3.05 Foreign Body in Ear
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agk's Library of Common Simple Emergencies

Presentation
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Sometimes a young child admits to putting 
something like a bead or a bean in his ear, or 
an adult witnesses the act. Sometimes the 
history is hidden and the child simply presents 
with a purulent discharge, pain, bleeding or 
hearing loss. Most dramatically, a patient 
arrives at the emergency department panic- 
stricken because he feels and hears a bug 
crawling around in his ear.

What to do:
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- If there is a live insect in the patient's 
   ear, simply fill the canal with mineral oil 
   (e.g., microscope immersion oil). Lay the 
   patient on his side and drop the oil down 
   the canal while pulling on the pinna to 
   remove air bubbles. This will suffocate the 
   intruder, so it can be removed using one of 
   the techniques below. The least invasive 
   methods should be tried first.
- Water irrigation is often effective for 
   safely removing a foreign body that is not 
   tightly wedged in the ear canal. This can be 
   accomplished with an irrigation syringe, 
   Water Pik, or a standard syringe and scalp 
   vein needle catheter cut short (see [Cerumen 
   impaction]). Tap water or normal saline at 
   body temperature can be used to flush out 
   the foreign body by directing the stream 
   along the wall of the ear canal and around 
   the object, thereby flushing it out.
- If the object is light and moves easily, 
   attempt to suction it out with a standard 
   metal suction tip or specialized flexible 
   tip, whichever can make a vacuum seal on the 
   foreign body.
- If a hard or spherical foreign body remains 
   in the ear canal, and the patient is able to 
   hold still, you can attempt to roll it out 
   with a right-angle hook, ear curette or wire 
   loop. Stabilize the patient's head and fix 
   your hand against it, holding the instrument 
   loosely between your fingers to reduce the 
   risk of injury should the patient move 
   suddenly. Under direct visualizaton through 
   an ear speculum, slide the tip of the 
   right-angle hook, ear curette or wire loop 
   behind the object (rotate the hook to catch) 
   and then roll or slide the foreign body out 
   of the ear.
- Alligator forceps are best for grasping soft 
   objects like cotton or paper. The wooden 
   shaft of a long cotton swab can be armed 
   with one drop of cyanoacrylate (Super Glue) 
   to adhere to a smooth, clean, dry foreign 
   body. Touch it to the foreign body, hold for 
   ten seconds, then pull. Try not to glue the 
   stick to the wall of the ear canal, but if 
   you do, be thankful for cerumen (above).

What not to do:
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- Do not use a rigid instrument to remove an 
   object from an uncooperative patient's ear. 
   An unexpected movement might lead to a 
   serious injury of the middle ear.
- Do not attempt to remove a large bug or 
   insect without killing it first. They tend 
   to be wily, evasive little creatures well 
   equipped for fighting in tunnels. In the 
   heat of battle, the patient can become 
   terrorized by the noise and pain and the 
   instrument that you are using is likely to 
   damage the ear canal.
- Do not attempt to irrigate a tightly wedged 
   bean or seed from an ear canal. The water 
   may cause the bean to swell.
- Do not attempt to remove a large or hard 
   object with bayonet or similar forceps. The 
   bony canal will slowly close the forceps as 
   they are advanced and the object will be 
   pushed farther into the canal. Alligator 
   forceps are designed for the canal, but even 
   they will push a large, hard foreign body 
   farther into the ear.

Discussion
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The cutaneous lining of the bony canal of the 
ear is very sensitive and is not much affected 
by topical anesthetics. If your patient is an 
uncooperative child, you might make one 
cautious attempt at removal under conscious 
sedation (see below) with firm head restraint, 
but your most prudent strategy is to schedule 
elective removal under general anesthesia by a 
specialist.

Irrigation techniques and the use of the ear 
curette can also be effective in removing 
excess cerumen from an ear canal (see [Cerumen 
impaction]). Whenever an instrument is used in 
an ear canal it is a good idea to warn the 
patient or parents beforehand that there may be 
a small amount of bleeding.

There should be no delay in removing an 
external auditory canal foreign body when there 
is an obvious infection or when the foreign 
body is a disk battery. On contact with most 
tissue, this type of alkaline battery is 
capable of producing a liquefactive necrosis 
extending into deep tissues. After removal, the 
canal should be irrigated to remove alkalai 
residue. Styrofoam beads can be instantly 
dissolved by spraying them with a small amount 
of ethyl chloride. Lidocaine has been shown to 
make cockroaches exit the ear canal, but this 
may be unpleasant for the patient. On telephone 
consultation, patients can be instructed to use 
cooking or baby oil to kill an intra-aural 
insect, which can then be removed in a 
subsequent office visit.

Complications of foreign body removal include 
trauma to the skin of the canal, canal 
hematoma, otitis externa, tympanic membrane 
perforations, ossicular dislocations and facial 
nerve palsy.

References
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- Bressler K, Shelton C: Ear foreign-body 
   removal: a review of 98 consecutive cases. 
   *Laryngoscope* 1993;103:367-370.
- O'Toole K, Paris PM, Stewart RD, Martinez R: 
   Removing cockroaches from the auditory 
   canal: controlled trial. *N Eng J Med* 
   1985;312:1197.
- Leffler S, Cherney P, Tandberg D: Chemical 
   immobilization and killing of intra-aural 
   roaches. An in-vitro comparative study. *Ann 
   Emerg Med* 1993;22:1795-1798.
- Brunskill AJ, Satterwaite K: Foreign bodies. 
   *Ann Emerg Med* 1994;24:757.
- Skinner DW, Chui P: The hazard of button- 
   sized batteries as foreign bodies in the 
   nose and ear. *J Laryngol Otol* 1986; 
   100:1315- 1319.

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