Foreign Body in the Ear

Objects in the external auditory canal, most often in children aged 2 to 8 years, in adults with cognitive impairment or psychiatric illness, and in anyone who uses objects to relieve itch. The clinical urgency and technique are determined entirely by what the object is.

Categories that determine management

• Inanimate inorganic: beads, small toy parts, pebbles, paper, cotton wool from bud tips, broken hearing aid components. Usually not urgent.
• Organic: seeds, beans, peas, food. These absorb water and swell, so irrigation is contraindicated and delay makes removal harder.
• Live insects: cause intense distress, pain and noise, and can lacerate the canal and drum by movement. Must be killed before removal.
• Button batteries: a true emergency. Current flow generates hydroxide at the negative pole with liquefactive necrosis of canal skin, tympanic membrane and ossicles within hours, and can produce facial nerve injury and permanent canal stenosis.
• Magnets, particularly paired neodymium magnets straddling the tympanic membrane, which cause pressure necrosis and perforation.
• Superglue, which sets hard and requires theatre.

The canal has two natural narrowings, at the junction of the cartilaginous and bony portions and at the isthmus. Objects lodged medial to the isthmus are far harder to remove and injury during blind attempts becomes likely.

• Frequently asymptomatic and discovered incidentally, particularly with beads and inert objects.
• Otalgia, aural fullness, hearing loss, bleeding or discharge.
• Chronic foul unilateral discharge in a child is a foreign body until proven otherwise.
• Insects: loud buzzing, movement sensation, severe pain, agitation.
• Battery: rapidly increasing pain, black or grey staining of the canal, necrotic slough, and bleeding.
• Vertigo, facial weakness or marked sensorineural symptoms indicate middle ear penetration.

Examination

Otoscopy identifies the object, its position relative to the isthmus, and any canal trauma. Assess the tympanic membrane where possible. Always examine the other ear, the nose and, in small children, consider ingestion or aspiration of a similar object.

• Otoscopy or microscopy is definitive. Document object type, position, canal condition and drum integrity before any attempt.
• Facial nerve function must be documented in every case involving a battery, penetrating injury or bleeding.
• Computed tomography of the temporal bone when there is suspected ossicular disruption, facial palsy, vertigo, sensorineural hearing loss, penetrating injury, or a retained battery with tissue destruction.
• Pure tone audiometry after removal in any case with bleeding, perforation, vertigo or a penetrating mechanism.
• Radiography is not needed for radiolucent objects but confirms position and orientation for a suspected battery.

The single attempt principle

The first attempt has the highest success rate. Each subsequent failed attempt causes oedema, bleeding and pain, converting a straightforward office procedure into a general anaesthetic. In a child who will not stay still, do not attempt removal in the clinic. Refer.

Technique by object type

• Irregular, graspable objects such as paper, cotton wool and foam: crocodile or alligator forceps under direct vision.
• Smooth spherical objects such as beads and pebbles: a right angled hook or Jobson Horne probe passed beyond the object and withdrawn, or a suction tip. Forceps push these medially and must not be used.
• Light debris: microsuction.
• Irrigation is acceptable only for small inorganic objects with a confirmed intact tympanic membrane, and never for organic material, batteries or where perforation is suspected.
• Balloon catheter techniques, in which a small catheter is passed beyond the object, inflated and withdrawn, are useful for round objects.
• Cyanoacrylate applied to a probe tip can lift smooth objects, but risks adherence to the canal skin and drum.

Live insects

• Immobilise before attempting removal. Fill the canal with 2 percent lidocaine solution, which kills or immobilises the insect within a few minutes and provides analgesia, or use mineral oil, olive oil or ethanol.
• Do not use lidocaine or oil if a perforation is suspected.
• Remove with forceps and microsuction, ensuring no fragments such as legs or wings remain, since retained fragments cause persistent otitis externa.

Button battery

• Immediate removal, ideally within hours. Escalate directly to otolaryngology.
• Do not irrigate and do not instil oil or any liquid. Moisture accelerates hydrolysis and tissue injury.
• Remove under the microscope, with general anaesthesia if the patient is uncooperative or the battery is medial and impacted.
• After removal, assess the canal, tympanic membrane, ossicular chain and facial nerve. Obtain computed tomography where destruction is evident.
• Debride necrotic tissue, apply ciprofloxacin with dexamethasone drops, and arrange close follow up with repeated microsuction, since canal stenosis and cholesteatoma are recognised late complications. Audiometry at 4 to 6 weeks.

Indications for removal under general anaesthesia

• Uncooperative child or adult.
• Object impacted medial to the isthmus or against the tympanic membrane.
• One or more failed attempts, with canal oedema or bleeding.
• Penetrating object, suspected or confirmed tympanic membrane perforation, ossicular involvement.
• Button battery that cannot be removed immediately and atraumatically.
• Sharp objects and hard organic material that has swollen.

After removal

• Inspect the canal and drum. Document any laceration or perforation.
• Ciprofloxacin 0.3 percent with dexamethasone 0.1 percent, 4 drops twice daily for 5 to 7 days when the canal is abraded or contaminated. This preparation is safe if the drum is perforated.
• Water precautions until healed.
• Audiometry when there is any hearing symptom, bleeding or perforation.
• Perforation caused by the object or by removal is managed as traumatic perforation, with the majority healing spontaneously within 3 months.

Complications

• Canal laceration, haematoma and secondary otitis externa.
• Tympanic membrane perforation and ossicular dislocation, most often incudostapedial separation, presenting as a conductive loss exceeding 40 dB after the ear is clear.
• Sensorineural hearing loss and vertigo from stapes footplate injury or perilymph fistula, which requires urgent exploration.
• Facial nerve injury.
• Retained fragments causing chronic granulation and discharge.
• Late canal stenosis and secondary cholesteatoma after battery injury.

Prevention advice

Counsel parents about small objects, batteries in toys and remote controls, and reinforce that nothing should be placed in the ear canal by children or adults.