Foreign bodies in the ear

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Foreign bodies in the ear are generally found in the external auditory canal and most often occur in children younger than 8 years of age. Toys (e.g., beads, marbles) are the predominant type of foreign body found in children, while cotton balls, jewelry, and insects are more common in adolescents and adults. Patients with a foreign body in the ear are often asymptomatic but may report symptoms such as a feeling of fullness in the ear, hearing loss, pruritus, otalgia, or discharge. Foreign bodies are diagnosed via otoscopy. Advanced imaging (CT/MRI) may be obtained if bony erosion, ossicular lesions, or other complications are suspected. Management consists of removal of the foreign body, with local anesthesia or procedural sedation as needed. In certain scenarios (e.g., tympanic membrane rupture, unsuccessful removal), specialist involvement may be required.

• Most often occurs in children < 8 years of age ^[2]

Epidemiological data refers to the US, unless otherwise specified.

• Children: mostly toys (e.g., beads, marbles), food ^[2][3]
• Adolescents and adults: cotton balls (e.g., from cotton swabs), jewelry (e.g., earrings), insects ^[2][3]

Patients are often asymptomatic, but they may present with nonspecific complaints (particularly children). ^[2][4]

• A feeling of fullness in the ear
• Hearing loss
• Pruritus
• Otalgia
• Otorrhea (hematic or purulent)
• Cough (due to the Arnold ear-cough reflex)
• Buzzing sound or sensation (if an insect is the foreign body)
• Hiccups

A caregiver's report of an inserted object or nonspecific signs and symptoms may be the only features of ear foreign bodies in nonverbal or very young patients.

• Otoscopy ^[4]
  • For a clear view of the ear canal, retract the pinna of the ear posterosuperiorly.
  • Typical locations of foreign bodies include:
    • Inner end of the cartilaginous canal
    • Isthmus (narrowing of the bony part of the canal)
  • Check for tympanic membrane rupture.
• Advanced imaging (CT/MRI): Consider if bony erosion, ossicular lesions, or other complications are suspected. ^[4]

Especially in children, consider inspecting the other ear canal and both nostrils for additional foreign bodies. ^[2]

Foreign body removal ^[2][4]

Instrument-assisted manual removal and/or irrigation are typically attempted in the emergency department or other outpatient settings.

Preparation

• Consider local anesthetic instillation or procedural sedation as needed.
• Document tympanic membrane perforation (if present) prior to attempting removal.

Removal techniques ^[5]

The appropriate removal technique for each patient will vary based on the type of foreign body and the patient's ability to tolerate the procedure.

• Instrument-assisted manual removal
  • Forceps
  • Blunt right-angle hook or ear curette
  • Balloon-tipped catheter (≤ 18 gauge)
  • Cyanoacrylate-tipped applicator ^[4][5]
  • Suction device
• Irrigation
  • A 20-mL syringe and 14 to 16-gauge catheter are used to irrigate the ear with water or saline. ^[4]
  • Contraindications
    • Button battery
    • Expansile object
    • Suspect tympanic membrane rupture

Removal may cause patient discomfort and/or minor bleeding.

Special considerations

• Insects: Kill or immobilize prior to attempting removal.
  • Avoid hydrogen peroxide due to risk of injury to the inner ear.
  • Local anesthetics (e.g., lidocaine), mineral oil, or alcohol may be used.
• Button batteries: Remove as soon as possible to avoid tissue necrosis and hemorrhage.
• Topical antibiotics (e.g., ofloxacin)
  • Indicated in patients with concurrent otitis externa (see “Treatment of otitis externa”)
  • Consider for patients with tympanic membrane rupture or canal lacerations.

Disposition ^[2][4]

Consult ENT for the following:

• Sedation required for removal
• Trauma to the external auditory canal or tympanic membrane
• Foreign bodies likely to cause tissue damage, e.g., sharp-edged objects, button batteries
• Unsuccessful removal attempts

• Bacterial superinfection (otitis externa, acute otitis media)
• Hearing loss
• Tympanic membrane perforation
• Skin necrosis
• External auditory canal laceration and bleeding

We list the most important complications. The selection is not exhaustive.