Aural Foreign Body removal
Dec 03, 2024
Case 1: Is that a Spider in her ear?
"Please help, there's something running around in my ear!" That was the triage. The patient woke with the feeling that something was crawling around in her ear. There were episodes where she became severely distressed.
I remember, as a child, my father telling me the fable of the lion, the king of the jungle, brought down by a fly in its ear. The incessant buzzing, driving the lion to insanity!
Case 2: "Sometimes she hears and others she doesn't".
A 7 yo is brought in with fluctuations in the hearing (from perfect to significantly reduced) of her left ear, for the last 3 days. The patient complaied of feeling something in the ear, although denied putting anything in the ear.
Foreign body in the Ear: An Approach.
The key is the right approach and the right equipment. The aim here is to make our first attempt the only attempt needed. This is because we know that multiple attempts are associated with increased risk of damage to the ear canal.
Things that increase the degree of difficulty include:
- Non-compliant patients, due to pain or movement. This especially applies to the very young, where sedation may be required, to avoid potential trauma to the ear canal, that may occur with patient movement.
- Foreign bodies such beads which are spherical in shape, not allowing easy grasping.
- Foreign bodies on the tympanic membrane or obscuring the tympanic membrane. These type of foerign bodies increase the risk of tympanic membrane damage, secondary to attempted blind retrieval.
My rules for attempting to remove an aural foreign body
- The patient has to be cooperative, so there is little chance of movement that might result in trauma
- The tympanic membrane must be visible, so that we do not damage this, especially when attempting direct removal.
- Procedure is performed is under direct visualisation, so that the foreign body is not pushed further into the ear and onto the tympanic membrane.
- I have the right equipment to attempt removal.
Equipment
I do NOT use any technique in the ear that is blind, or that requires us to move past the object and inflate a ballon to remove it. An example of this is the Katz extraction catheter. There are good for nasal foreign bodies, but not for aural ones.
A further technique I use is skin glue and a ‘swab’ is useful for removing shperical objects.
Take a swab and remove much of the cotton fibres from the tip, to reduce the bulk to be introduced into the ear. Then use a small amount of simple skin glue on the tip. Wait a few seconds then insert into the ear and remove the object. I use an ear speculum if possible. it provides a guide and allows insertion under visualisation. It also minimises the risk of glueing the swab stick to the ear canal.
Button Batteries in the Ear
A magnet (a telescopic magnet pen is shown here) may beused to remove small button batteries. Never irrigate the ear if there is a button battery, as there is a risk of liquefactive necrosis.
Removal of Insects
If the insect is alive, it should first be killed, as it is almost impossible to remove a live insect. Trying to suction or grasp, the insect doesn’t work as it moves. There is also the risk of trauma to the canal or tympanic membrane.
The best approach to killing moving insects includes:
- Lignocaine immersion: 1% or 2 % lignocaine can be used. It takes less than a minute to kill the insect, and may also provide some analgesic effect for the patient
- Other recommended compunds such as mineral oil, or liquid alcohol are very difficult to find in the emergency department.
- Water immersion doesn’t appear to be effective.
Case 1: What happenned?
The initial otoscopic examination of the ear, revealed a lot of wax and nothing else. We did not have cerumen removal equipment and used a small soft suction catheter under visualisation to disloge and remove some wax.
Following this, we could see an intact tympanic membrane, but nothing else, although the patient was agitated saying she could feel it moving inside.
The next step was syringe irrigation of the ear, with room temperature water. Nothing but a small amount of wax was washed out.
A further look in and THERE IT WAS! We could see multiple legs……..and were they scopulae (the hairs on spiders’ legs)? No body could be seen. This was potentially a spider, quite large.
1% lignocaine was instilled in the ear for a minute and then we attempted to irrigate and then suction, but were not able to remove, nor able to kill the intruder. There was no mineral oil or liquid alcohol in the department.
Following one more unsuccessful attempt, we got the assistance of ENT, who had all the right equipment to remove it.
Case 2: What happenned?
The initial otoscopic examination showed a large bead in the ear, which had a central hole (probably used in a necklace). The patient then remembered putting the bead in the ear. The patient was very cooperative and an attempt was made to insert a right angle probe into the central hole of the bead, but this was unsuccessful. As an aside, the patient’s fluctuation in hearing was explained, by the bead’s rotation ie., when the central hole aligned with the tympanic memberane and the external canal, the patient could hear, but when the bead rotated, so that the hole was not aligned, the hearing decreased.
The technique of ‘swab and skin glue’ described above was used successfully to remove the bead, with very gentle pressure (the swab just touched the bead), to minimise any chance of pushing of the bead further into the canal. The tympanic membrane was intact.
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