Overview
Definition:
A foreign body in the ear refers to any inanimate object or organic material lodged within the external auditory canal of a child
Common foreign bodies include beads, small toys, peas, seeds, insects, and cotton swabs
Management strategies aim for safe and complete removal with minimal trauma to the ear canal and tympanic membrane.
Epidemiology:
Foreign bodies in the ear are a common pediatric emergency, with an incidence that peaks in preschool-aged children (2-5 years)
Boys are more frequently affected than girls
Bilateral involvement is rare
The prevalence is higher in children with a history of putting objects in their nose or ears.
Clinical Significance:
Untreated or improperly managed ear foreign bodies can lead to significant morbidity, including pain, hearing loss, otitis externa, tympanic membrane perforation, granulation tissue formation, and even conductive hearing loss
Prompt and appropriate intervention is crucial to prevent these complications and ensure good auditory outcomes.
Clinical Presentation
Symptoms:
Most common symptom is otalgia (ear pain)
May present with a sensation of fullness or blockage in the ear
Decreased hearing (conductive hearing loss) may be reported
Intermittent or persistent otorrhea (ear discharge) can occur, especially with organic foreign bodies
Children may exhibit irritability, fussiness, or tugging at the affected ear
Some may be asymptomatic, with the foreign body discovered incidentally.
Signs:
Visualisation of the foreign body within the external auditory canal using an otoscope
Edema or erythema of the ear canal may be present, indicating inflammation
Bleeding from the ear canal suggests trauma during insertion or a sharp foreign body
Otorrhea may be serous, purulent, or bloody
The tympanic membrane may be obscured by the foreign body or inflammatory changes.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on a history suggestive of ear foreign body insertion and direct visualization of the object in the external auditory canal via otoscopy
There are no specific laboratory or imaging criteria for diagnosis, although imaging may be considered for suspected intraluminal migration or when a radio-opaque object is suspected and difficult to visualize.
Diagnostic Approach
History Taking:
Key history points include the type of object (e.g., organic vs
inorganic), duration of presence, any associated trauma or pain, previous attempts at removal, and any symptoms of infection (fever, discharge)
Ask about the child's developmental stage and propensity for placing objects in orifices
Red flags include a history of sudden severe pain, profuse bleeding, or sudden hearing loss, suggestive of tympanic membrane perforation or significant trauma.
Physical Examination:
A thorough otoscopic examination of both ears is essential
Gentle manipulation is key to avoid pushing the foreign body deeper or causing trauma
Assess the ear canal for edema, erythema, abrasions, or bleeding
Visualize the tympanic membrane if possible
if obscured, note the extent of the obstruction
Examine the surrounding facial structures for signs of infection or injury.
Investigations:
In most cases, no investigations are required
If the foreign body is suspected to be radio-opaque (e.g., metal), a plain X-ray of the ear may be helpful, especially if visualization is difficult
However, this is rarely necessary
If significant trauma is suspected or complications like perforation are present, a Weber and Rinne test can assess hearing
Audiometry may be considered post-removal if hearing loss persists.
Differential Diagnosis:
Cerumen impaction is the most common differential diagnosis and can mimic a foreign body
Other considerations include otitis externa, otomycosis (fungal infection), polyp in the ear canal, or a granuloma
In infants, a patent external auditory canal is normal and should not be mistaken for a foreign body.
Management
Initial Management:
The primary goal is safe and complete removal of the foreign body
The child should be kept calm and reassured
Sedation or general anesthesia may be required for uncooperative children or when instruments are used
If there is profuse bleeding or suspicion of tympanic membrane perforation, avoid irrigation and proceed with caution using instruments.
Irrigation Technique:
This method is best suited for smooth, non-porous, inorganic foreign bodies that are not blocking the entire ear canal
Use lukewarm water or saline (body temperature) to avoid inducing vertigo
A syringe or nasal bulb syringe can be used to gently irrigate the canal
Direct the stream of fluid toward the superior aspect of the ear canal to allow the foreign body to float out
Ensure adequate suction or towels to manage the outflowing fluid
Contraindicated if tympanic membrane perforation is suspected or if the foreign body is organic (e.g., beans, seeds) which can swell.
Instrumental Removal:
This is the preferred method for sharp, irregular, or organic foreign bodies, or when irrigation is contraindicated or has failed
Instruments include alligator forceps, curettes, and specialized ear hooks
Use a well-lit otoscope for visualization
Grasp the foreign body firmly with forceps and gently extract it
Curettes can be used to dislodge objects lodged deeper
Specialized suction devices may be useful for small, rounded objects
This technique requires skill and practice to avoid injuring the ear canal or tympanic membrane
Local anesthesia may be used for the ear canal lining.
Medications And Follow Up:
If otitis externa develops, topical antibiotic or steroid ear drops may be prescribed
If an insect is the foreign body, it should be killed first with topical anesthetic drops (e.g., lidocaine) or mineral oil before removal
Following successful removal, a follow-up otoscopic examination is recommended to ensure complete removal and assess for any trauma or complications
Advise parents on prevention strategies.
Complications
Early Complications:
Trauma to the ear canal (abrasions, lacerations, bleeding)
Perforation of the tympanic membrane
Pain and discomfort
Infection of the ear canal (otitis externa)
Pushing the foreign body deeper into the canal or middle ear.
Late Complications:
Conductive hearing loss secondary to prolonged obstruction or tympanic membrane damage
Granulation tissue formation in the ear canal
Chronic otitis media if the foreign body erodes into the middle ear
Scarring of the ear canal.
Prevention Strategies:
Educate parents and caregivers about the dangers of small objects and supervise children closely
Advise against allowing children to put small toys, beads, seeds, or other potentially harmful items in their ears or nose
Keep small objects out of reach of young children.
Key Points
Exam Focus:
Differentiate between inorganic (smooth, non-swelling) and organic (swelling) foreign bodies
Understand contraindications for irrigation (perforation, organic material)
Recall common instruments used for removal (forceps, curettes)
Recognize signs of tympanic membrane perforation
Know the indications for sedation/anesthesia.
Clinical Pearls:
Always use lukewarm solutions for irrigation to prevent vertigo
If irrigating, ensure the tympanic membrane is intact and the object is not obstructing the entire canal
When using instruments, excellent visualization and a steady hand are paramount
If an insect is present, kill it first before attempting removal to prevent it from moving
Consider indirect methods if direct visualization is poor, but be cautious.
Common Mistakes:
Attempting irrigation with organic material or a perforated tympanic membrane
Aggressively probing or pushing the foreign body deeper
Failure to adequately visualize the foreign body or the tympanic membrane
Using inappropriate instruments or techniques leading to iatrogenic injury
Over-sedation or under-sedation of the child.