While ear foreign bodies can happen at any age, the majority occur in children less than 7 years of age.¹ The younger the patient, the less likely they are cooperative with the exam and, therefore, the less chance of successful foreign body removal. The first attempt at removal is the best, so it is important to make it count. Similarly, different types of foreign bodies call for different “tools” for removal. It is important to understand when to attempt removal in the emergency department (ED) and what tools are available. This blog post will help you optimize your first pass success at foreign body removal by understanding what tools are at your disposal.

When to refer to Otolaryngology for removal?

Emergency physicians have a high success rate (77%) in removing ear foreign bodies with direct visualization.² Otolaryngology uses otomicroscopy, a binocular microscope, for difficult cases.

When attempting direct visualization, the keys to success are:

• Adequate visualization
• Appropriate equipment
• Cooperative patient

Risk factors that indicate difficult removal via direct visualization and should be considered for referral to an otolaryngology specialist include:

• Spherical objects²
• Sharp objects³
• Objects touching the tympanic membrane²
• Object in ear canal for more than 24 hours²
• Signs of trauma to ear canal (bleeding, limited visibility)
• Multiple attempts^1,4

Multiple attempts increases the complication rate the greatest. In one study the complication rate reached 100% when patient had removal attempted 3 times with direct visualization.^1,4 Thus no more than 2 attempts should be made while in the ED, to minimize swelling, bleeding, and other complications.

Optimizing the conditions and patient

1. Ensure good lighting with a headlamp or direct lighting is necessary for easy removal. Example: Pediatric video laryngoscope (Miller 0 blade) can also help obtain better visualization.
2. Do not use restraints or force when possible. This will usually make exam more difficult in young patients.
3. Utilize child calming techniques and child life specialists when available. Have parents to assist with exam.
4. In children <5 years old, procedural sedation or intranasal sedative is encouraged, if a difficult foreign body or uncooperative child is suspected.
5. Use topical lidocaine in ear canal for analgesia, although this is contraindicated in tympanic membrane perforations.

Tools at your disposal

There are many options to remove various shapes and sizes of foreign bodies. Below are the techniques and pros and cons of each:

Alligator Forceps

• Tool: May need to get smaller varieties from operating room or otolaryngology clinic if not readily available in the ED
• Pros: Commonly available, most commonly used,² and able to grasp ridged or solid objects
• Cons: Less successful with spherical foreign bodies²

Irrigation

• Tool: 60 mL syringe, butterfly needle (needle cut off), room temp water/saline
• Irrigation options: Normal saline, alcohol, 2% lidocaine, or mineral oil
• Pros: Effective for non-ridged items and those loosely lodged in ear canal
• Contraindications:
  • Disk batteries due to risk of liquefaction necrosis²
  • Organic material due to risk of expansion damaging the ear canal²
  • Suspected tympanic membrane perforation (including a myringotomy tube)
  • Monomeric or dimeric tympanic membrane (a thin, weak area of the membrane where one or two layers have healed after perforation)
  • History of ear surgery

Schuknecht suction catheter (AKA Frazier suction device)

• Tool: Elongated and narrow suction catheter; see ALiEM trick of the trade
• Pros: Non-grasping thus better success with spherical foreign bodies
• Cons: May need to get from operating room or otolaryngology clinic if not readily available in the ED. Some irregular objects will be difficult to get a suction seal around.

Bionix ear curette

• Tool: Illuminating curette (comes in a forceps form)
• Pros:
  • Similar usability as alligator forceps
  • Built in light source and magnification to assist with good visualization.
  • Scoop at tip to help with cerumen impaction.
• Cons: May not be available in your department

Cerumen loops

• Tool: Metal or plastic loops
• Pros: Commonly available; useful for ear wax removal
• Cons: Unable to grasp

Right angle ball hook

• Tool: Insert hook beyond object, turn 90 degrees, and retract.
• Pros: Non-grasping and thus better success with spherical foreign bodies
• Cons: Not ideal for objects close to the tympanic membrane

Cyanoacrylate “super” glue impregnated long Q-Tip sticks

• Tool:
  • Apply a few drops of adhesive on the wood stick end of a long Q-tip.
  • Insert and apply to foreign body.
  • Allow drying for 20-30 seconds.
  • Remove foreign body and Q-tip as a unit
  • Variation on the trick: Insert an otoscope speculum into the ear to protect the canal from inadvertent adhesive contact before inserting the long Q-tip
  • More detailed explanation of trick
• Pros: Useful for spherical foreign bodies
• Cons: Requires cooperative patient to allow the adhesive to dry

Telescoping magnet

• Tool:
  • Can be bought from most hardware stores
  • Magnet head <0.75 cm
  • Used to grab hold of metal objects
• Pros: Useful for metal or magnetic objects that are freely moving; can use for lodged disk batteries
• Cons: Limited ability to directly visualize when in ear canal

Acetone (nail polish remover)

• Tool: Over the counter nail polish remover (60~70% acetone)
  • Dissolves styrofoam foreign bodies
  • For super glue removal⁵
    • Instill in ear canal and wait 30 minutes.
    • Add local anesthetic.
    • Use direct visualization tool to peel off.
• Pros: Low in ototoxicity risk; rapidly evaporating
• Contraindicated for suspected tympanic membrane perforation (including a myringotomy tube)

A note on insects

• Kill the insect prior to removal
• Instill alcohol, 2% lidocaine, or mineral oil into ear canal.
  • Contraindicated for suspected tympanic membrane perforation (including a myringotomy tube)
• Detailed procedure instructions

Menu of options

Notable foreign bodies removed from the ear by our pediatric emergency department staff include: Barbie shoe, piece of Gak, Button from a Nintendo controller, and a primary tooth.

Having the right tool for the job is important in order to reduce attempts, below are some quick recommendations on what to to use first.

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