become acutely aware of broken off materials remaining in the ear canal.

The list of objects that children put in their ears is endless. Unless a witness observes a child placing a foreign body in the canal, its presence may not be discovered until routine physical examination detects the object or problems arise because of its presence. Objects that occlude the ear canal can produce hearing loss. This is a common chief complaint in an aware child or adult. Inflammation caused by the foreign object may result in infection and drainage. Localized aural discharge, cellulitis of the concha and external meatus, or serosanguineous otorrhea would prompt further evaluation. Some materials are more difficult to extract from the ear canal. Once water enters the external canal, vegetable materials such as beans and peas can swell and cause obstruction, pain, and maceration. Other materials that have been found in the ear canal include small toys, beads, erasers, crayons, pits from fruit, disk batteries, nuts, and stones. Disk batteries should be removed as soon as possible to avoid the liquefaction necrosis that results when moisture and secretions permit the flow of electrons. Irrigation of the ear canal should be avoided to minimize the risk of generating an electric current. Similarly, unsuccessful attempts at removal of the battery that result in trauma and bleeding in the ear canal would also allow flow of current and thus lead to further tissue destruction.

Insects occasionally find their way into the ear canals of children and adults alike. These are usually flying insects, but crawling insects may also enter the canal, especially when a person is sleeping. Patients become acutely aware of such a situation because of the noise generated by the insect and the associated pain. Management in this situation becomes more urgent than that called for by inanimate objects.

Key Operative Learning Points

• 1.

  Aural irrigation to remove foreign bodies (other than insects) in the external auditory canal should be avoided because the object is rarely flushed out and skin maceration often results.

• 2.

  Firm, rounded objects are notoriously difficult to grasp and remove.

• 3.

  Live insects should be drowned with alcohol, mineral oil, or topical anesthetics (Pontocaine, Xylocaine).

• 4.

  A large nasal suction (10-12 French) device may make sufficient contact with the object to remove it from the canal.

• 5.

  Passing a right-angled hook parallel to the object and then beyond it allows optimal placement of instruments for extraction.

• 6.

  Injection of a local anesthetic followed by canal dilatation with progressively larger specula may facilitate removal of the foreign body.

• 7.

  Ease of extraction is directly proportional to the number of previous failed attempts.

Preoperative Period