Aural Foreign Body

An aural foreign body is an object lodged in the external ear canal, most commonly in children aged 2 to 8 years, and includes beads, seeds, insects, cotton wool, paper and button batteries.

• Objects are placed by the child, or insects enter naturally. Adults may have cotton bud tips or hearing aid parts.
• Attempts at removal by non-experts are the main cause of canal trauma and impaction.
• Button batteries are an emergency because of rapid alkaline and electrical tissue injury.
• Organic matter (seeds, beans) swells with moisture, and live insects cause distress.

Many are asymptomatic and found incidentally.

• Ear pain, a feeling of fullness, hearing loss, itching and discharge (foul, bloody if long-standing).
• A live insect gives buzzing noise and severe distress.
• Visible object on otoscopy, with canal oedema, erythema, abrasion or bleeding.
• Tympanic membrane perforation from sharp objects or poor attempts at removal.
• Differential diagnosis: otitis externa, cerumen impaction, furuncle, cholesteatoma, canal polyp or tumour, and trauma.
• Complications: canal laceration, otitis externa, tympanic membrane perforation, ossicular injury, hearing loss, facial nerve injury (button battery), and permanent canal stenosis.

Diagnosis is by direct visualisation.

• Otoscopy or microscopy to identify the type, position and relation to the drum.
• Ask about the object type and the time of insertion. Check the other ear and the nose.
• Look for tympanic membrane perforation before irrigating.
• X-ray or computed tomography for suspected button battery or object deeper in the canal.

Remove the object using the safest method for its type.

• Supportive: calm and reassure the child; restrain gently (wrapping in a blanket) or use sedation if needed. Do not poke blindly; unsuccessful attempts push the object deeper.
• Live insect: kill it first by instilling mineral oil, olive oil or 2 percent lidocaine, then remove by irrigation or suction. Do not use oil if the drum is perforated.
• Non-organic hard objects (beads): remove with a right-angled hook or probe passed behind the object, or alligator forceps for irregular objects. Round smooth objects can be removed with a hook or irrigation.
• Soft objects (cotton wool, paper): alligator forceps or suction.
• Organic matter (seeds, beans): avoid water irrigation because it swells the object; use hook, forceps or suction.
• Irrigation with warm water (body temperature) is acceptable for non-organic objects when the drum is intact.
• Button battery: emergency removal; do not irrigate or use oil; use a hook or magnet. After removal, irrigate the canal with 0.25 percent acetic acid or normal saline to neutralise alkaline leakage.
• Pharmacological: after removal, treat canal injury or infection with topical ciprofloxacin 0.3 percent drops, 3 to 5 drops twice daily for 5 to 7 days. Analgesia with paracetamol 15 mg/kg (children) or 1 g (adults).
• Procedures: general anaesthesia and operating microscope for an impacted, deeply situated or unsettled child, or after two unsuccessful attempts.
• Special groups: children who are uncooperative need sedation or general anaesthesia. Look for objects in the nose and other ear.
• Red flags: button battery, sharp object, tympanic membrane perforation, facial weakness, vertigo, bleeding, hearing loss and cerebrospinal fluid leak.
• Follow-up: review at 1 week for infection or perforation. Audiometry if hearing loss persists.