Treatment and Management of Foreign Body in the Ear

Upon a patient’s arrival at the hospital with a suspected foreign body in the ear, the initial approach prioritizes creating a welcoming and comfortable environment before commencing the removal process.

1. Initial Patient Assessment:

   • Biodata Collection: Gather essential patient details, including name, age, contact information, and relevant medical history.

   • Detailed History Elicitation: Obtain a comprehensive account of the incident, focusing on:

     • The nature of the suspected foreign object.

     • How long the object has been lodged in the ear.

     • Any associated symptoms the patient is experiencing.

2. Ear, Nose, and Throat (ENT) Specialist Consultation:

   • Prompt Referral: Immediately refer the patient to an ENT specialist for expert evaluation and management.

   • ENT Examination: The ENT specialist will conduct a thorough examination of the ear, utilizing an otoscope to:

     • Visually identify the foreign body.

     • Determine the object’s location within the ear canal.

     • Assess the characteristics of the foreign body.

3. Therapeutic Approach Determination:

   • Individualized Removal Plan: The ENT specialist will decide on the most suitable removal technique, taking into account:

     • The foreign body’s size and dimensions.

     • Its shape and configuration.

     • The material composition of the object.

     • The precise location of the object within the ear canal.

   • Removal Techniques: A variety of techniques may be employed, depending on the specific case, including:

     • Gentle suction using specialized equipment.

     • Fine forceps for grasping and extraction.

     • Looped instruments designed for foreign body retrieval.

     • Magnetic tools, specifically for removing metallic foreign bodies.

   • Ear Canal Irrigation: If the eardrum is confirmed to be intact, warm water irrigation using a small, flexible catheter may be utilized to gently flush out the object.

   • Sedation Considerations: In the case of young children or individuals who may not tolerate potentially uncomfortable removal procedures, sedation may be considered to ensure cooperation and minimize distress.

4. Management of Specific Foreign Body Types:

   • Insects: For live insects in the ear canal:

     • Insect Immobilization: Typically, insects are first immobilized and killed by instilling lidocaine (anesthetic) or mineral oil into the ear canal.

     • Gentle Irrigation: Following insect death, gentle irrigation with warm water is often used to flush out the insect.

   • Button Batteries: Button batteries require immediate and urgent removal due to the significant risk of chemical burns and tissue damage from battery leakage.

   • Food or Plant Matter: Organic materials like food or plant matter necessitate prompt removal as they can:

     • Swell and expand upon contact with moisture in the ear canal.

     • Lead to increased obstruction and patient discomfort.

   • Live Animate Objects: Living foreign bodies, like insects, can be killed by instilling oily ear drops into the ear canal. This suffocates the insect, which can then be:

     • Removed using forceps.

     • Extracted with gentle syringe irrigation.

   • Inorganic and Small Objects: For inanimate objects such as metallic foreign bodies, glass beads, and small food grains, removal can often be achieved by:

     • Ear syringing with warm water.

     • Magnetic Removal: Magnets can sometimes be effective for extracting metallic objects.

     • Suction: Suction devices can assist in gently pulling out certain foreign bodies.

     • Forceps Extraction: If the object is readily visible and easily grasped, fine tweezers may be used for gentle removal.

   • Post-Removal Otoscopic Examination: After removing any foreign body, a thorough re-examination of the ear canal using an otoscope is essential to:

     • Check for any trauma or injury to the ear canal walls.

   • Antibiotic Ear Drops (Prophylactic Use): Antibiotic ear drops may be prescribed, typically for a short course, to prevent potential secondary infections, particularly if there was trauma or risk of contamination during removal.

5. Post-Removal Aftercare:

   • Antibiotic Ear Drops: If prescribed, administer antibiotic ear drops for the duration recommended by the ENT specialist, usually 5-7 days, to prevent infection.

   • Follow-Up Appointment: A follow-up appointment within approximately one week is typically advised to:

     • Ensure proper healing of the ear canal.

     • Assess for any signs of complications.

     • Address any persistent symptoms.

     • If persistent issues like bleeding, ear discharge, or pain are present, further evaluation and management are necessary.

6. Indications for Urgent Foreign Body Removal: Immediate removal of a foreign body is warranted in situations involving:

   • Severe Pain: Intense ear pain or escalating discomfort.

   • Significant Hearing Loss: A noticeable decrease in hearing acuity in the affected ear.

   • Dizziness: Onset of dizziness or vertigo, suggesting possible middle ear involvement or irritation of the inner ear.

General Management Principles (Key Considerations for Removal)

• Avoid Forceps for Deep Insertion: Do not attempt to use forceps to grasp objects deeply lodged in the ear canal, as this may push the object further inward, increasing impaction and risk of eardrum injury.

• Forceps for Edge Grasping: If the foreign body presents an edge or projection that can be safely grasped, Hartmann forceps (or similar “crocodile” forceps), designed for ear procedures, may be used for extraction.

• Syringing with Lukewarm Water: Ear syringing using lukewarm water is a common technique for non-impacted, mobile foreign bodies, particularly smooth, round objects.

• Foreign Body Hook for Syringing Failures: If syringing proves ineffective in removing the foreign body, a specialized foreign body hook can be used by trained personnel to gently manipulate and extract the object.

• General Anesthesia in Children: In young or uncooperative children, general anesthesia may be required to ensure safe, atraumatic, and effective removal, especially for deeply embedded or challenging foreign bodies.

• Insect Immobilization Before Syringing: For insects, always kill or immobilize the insect first using clean cooking oil or water before attempting to syringe it out with warm water. This prevents the insect from further agitation and potential damage during removal attempts.

• Syringing for Smooth, Round Objects: For smooth, round foreign bodies that are not impacted, syringing with lukewarm water is often the initial removal method of choice.

• Foreign Body Hook for Syringing Failures (Round Objects): If syringing is unsuccessful for round objects, a foreign body hook can be employed for extraction.

• General Anesthesia (Children and Sensitive Adults): General anesthesia may be necessary for foreign body removal in:

  • Children who are unable to cooperate with removal procedures.

  • Sensitive adults who may experience significant discomfort or anxiety during removal.

• Avoid Forceps on Round Objects: Do not use forceps to attempt to grasp round objects lodged in the ear canal. This approach is likely to simply push the object further into the canal, making removal more difficult and potentially causing injury.

• Hartmann Forceps for Edged Objects: For foreign bodies with an edge or graspable point, Hartmann (crocodile) forceps are appropriate for gentle and controlled removal.

• Cockroach Removal with Forceps: Cockroaches are best removed with crocodile forceps rather than syringing, as their legs have hooks that can make syringing ineffective and potentially traumatic.

• Avoid Syringing Impacted Seeds: Do not syringe with water if the foreign body is a seed. Water can cause seeds to swell, potentially worsening the impaction and making removal more challenging. Immediate referral is advised if seed removal with a hook is not possible.

• Suction for Specific Foreign Bodies: Suction devices can be useful for removing certain types of foreign bodies that can be grasped or drawn into the suction tip.

• Magnetic Removal of Metallic Objects: Magnets can be utilized in cases where the foreign body is confirmed to be metallic, providing a non-traumatic removal option.

• Post-Removal Antibiotic Ear Drops and Pain Relief: After successful removal, antibiotic ear drops are often prescribed to prevent secondary infection. Pain relievers (analgesics) may also be recommended to manage any post-procedure discomfort.

WAX IN THE EAR OR IMPACTED CERUMEN

Impacted cerumen (earwax) refers to an accumulation of earwax in the external ear canal that becomes excessive and causes obstruction of the external acoustic meatus (ear canal opening).

Earwax is a normal, naturally produced substance in the external ear canal. It is composed of:

• Epithelial scales (shed skin cells).

• Secretions from specialized glands within the skin of the outer ear canal.

Earwax serves a protective function in the ear canal, trapping dust, debris, and microorganisms, and typically self-expels naturally over time. In most individuals, earwax naturally migrates out of the ear canal without intervention. However, in some cases, it accumulates and forms a wax plug, causing blockage and potentially leading to hearing impairment.

Causes of Impacted Cerumen

Factors contributing to impacted earwax include:

• Excessive or Thick Wax Production: Some individuals naturally produce more earwax or wax with a thicker consistency, increasing the likelihood of impaction.

• Narrow, Tortuous, or Hairy Ear Canal: The anatomy of the ear canal, if narrow, winding (tortuous), or excessively hairy, can hinder natural wax expulsion, leading to buildup.

• Ear Pad or Hearing Aid Use: Regular use of ear pads (earplugs, headphones) or hearing aids can impede the natural migration of earwax out of the ear canal, promoting impaction.

• Cotton Swab Use: Paradoxically, attempts to clean the ears with cotton swabs often push earwax further into the canal, contributing to impaction rather than removing wax effectively.

Clinical Features of Impacted Cerumen

Common symptoms of impacted earwax include:

• Sensation of Blocked Ears: A feeling of ear blockage or fullness in the affected ear.

• Tinnitus (Ear Noises): Buzzing, ringing, or other sounds in the ear.

• Hearing Loss: Reduced hearing acuity in the affected ear, often described as a muffled or plugged sensation.

• Mild Pain (Otalgia): In some cases, mild ear pain or discomfort may be present due to pressure from the wax plug.

Management of Impacted Cerumen

Management aims to soften and remove the impacted wax safely:

• Ceruminolytic Ear Drops (Wax Softeners): Initial treatment often involves using ear drops to soften the impacted wax. Common types include:

  • Olive oil

  • Vegetable oil

  • Glycerine

  • Sodium bicarbonate ear drops

  • Liquid paraffin ear drops
    Application: Instill ear drops three times a day for a few days to soften the wax plug. Often, after softening, the earwax will naturally fall out on its own due to normal ear canal movements.

• Ear Syringing (Irrigation): If ear drops alone are insufficient to remove the wax plug, ear syringing may be necessary.

  • Warm Water Irrigation: Use clean water warmed to body temperature for ear syringing. This is crucial to:

    • Soften the impacted wax during irrigation.

    • Minimize stimulation of the inner ear, which could induce dizziness or vertigo.

  • Syringing Procedure Timing: Perform ear syringing after the wax has been softened by ear drops to facilitate easier and less traumatic removal.

  • Gentle Drying: After syringing, gently dry the ear canal to remove excess moisture.

  • Otoscopic Re-Examination: Following syringing, re-examine the ear canal with an otoscope to:

    • Confirm complete wax removal.

    • Exclude any damage to the tympanic membrane (eardrum) caused by syringing.

Important Notes on Wax Removal

• Avoid Sharp Objects: Advise patients strongly against using any sharp objects (e.g., cotton swabs, hairpins, keys) in the ear canal in an attempt to remove earwax. This practice is highly risky and can lead to:
  * Eardrum damage (perforation).
  * Ear canal injury or infection.

• Contraindications for Syringing: Do not perform ear syringing in the following situations:
  * History of ear discharge (otorrhea), which may indicate a perforated eardrum or active infection.
  * Presence of ear pain (otalgia), which may suggest underlying infection or eardrum perforation.

Complications of Foreign Body in the Ear (and Removal Attempts)

Potential complications associated with foreign bodies in the ear and their removal include:

• Ear Canal Infection (Otitis Externa): Infection of the external ear canal is a possible complication, but it usually:

  • Responds well to topical antibiotic ear drops.

• Tympanic Membrane (Eardrum) Damage: Attempts at self-removal or improper removal techniques, especially with sharp objects, can potentially cause:

  • Eardrum perforation (rupture), leading to hearing loss and potential middle ear infection.

• Persistent Symptoms: Ongoing symptoms like pain, bleeding, or ear discharge following foreign body removal may indicate:

  • Residual irritation or inflammation.

  • Injury to the ear canal.

  • Secondary infection.

FOREIGN BODIES IN THE NOSE

Foreign body in the nose refers to any object that has been placed into the nasal cavity and is causing symptoms or obstruction.

Foreign bodies in the nasal passages are relatively common, particularly in:

• Children, especially toddlers, due to their exploratory behavior.

• Adults with intellectual disabilities or cognitive impairment, who may lack awareness or control over object insertion.

• Objects typically enter through the anterior nares (nostrils). However, foreign bodies can also:

  • Enter from the mouth or stomach during vomiting or forceful coughing.

  • Be unintentionally left in the nose during nasal surgery or procedures.

Types of Foreign Bodies in the Nose

Common types of foreign objects found in the nasal passages include:

1. Small Toys: Miniature toys or toy parts, such as:

   • Lego bricks

   • Small beads

   • Miniature action figures.
     Children, especially toddlers, may insert these out of curiosity or during play.

2. Eraser Pieces: Fragments of erasers from pencils or other stationery items, which can break off and become lodged.

3. Tissue Paper: Pieces of tissue paper or facial tissue, especially if inserted while attempting to stop a nosebleed or accidentally during nose blowing.

4. Clay or Modeling Compounds: Small pieces of clay, playdough, or modeling materials used in arts and crafts, particularly in children.

5. Food Items: Small food particles, such as:

   • Peas

   • Beans

   • Nuts

   • Other small edible items, often inserted by young children while eating or playing.

6. Small Objects from Outdoors: Items children may pick up while playing outside, such as:

   • Small stones

   • Pebbles

   • Dirt clods or mud.

7. Paired Disc Magnets: Small, powerful disc magnets, often used for attaching earrings or nose rings, can be hazardous if inserted in the nose. When multiple magnets are inserted, they can:

   • Attract each other across the nasal septum (the wall separating the nostrils).

   • Cause pressure necrosis and damage to the nasal tissue over time, potentially leading to septal perforation.

8. Button Batteries: Small, round button batteries, commonly found in watches, hearing aids, and electronic toys, pose a serious hazard if inserted into the nose. Button batteries can cause:

   • Liquefaction necrosis: Severe tissue damage due to battery leakage and chemical burns.

   • Emergency: Button battery insertion into the nose requires immediate and urgent medical attention.

Clinical Manifestations of Nasal Foreign Body

The presentation of a nasal foreign body can vary, but common signs and symptoms include:

• Visible Foreign Body: In some cases, the foreign object may be directly visible upon external nasal examination or during anterior rhinoscopy.

• Nasal Congestion: Blockage of the nasal passage on the affected side, leading to nasal stuffiness or difficulty breathing through the nostril.

• Persistent Sneezing: Irritation from the foreign body can trigger frequent and persistent sneezing.

• Breathing Difficulty: If the foreign body obstructs a significant portion of the nasal passage, it can cause difficulty breathing through the nose, potentially leading to mouth breathing.

• Irritability: Discomfort and inability to communicate the problem, particularly in infants and young children, may manifest as general irritability and restlessness.

• Persistent Crying (Infants): In infants, nasal foreign bodies can cause persistent crying or fussiness due to discomfort and nasal obstruction.

• Blood-Tinged Nasal Discharge: Nasal discharge streaked with blood (blood-tinged) can occur due to irritation or trauma to the nasal mucosa from the foreign body.

• Rhinorrhea: Runny nose or nasal discharge, which may be clear, mucous-like, or mucopurulent depending on the duration and presence of infection.

• Foul-Smelling Nasal Discharge: A particularly concerning sign is a unilateral, foul-smelling nasal discharge, which is highly suggestive of a nasal foreign body, especially if the discharge is also blood-stained. The foul odor is often due to trapped secretions and bacterial overgrowth behind the obstruction.

Diagnosis of Nasal Foreign Body

Diagnosing a nasal foreign body typically involves:

• History: A patient history, particularly in children with sudden onset of nasal obstruction and discharge. A history of unilateral, foul-smelling, and bloody nasal discharge in a child should raise strong suspicion of a nasal foreign body.

• Anterior Rhinoscopy: Examination of the nasal cavity using an anterior rhinoscopy technique, involving a nasal speculum and a light source. This may:

  • Directly reveal the foreign body in some cases.

  • Show the foreign body may be obscured by mucopurulent discharge (pus-containing mucus) and granulations (inflammatory tissue) that have formed around the object over time.

• Probing: Gentle probing of the nasal cavity using a blunt probe may help to:

  • Detect the presence of a foreign body if it is not immediately visible.

• Radiological Examination (Selective Cases): Radiological examination (X-ray) of the nose and sinuses may be helpful in certain cases, particularly to:

  • Identify radiopaque foreign bodies, such as metallic objects or button batteries, which are visible on X-ray.

Management of Nasal Foreign Body

Nasal foreign body removal typically involves the following steps:

• Patient Positioning: The patient, especially a child, is usually held in an upright or seated position, often with parental assistance for immobilization.

• Nasal Fossae Illumination: The nasal passages (nares) are adequately illuminated using a headlight or external light source to improve visualization.

• Curved Hook Extraction: A specialized curved hook instrument (or similar angled instrument) is often used to:

  • Gently manipulate the foreign body.

  • Pull the foreign body forward and out of the nasal cavity.

  • An Eustachian catheter, a thin, curved catheter commonly used in ear procedures, can sometimes be adapted for use as a nasal hook in certain cases.

• General Anesthesia (Uncooperative Patients): In cases involving:

  • Uncooperative patients, especially young children who are unable to remain still.

  • Deeply seated foreign bodies that are difficult to reach or remove with simple techniques.
    General anesthesia may be necessary to ensure safe and atraumatic removal in a controlled setting.

Specific Removal Techniques

• Pre-Removal Preparation: Before attempting removal, the following may be helpful:

  • Decongest Nasal Mucosa: Apply a topical nasal decongestant, such as 0.5% phenylephrine (Neo-Synephrine) nasal spray, to:

    • Reduce swelling of the nasal lining (mucosa).

    • Improve visualization and access to the foreign body.

  • Provide Topical Anesthesia: Apply a topical anesthetic agent, such as lidocaine gel or spray, to:

    • Numb the area and reduce pain sensation during the removal procedure.

• Direct Instrumentation: Utilize instruments for direct visualization and removal:

  1. Direct Visualization and Removal: Use tools that allow direct visualization and grasping of the foreign body, including:

     • Fine forceps (e.g., alligator forceps, Hartmann forceps).

     • Small curved hooks or probes.

     • Cerumen loops (small wire loops).

     • Suction catheters, for suction-assisted removal of small, loose objects.

• Balloon Catheter Method: Employ a balloon catheter technique for certain foreign bodies:
  2. Balloon Catheter Technique:
  * Pass Catheter Beyond Object: Carefully pass a thin, lubricated balloon-tip catheter gently past the foreign body within the nasal passage.
  * Balloon Inflation: Inflate the balloon tip of the catheter distal to (behind) the foreign body.
  * Forward Traction: Gently pull the catheter forward, using the inflated balloon to push the foreign body anteriorly and move it out through the nostril for removal.

• Self-Removal Encouragement: In cooperative patients, particularly older children or adults, encourage self-removal attempts using simple methods:
  3. Blowing Nose Technique:
  * Instruct Patient to Blow Nose: Instruct the patient to attempt to forcefully blow their nose to expel the foreign body.
  * Nostril Occlusion: While blowing, instruct them to block the opposite nostril with a finger to increase pressure in the affected nostril.

• Positive Pressure Ventilation (Parent’s Kiss Technique): For uncooperative patients, particularly young children, and when direct instrumentation is challenging, positive pressure ventilation techniques can be considered:
  4. Positive Pressure Ventilation:
  * Caregiver Air Puff (Parent’s Kiss Technique): A caregiver (parent) can deliver a gentle puff of air into the child’s mouth while occluding the unaffected nostril. The sudden burst of air pressure may help dislodge the object and expel it from the affected nostril.
  * Bag-Valve-Mask (Ambu Bag) Ventilation: Positive pressure ventilation can also be delivered more formally using a bag-valve-mask (Ambu bag) connected to the mouth and nose.
  * Nasal Oxygen Tubing Ventilation: Positive pressure may also be delivered through the nose using oxygen tubing connected to an oxygen source, delivering a controlled puff of air.

Specific Foreign Body Considerations

• Button Batteries – Emergency Removal: Button batteries lodged in the nose must be removed immediately due to the high risk of liquefaction necrosis (tissue death) caused by leakage of battery contents and electrical current.

• Infection Control Precautions: When removing nasal foreign bodies, adhere to appropriate infection control precautions. Expect that the expelled foreign body will likely be:
  * Expelled with force against the caregiver’s cheek or clothing.
  * Covered in nasal mucus.
  * Potentially contaminated with blood.