External Auditory Canal Foreign Body
2006/07/25
R3 石堅
INTRODUCTION1,2,4,6
 Frequent in ER(57~68.4%) or ENT clinics(31.6%).
 Ear FBs were the commonest (67%) of the FBs in ENT fields.
 Referred to Otolaryngologists: patient with previous unsuccessful FB removal.
 Few studies or literature regarding auditory FBs and their appropriate management.
 Not always an easy task.
 A quick and atraumatic removal in a child remains a major challenge today.
 A simple problem can become a significant morbidity and financial cost.
HISTORY / SYMPTOMS
AND SIGNS1,3,8
 A patient, caretaker, or
sibling intentionally
places an object in the
ear canal.
 Local pain(47%), verbal
admission by the child
(33.3%), incident
witnessed by the caregiver (6.8%), bleeding
(4.3%), discharge (0.9%), tinnitus (2.6%),
fever (1.8%), others (4.2%).
 Rare: cough, nausea
 Delayed presentation: foul-smelling discharge.
 Repeated foreign body presentation in the
young child: possible Munchausen by proxy
syndrome (exaggeration or fabrication of
illnesses or symptoms by a primary caretaker).
Causes8
 Irritation of preexisting otologic diseases
 cerumen impaction, otitis externa / media.
 Mental retardation, curiosity, accidental placement,
fun-making.
 Adult: picking ear, parts of H.A. (eg. button battery).
 Insects.
Differential diagnosis3,8
Abrasions to ear canal, Cerumen impaction, Hematoma,
Otitis externa, Tumor, Tympanic membrane perforation.
Incidence 1,4,5,6,7,8,9
 0.74% of all ENT diseases.
 1~91 years old.
 mean age:16.8 y; median age:8~9 y.
 80%: < 8y
 1~2y: 42%; 3~5y: 35%
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 highest incidence: 0~6y
Male:female ≒ 1:1
(Japan = 3:2; Singapore = 2:1)
Right:Left ≒ 1:1
(Bilateral: 0.8%)
Peaking: during July ~ August, organic FBs.
Treated within 24hr: 46~92%; 15% within 3days, 8% >1week.
Incidentally finding: 5%.
Previous attempts: 46~48%.
Organic : inorganic = 4:6
Suburb > downtown
Types of FBs1,2,6
Overall (1~91y)
Pediatric patient
FB type of the
patients
Remove FB under
direct vision.
Firm, round FBs were removed more successfully under
otomicroscope.
Location
 Lateral 1/3 v.s. medial 2/3 of the EAC.
 EAC narrows at the junction of cartilaginous and osseous portions.
 Potentially painful and traumatic: the skin overlying the periosteum is exquisitely tender,
highly vascular, and not much affected by topical anesthetics.
MANAGEMENT6,8,9
 Experience and skills of the Otolaryngologists.
 Seen on directed vision (90.6%)
 The type, shape, size of FB, condition of the EAC
and visibility of the TM.
 Head mirror with a strong light source, otoscope, ear speculum.
 Instrumentation: tip suctions, alligator forceps, Hartman forceps, ear curette, wire loops,
right-angle ball hooks.
 Stabilize the patient's head, fix your hand against it, holding the instrument loosely to
reduce the risk of injury should the patient move suddenly.
 Alligator forceps will push a large, hard foreign body farther into the ear.
 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.
 Live insects:
 Quite painful, significant amount of physical and emotional distress.
 Initial priority: to kill or immobilize the insect.
 mineral oil: more effective than lidocaine for immobilizing cockroaches.
 Subsequent microscope examination: to be sure no insect anatomic parts left
 remaining barbed appendages  delayed EAC inflammation.
 Aural irrigation
 Nonimpacted, relatively small FBs.
 The integrity of the tympanic membrane must be established by pneumatoscopy before
irrigating.
 Warm solution at body temperature.
 Irrigation syringe, standard syringe and scalp vein needle catheter cut short.
 Hygroscopic objects: vegetables, beans, food matter.
 Swell with subsequent greater EAC impaction on contact with moisture.
 Indications for otomicroscope.
 Failure to remove foreign body on initial attempt(s). (46~48%)
 Existent injury to the external auditory canal or tympanic membrane.
 Round solid subjects. (78%)
 Object wedged in the medial external auditory canal or up against tympanic membrane.
 Glass or other sharp-edged foreign body.
 Special circumstances such as insects, putty, and disc batteries.
 Uncooperative patient
 Restrained: child seated in an adult’s lap in the exam chair with the child’s arms and
torso held securely by the adult. An additional staff member immobilize the child’s head.
 Only one or two chances before the child loses his patience and becomes
uncooperative.
 Sedation (19.7%): Ketamine, Dormicum (Midazolam).
 General anesthesia for Operative Extraction: 30~6% (88% <7y)
 Mask inhalation without intubation.
 Indications for otomicroscope in younger children.
 End-aural incision. (India)
 After removal: thorough examination of the EAC and tympanic membrane.
 Opposite ear and nostrils should be examined.
 Not uncommon for multiple foreign bodies in the same child.
 Uncomplicated, atraumatic foreign body removal: require no further follow-up care.
COMPLICATIONS6,8,9
 Not related to age and gender.
 Factors:
(i)
irregular shape of the FB, namely, stone,
(ii)
duration of lodgments as longer stay (>24hr) in EAC leads to otitis externa,
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(iii)
degree of cooperation of the child during removal,
(iv)
experience of the surgeon.
Failure of FB removal(22.2%), laceration(5.1%), perforated tympanic membrane(1~6%)
Other complications(4.3%): bleeding, hematoma, edema, traumatic otitis externa.
Injury to tympanic membrane or ossicles: audiogram.
Prolonged FBs: otitis media / externa.
Treated with antibiotic or steroid otic drops and given water precautions until healing.
BUTTON BATTERY INJURY8,10
 Dry cell, mercury cell and alkaline.
 Electrolyte: sodium hydroxide or potassium hydroxide.
 Smooth and shiny appearance makes them quite attractive and noticeable to children.
 Size: 7.9~23mm diameters, 1~10 g in weight.
 In 97% of cases, the size of the battery is less than 15mm.
 44.6% were intended for use in a hearing aid.
 32.8% were removed from the child’s own hearing aid.
 Majority in the 0~5y (61~71%); peak incidence between 1~2y; 57% are male.
 children of that age range are more able to obtain and remove the batteries from those
products that contain them.
 5~12y: 5.4%
 Presenting to ER: 3~24h.
 Symptoms:
 no signs or symptoms.
 non-specific signs: pain, cough, vomiting, irritability, fever and tachycardia.
 More specific s/s: EAC ulceration, foul or dark otorrhea, mimicking malignant otitis
externa.
 Mechanisms of injury: liquefactive necrosis extending into deep tissues.
 Electrolyte leakage
 marked ulceration within 2 h of placement.
 necrosis of the inner muscularis layer after 1~2 h.
 progressing to full thickness necrosis from 2~4 h.
 Alkali produced de novo
 2H2O + 2e− → 2OH− + H+
 Hydrogen ions accumulates at the anode  more substantial damage.
 A mercury cell: 1ml of 13% sodium hydroxide after 48 h of mucosa contact.
 Mercury toxicity
 Theoretical risk
 Only 2 two case reports: no systemic s/s of mercury toxicity, treated with oral
chelators.
 Lethal dose of mercuric salts: 0.5~1.0g
 Mercury button batteries: 0.9~21g of mercuric oxide, poorly absorbed  reduced
to elemental mercury, virtually non-toxic.
 Pressure necrosis
 Theoretical risk, no evidence or case reports.
 Should never be irrigated before removal.
 After removal, the canal should be irrigated to remove alkalai residue.
 Complications: tympanic membrane perforation, EAC stenosis.
Reference:
1. Thompson SK, Wein RO, Dutcher PO. External auditory canal foreign body removal: management practices and outcomes.
Laryngoscope. 2003 Nov;113(11):1912-5.
2. Schulze SL, Kerschner J, Beste D. Pediatric external auditory canal foreign bodies: a review of 698 cases. Otolaryngol
Head Neck Surg. 2002 Jul;127(1):73-8.
3. Robin Mantooth. Foreign Bodies, Ear. http://www.emedicine.com/emerg/topic185.htm
4. Wada I, Kase Y, Iinuma T. Statistical study on the case of aural foreign bodies. Nippon Jibiinkoka Gakkai Kaiho. 2003
Jun;106(6):678-84.
5. Balbani AP, Sanchez TG, Butugan O, Kii MA, Angelico FV Jr, Ikino CM, D'Antonio WE. Ear and nose foreign body removal in
children. Int J Pediatr Otorhinolaryngol. 1998 Nov 15;46(1-2):37-42.
6. Endican S, Garap JP, Dubey SP. Ear, nose and throat foreign bodies in Melanesian children: An analysis of 1037 cases. Int
J Pediatr Otorhinolaryngol. 2006 May 15.
7. Ng KC, Sim TP. Otorhinolaryngeal foreign bodies in children presenting to the emergency department. Singapore Med J.
2005 Apr;46(4):172-8.
8. Ansley JF, Cunningham MJ. Treatment of aural foreign bodies in children. Pediatrics. 1998 Apr;101(4 Pt 1):638-41.
9. Mishra A, Shukla GK, Bhatia N. Aural foreign bodies. Indian J Pediatr. 2000 Apr;67(4):267-9.
10. Lin VY, Daniel SJ, Papsin BC. Button batteries in the ear, nose and upper aerodigestive tract. Int J Pediatr
Otorhinolaryngol. 2004 Apr;68(4):473-9.