Overview
Definition:
Foreign body removal from the ear and nose refers to the medical and procedural management of exogenous objects lodged within the external auditory canal or nasal cavity in children
This is a common pediatric emergency encountered by primary care physicians, pediatricians, and otolaryngologists.
Epidemiology:
Commonly seen in children aged 1-6 years
Approximately 50% of cases involve children under 4 years old
In the nose, beads, small toys, and food items are frequent culprits
In the ear, beads, small stones, insects, and cotton swabs are common
Bilateral involvement is rare.
Clinical Significance:
Untreated foreign bodies can lead to significant complications including infection, pain, hearing loss (in the ear), epistaxis, nasal obstruction, anosmia, and in rare cases, aspiration or airway compromise
Prompt and appropriate management is crucial for preventing morbidity and ensuring patient comfort.
Clinical Presentation
Ear Symptoms:
Sudden onset of ear discomfort or pain
Sensation of fullness in the ear
Decreased hearing acuity
Tinnitus
Otorrhea, often foul-smelling if the object has been present for some time or is organic
Bleeding from the ear canal
Child may be irritable or fussy, especially if younger
May be asymptomatic and discovered incidentally.
Nose Symptoms:
Unilateral nasal obstruction
Purulent, foul-smelling nasal discharge (often unilateral, termed "ozena")
Epistaxis
Sensation of something stuck in the nose
Decreased sense of smell (anosmia)
Mouth breathing due to nasal obstruction
Child may be reluctant to allow examination of the nose.
Signs:
Visualisation of a foreign object in the ear canal or nasal cavity
Ear canal erythema or edema
Nasal mucosa erythema or edema
Presence of purulent discharge
Tympanic membrane may be obscured or even perforated if the object is sharp or inserted forcefully
Visible granulation tissue around the foreign body.
Diagnostic Approach
History Taking:
Detailed history regarding the type of object (organic vs
inorganic, sharp vs
smooth), duration of symptoms, any preceding trauma, and previous attempts at removal
Age of the child is critical for understanding typical behaviors and common objects
Inquire about any respiratory distress or stridor which could suggest concomitant aspiration.
Physical Examination:
For the ear: Gentle external examination, followed by otoscopy
Use of a cerumen curette or nasal speculum can aid visualization
For the nose: Nasal speculum examination is essential
Use of topical anesthetic spray can help with patient cooperation
Adequate lighting is paramount
Avoid vigorous manipulation that could push the object deeper or cause trauma.
Investigations:
Imaging is typically not required for simple, visible foreign bodies
Radiographs (X-rays) may be considered for radio-opaque objects or if there is suspicion of associated fracture or deeper penetration, though its utility is limited for common plastic or organic materials
CT scan is rarely needed but may be used for complex or deeply impacted objects.
Differential Diagnosis:
In the ear: Cerumen impaction, otitis externa, polyps, exostosis
In the nose: Nasal polyps, hypertrophied adenoids, chronic rhinitis with crusting, nasal tumors (rare).
Management
Ear Removal Techniques:
For smooth, non-irritant objects: Removal with instruments like alligator forceps, Jobson-Horne probe, or a right-angled hook
For small, mobile objects: Suction or irrigation (if tympanic membrane is intact and object is not obstructing the canal)
Irrigation should be with lukewarm water or saline to avoid vertigo
Boric acid or alcohol drops can be used for insecticidal effect before removal
Sedation or general anesthesia may be required for uncooperative children or difficult removals.
Nose Removal Techniques:
For accessible objects: Direct visualization and removal using forceps or a blunt hook
The "parental kiss" or "mouth-to-mouth" technique: occlude the contralateral nostril and blow gently into the child's mouth, which can dislodge the object
If this fails, or for more challenging cases, instrumental removal under direct vision with a nasal speculum and forceps is preferred
Topical anesthetic and vasoconstrictor sprays (e.g., xylocaine with epinephrine or phenylephrine) may be helpful
General anesthesia may be necessary for deeply impacted or very challenging cases.
Organic Foreign Bodies:
Organic foreign bodies (e.g., peas, beans) in the ear are particularly concerning as they can swell with moisture, leading to significant edema and risk of infection
These should be removed promptly, often without irrigation, and surgical removal may be considered if difficult
Insect foreign bodies should be killed with lidocaine drops or mineral oil before removal.
Post Removal Care:
After successful removal, re-examine the ear or nasal cavity to ensure no residual fragments and to assess for trauma
Topical antibiotics (ear drops or nasal spray) may be prescribed to prevent secondary infection, especially if there was significant manipulation or mucosal injury
Advise parents to observe for signs of infection or bleeding and to return if symptoms recur
A follow-up visit may be recommended, especially for ear foreign bodies
For ear foreign bodies, checking hearing post-removal is important.
Complications
Ear Complications:
Perforation of the tympanic membrane
Laceration or abrasion of the ear canal
Otitis externa
Middle ear infection (otitis media)
Hearing loss (conductive or sensorineural)
Granulation tissue formation
Chondritis
Tinnitus
Vertigo.
Nose Complications:
Perforation of the nasal septum
Laceration or bleeding from the nasal mucosa
Nasal synechiae (adhesions)
Chronic rhinitis
Sinusitis
Anosmia
In rare cases, aspiration into the lungs.
Prevention Strategies:
Educate parents and caregivers about the risks of small objects and encourage safe play environments
Keep small objects out of reach of young children
Supervise children during play
Teach children not to place objects in their nose or ears
Promptly address any signs of foreign body presence.
Key Points
Exam Focus:
Recognize common pediatric ear and nasal foreign bodies and their typical presentations
Differentiate between organic and inorganic objects, understanding the implications for management
Master the armamentarium of instruments and techniques for safe removal, including indications for sedation or general anesthesia
Understand potential complications and their management.
Clinical Pearls:
Always use adequate lighting and magnification
Prioritize patient cooperation
sedation may be safer than struggling
Avoid irrigating if the tympanic membrane is not visualized or if the object is organic and can swell
For nasal foreign bodies, the "parental kiss" is a simple, effective first-line maneuver
Never leave a child unattended with potential airway compromise.
Common Mistakes:
Attempting removal without adequate visualization
Pushing the foreign body deeper
Causing trauma to the ear canal or nasal mucosa
Not considering sedation for uncooperative children
Failing to identify organic foreign bodies and their unique risks
Inadequate post-removal assessment and follow-up.