Rosen & Barkin's 5-Minute Emergency Medicine Consult (278 page)

• Cautions:
  
  • Severe ear pain, sensation of movement, and loud, buzzing sound:
    
    • Typical signs of a live insect in external auditory canal
      
    • Instill warm lidocaine or mineral oil into affected ear to kill insect
      
• Controversies:
  
  • Attempts at removal in the field are not indicated:
    
    • Lack of appropriate equipment
      
    • Prior failed attempts may make future attempts more difficult
      

For a patient in distress because of a live insect:

• Drown or immobilize insect before any removal attempts
  
• Instill warm solution into the external auditory canal:
  
  • 2% lidocaine solution
    
  • Ether
    
  • Alcohol
    
  • Mineral oil
    
• Cold fluids should not be used so as to avoid a caloric response
  

• Prepare the equipment and the patient:
  
  • Strong light source
    
  • Otoscope or operating microscope
    
  • Achieve proper head immobilization
    
  • Retract the pinna of the ear in a posterosuperior direction to straighten the canal
    
• Analgesia:
  
  • Lidocaine instillation for topical anesthesia:
    
    • Liquid 1–2% solution is preferred to viscous lidocaine.
      
    • Lidocaine injection of the 4 quadrants of the canal using a tuberculin syringe through the otoscope
      
    • 1–2% lidocaine, with or without epinephrine
      
• Procedural sedation:
  
  • Indicated for children and uncooperative adults
    
  • Use before attempts, as unsuccessful efforts may produce bleeding, edema, or injury to the tympanic membrane
    
  • Ketamine for children
    
  • Benzodiazepines for older patients
    
  • Consider fentanyl if analgesia is indicated during removal
    
• Options for removal:
  
  • Water irrigation:
    
    • Perform careful visualization
      
    • Place an Angiocath catheter adjacent to, or preferably distal to, the FB
      
    • Inject warm water or sterile saline through catheter via a syringe
      
    • Backwash the FB out
      
    • Never attempt removal by irrigation when the FB is a button battery
      
  • Use of instruments to dislodge the FB:
    
    • Alligator forceps removal
      
    • Cupped forceps: Numbers 3, 5, and 7 suction tips, preferably with Frazier suction cups
      
    • Cerumen loops
      
    • Right-angle blunt hooks
      
  • Suction catheters:
    
    • Best used for small objects
      
  • Fogarty catheter:
    
    • Carefully pass beyond the FB and inflate and withdraw; this approach puts the tympanic membrane at particular risk of inadvertent injury
      
  • Cyanoacrylate glue on the tip of a blunt probe:
    
    • Place on the FB for 10 sec, and then pull
      
    • May contaminate the ear with glue, and this technique has been associated with tympanic membrane rupture
      
  • Acetone:
    
    • Used to dissolve Styrofoam FBs or loosen superglue
      
  • Otomicroscopy:
    
    • Usually performed in the OR although reports of use in the ED have been positive
      
• Vegetable matter:
  
  • Avoid irrigation of FBs that will swell when exposed to water
    
  • Attempt removal with instrument
    
  • Forceps usually work with graspable objects
    
  • Be certain to delineate clearly between FB and inflamed external auditory canal tissue
    
• Nonvegetable inanimate FB removal:
  
  • If easily grasped, attempt removal with forceps
    
  • If not accessible, attempt removal with irrigation
    
• Polished or smooth object extraction:
  
  • Visualize
    
  • Direct suction
    
  • Blunt right-angled probe: Pass beyond the FB; rotate 90°; remove it with the FB
    
  • Fogarty catheter
    
  • Cyanoacrylate glue
    
• Insect removal:
  
  • Kill insect by rapidly instilling alcohol, 2% lidocaine (Xylocaine), or mineral oil into the ear
    
  • Once killed, remove with forceps or by irrigation
    
  • Re-examine to ensure that all insect parts are removed
    
• Sharp objects:
  
  • Remove with operating microscope
    
  • Consider otolaryngologic referral if there is evidence of trauma or if patient is uncooperative
    

• Fentanyl: 1 μg/kg IV
  
• Ketamine: 1–2 mg/kg IV or 4 mg/kg IM
  
• Midazolam: 1 mg IV slowly q2–3min up to 5 mg (peds: 6 mo–5 yr, 0.05–0.1 mg/kg, titrate to max. of 0.6 mg/kg; 6–12 yr, 0.025–0.05 mg/kg, titrate to max. of 0.4 mg/kg)
  

• Cortisporin otic: 4 gtt in ear QID
  
• Amoxicillin: 500 mg PO (peds: 80–90 mg/kg/24 h) PO TID for 7–10 days.
  
• Augmentin: 875 mg (peds: 90 mg/kg/24 h) PO BID for 7–10 days.
  
• Fill ear canal 5× per day with a combination of antibiotic and steroid otic solution for 5–7 days if there is suspected infection or abrasion
  

FOLLOW-UP

Hospital admission if the FB is a button battery that cannot be removed

• FB removed
  
• Inability to remove a FB that will not cause rapid tissue necrosis
  
• Oral antibiotics (amoxicillin or Augmentin) should be initiated in cases with tympanic membrane perforation
  

Follow-up with ENT specialist as an outpatient:

• Inability to remove a FB
  
• Immunocompromised patients with signs of otitis externa
  

• Patient should be instructed not to place any objects in ear
  
• A short course of analgesics after traumatic FB removal
  
• Otitis externa:
  
  • Topical antimicrobial such as Cortisporin suspension
    
• Immunocompromised patients may require oral antibiotics
  
• Perforated tympanic membrane:
  
  • Prophylaxis with antibiotics
    
  • Follow-up with ENT specialist
    
• Avoid submersion in water until follow-up if trauma or infection present
  

• Use procedural sedation with uncooperative patients or when a difficult removal is anticipated
  
• Irrigation in patients with button batteries in the ear should never be performed as the electrical current or battery contents can cause liquefaction tissue necrosis.
  

• Brown L, Denmark TK, Wittlake WA, et al. Procedural sedation use in the ED: Management of pediatric ear and nose foreign bodies.
  Am J Emerg Med
  . 2004;22:310–314.
  
• Cederberg CA, Kerschner JE. Otomicroscope in the emergency department management of pediatric ear foreign bodies.
  Int J Pediatr Otorhinolaryngol
  . 2009;73:589–591.
  
• Dance D, Riley M, Ludemann P. Removal of ear canal foreign bodies in children: What can go wrong and when to refer.
  BCMJ.
  2009;51:20–24.
  
• Davies PH, Benger JR. Foreign bodies in the nose and ear: A review of techniques for removal in the emergency department.
  J Accid Emerg Med
  . 2000;17:91–94.
  
• Erkalp K, Kalekoğlu Erkalp N, Ozdemir H. Acute otalgia during sleep (live insect in the ear): A case report.
  Agri
  . 2009;21:36--38.
  
• Heim SW, Maughan KL. Foreign bodies in the ear, nose, and throat.
  Am Fam Physician.
  2007;76:1185–1189.
  
• Kumar S, Kumar M, Lesser T, et al. Foreign bodies in the ear: A simple technique for removal analysed in vitro.
  Emerg Med J
  . 2005;22:266–268.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Tympanic Membrane Perforation
  
• Procedural Sedation
  

CODES

931 Foreign body in ear

BASICS

• Esophageal foreign bodies (FBs) typically lodge at 3 sites of physiologic constriction:
  
  • Cricopharyngeal muscle—63%, most common (C6)
    
  • Gastroesophageal junction—20% (T11)
    
  • Aortic arch—10% (T4)
    
• 90% of ingested FBs pass spontaneously.
  
• 10–20% are removed endoscopically, and 1% or less require surgery.
  

• Most common adult and adolescent FBs are food boluses and bones
  
• Increased risk:
  
  • Edentulous adults
    
  • Intoxicated patients
    
  • Patients with underlying esophageal disease: Schatzki B-rings or peptic strictures are most common