Several techniques are available for removal of a foreign body from the external ear. Selection of technique depends on the shape, composition, and location of the foreign body in the canal.
Irrigation: For loose small objects (less than 2 mm in diameter), such as small insects, sand, or dirt
Suction-tipped catheters: For objects that are soft (such as molding clay), that crumble on palpation, or that are round, smooth and difficult to grasp (eg, small beads)
Manual instruments (eg, cerumen loop curettes, right-angle hooks): For removal of a wide variety of objects, including large insects, cotton tips, button batteries, and large beads
If a button battery in the ear cannot be easily removed, an otolaryngologist should be promptly consulted because a battery or magnet can be difficult to remove and can cause significant damage in just a few hours
(See also Foreign Bodies in the Ear.)
Indications for Removing an Ear Foreign Body
A foreign body should always be removed from the external canal.
Removal can be attempted in the outpatient or emergency room setting. However, early consultation with an otolaryngologist should be considered if a few attempts have failed.
Contraindications to Removing an Ear Foreign Body
Absolute contraindications
Irrigation should not be attempted if there is known or suspected perforation of the tympanic membrane. Symptoms suggesting perforation are vertigo, tinnitus, significant hearing loss, or bleeding from behind the object.
Irrigation should not be attempted if the object is soft or a seed or other vegetable matter that may swell when water is added.
Irrigation should not be attempted if the object is a battery or magnet, because water may accelerate damage.
Relative contraindications (otolaryngologist should be consulted)
External auricular canal infection or swelling around the object
Impacted object
Complications of Removing an Ear Foreign Body
Perforation of the tympanic membrane
Infection from retained organic matter or irrigant
Injury (eg, laceration, bleeding, edema) of the external canal
Rarely, damage to the middle and inner ear
Equipment for Ear Foreign Body Removal
Handheld otoscope
Otoscopy speculum: Use the largest speculum that fits into the external canal
For irrigation: 30- to 60-mL syringe filled with sterile water warmed to body temperature and attached to a 16- to 19-gauge catheter or tubing (such as a butterfly cannula with the needle cut off)
Ear suction catheter (#5 or #7 Baron suction with thumb control hole)
Alligator forceps
Right-angle hook or cerumen loop/curette
A headlamp and magnifying loupes if available
Additional Considerations for Ear Foreign Body Removal
Document any preexisting injury to the external canal or possible perforation of the tympanic membrane before the procedure so that this cannot be attributed to the procedure.
Refer to an otolaryngologist if the object has not been removed after a few attempts; there is injury to the external canal or tympanic membrane, perforation of the tympanic membrane, infection of the external canal; the foreign body is smooth, rounded, and not impacted; the object is wedged in the medial part of the external canal or up against the tympanic membrane; or glass or other sharp foreign bodies, disc batteries, magnets, or other foreign objects are present.
Consider procedural sedation and analgesia, especially in children, who rarely are fully cooperative.
Relevant Anatomy for Ear Foreign Body Removal
The anatomy of the external canal varies from person to person and the canal can be tortuous, making removal of hard foreign bodies that are deep in the canal potentially traumatic.
The canal narrows in its midportion, where a foreign body can become impacted.
Positioning for Ear Foreign Body Removal
The sitting or semi-reclined position is used for irrigation so water can flow out of the ear. This is also usually the preferred position for the suction and manual removal techniques so that gravity is not working against the effort to remove the object.
The supine position is sometimes necessary in children and sedated patients to enable an assistant to stabilize the patient's head and prevent withdrawal reflexes.
Consider immobilizing certain children (eg, the very young, those with anesthesia risks or a battery in the ear) using a restraining board or sitting in a trusted adult's lap with arms, legs, and head held firmly; the emotional trauma of being restrained is usually less consequential than that of a prolonged visit plus the risks of general anesthesia.
Step-by-Step Description of Ear Foreign Body Removal
General considerations
Do a pre-procedure screening bedside hearing assessment, depending on the patient's ability to cooperate and on available equipment.
Advise the patient not to move the head, to minimize any trauma that could result from a sudden movement while an instrument is in the ear canal.
Pull (or have an assistant pull) the pinna up and backward (for adults) or down and backward (for children), to straighten the canal.
Visualize the external canal and foreign object before and after removal for each of the following techniques.
Irrigation
Use irrigation for loose small objects such as sand or dirt but not for objects that can swell when wet (eg, seed).
Pain on irrigation is a sign of canal laceration or tympanic membrane perforation and should prompt immediate cessation of the irrigation procedure.
Fill the syringe with body-temperature water and attach the irrigation catheter.
Hold a kidney (emesis) basin under the ear to catch the water.
Inject a stream of water into the superior aspect of the external canal behind the foreign object using moderate pressure.
Inject enough water to flush the object out of the ear; try starting with 30 to 60 mL.
Suction
Begin with suction to remove small insects, or soft, rounded, and smooth objects that are not impacted.
Optimize your view using a headlamp and magnifying loupes if available.
With the thumb-release valve uncovered, insert the suction tip under direct view; avoid contact with the ear canal skin.
Place the tip of the catheter against the surface of the object.
Cover the release valve with your thumb to initiate suction in the catheter.
Slowly withdraw the suction catheter to pull the object out of the ear.
Manual instrument technique
Optimize your view using a headlamp and magnifying loupes if available.
Use an alligator forceps for graspable objects such as paper, insects, or cotton.
Use a right-angle hook or loop for harder objects.
Insert the instrument to the edge of the object under direct visualization.
When using a right-angle hook or curette/loop slip the instrument behind the object and gently pull it out of the canal.
Gently grasp the body, wing, or leg of the insect with an alligator forceps and gently pull the entire insect out of the ear. The body of the insect may fragment if the forceps are used with too much pressure, making extraction more difficult.
You may need to use the suction or irrigation techniques to remove any fragments that remain after using the manual method.
Aftercare for Ear Foreign Body Removal
If pre-procedure hearing was assessed, repeat the examination to ensure no loss of hearing.
For atraumatic foreign body removal, no follow-up or special aftercare is needed.
Warnings and Common Errors for Ear Foreign Body Removal
If manipulating a presumed foreign body results in bleeding, stop further attempts at removal and immediately consult an otolaryngologist. Bleeding may indicate a laceration of the canal skin or that the foreign body is actually a middle ear polyp.
With each of the techniques, be careful not to push the object further into the external canal.
Consider setting a limit for number and/or duration of removal attempts before beginning the procedure.
Ensure that button batteries are removed promptly; refer as indicated.
Tips and Tricks for Ear Foreign Body Removal
In children, the other ear and nose should be examined to exclude additional foreign bodies.
Because the first attempt is the best shot at simple atraumatic removal, obtain optimal cooperation by explaining the procedure to the patient and companions in detail, stressing that the patient will need to remain very still throughout the procedure, even during the expected discomfort.
For hard round objects, the suction and right-angle-hook–removal techniques work best.
The ear canal can swell quickly from multiple attempts at removal. Plan your approach, recruit an assistant, and limit the attempts to minimize trauma.
