In a cooperative patient, it is possible to remove an FB from the external auditory canal by a single provider. Depending on how cooperative the patient is, one or more assistants may be required to maintain the patient in the proper position and keep the patient still. This is especially common in pediatric patients.[5]

Evaluation should include noting any injury to the external auditory canal and tympanic membrane (TM) before removal attempts. The patient's hearing should also be assessed, especially if there is suspicion for TM injury/perforation or middle ear injury once the FB is removed. If the patient is complaining of hearing loss before the FB is removed, audiometry or tuning fork testing should be used to ensure an appropriate conductive loss is demonstrated. If the hearing loss is greater than expected, or a sensorineural hearing loss is encountered, the patient should be urgently referred to an otolaryngologist for evaluation and removal, likely in the operating room.

Patient positioning is important. Cooperative patients can either sit or lie down with the affected ear turned towards the provider. For younger children, there are several options for positioning. The patient can sit in the parent’s lap with the parent holding the patient’s body with one hand and the other around the head with the head turned. The patient can also lie down, either supine or prone, on the stretcher with their head turned.[7]

The technique for removal of an FB from the external auditory canal should be based on the initial evaluation of the patient for possible TM injury, the type of FB and location in the external auditory canal, as well as the ability of the patient to cooperate. Before beginning the procedure, the physician should determine how many attempts will be made (usually only one or two) and if more than one attempt is planned, what technique should be used for the subsequent attempt. If unsuccessful after one or two attempts, further attempts should be aborted, and the patient should be referred to an ear, nose, and throat (ENT) specialist. Consider examining the contralateral ear and nose for other foreign bodies as well, particularly in children.

Specific Techniques

Manual instrumentation (e.g., forceps, curettes, angle hook)

These are typically used in conjunction with the operating head of an otoscope, but can also be used with the diagnostic head. Binocular microscopy is ideal, though may not be available in all settings. The pinna should be retracted, and the FB visualized. When using forceps, the FB can be grasped and removed. Both curettes and right-angle hooks should be gently maneuvered behind the FB and rotated so the end is behind the FB, which can then be pulled out.[4]

Irrigation

This can be performed with either an angiocatheter or a section of tubing from a butterfly syringe. Using body temperature water, retract the pinna, and squirt water superiorly in the external auditory canal, behind the FB which will then be washed out of the canal.[4]

Suction

This should be performed with a suction tipped catheter that has a thumb controlled release valve, such as a Frazier tip. Insert the suction against the FB under direct visualization and then activate the suctions and remove the FB, maintaining suction until the FB is completely out of the external auditory canal.[4]

Cyanoacrylate

Apply a small amount of cyanoacrylate or skin glue to the blunt end of a cotton-tipped applicator. Once the glue is tacky, insert it against the FB under direct visualization and hold it in place until the glue dries. Once the FB is secured onto the applicator, it can be removed onto the applicator.[4]

Insect removal

The first step is to kill the insect, which will allow the patient to be more comfortable and allow for removal of the insect after. There are multiple recommended agents for killing the insect. Studies indicate that mineral oil is the most effective, followed by lidocaine.[8] Both can be instilled in the external auditory canal, and once the insect is neutralized, it can be removed by any of the above methods. In practice, lidocaine offers the advantage of anesthetizing the EAC as the insect struggles, which can scratch the EAC and cause pain.[4]

The most common complications from FB in the external auditory canal, and attempts at removal of the FB, include excoriations and lacerations of the external auditory canal. As a result, it is important to document a pre-removal and post-removal exam, noting the presence of any pre-removal injuries. These typically heal rapidly by keeping the external auditory canal clean and dry. Antibiotic eardrops can be considered as well. Much rarer, and much more serious, complications of FB removal include TM perforation or ossicular chain damage. These are potentially devastating and should be avoided at all costs. If the physician is unable to, or uncomfortable, removing EAC FB then the patient should be referred to an otolaryngologist.[7]

Physicians involved in acute patient care can expect to manage patients with an FB in the external auditory canal during the course of their career. As such, it is important to recognize both provider skill and equipment limitations. The type and location of FB in the external auditory canal, along with the ability of the patient to cooperate are the key factors in determining whether an attempt should be made. Referal to a specialist or a location where sedation can be performed is recommended if the FB removal is not practical after the initial evaluation. In general, complications tend to be minor and easily managed.

Successful removal of an ear foreign body requires the cooperation of the patient, and may require the assistance of family members as well as other medical team members. Patient positioning and a well thought out plan are keys to the success of the procedure. Explaining to patients and family what will happen and gaining their cooperation is important. Involving family members and/or staff members for positioning can be very helpful. Another consideration is the use of medications for anxiolysis or procedural sedation to facilitate patient cooperation. This requires appropriate ancillary staff, such as nursing for intravenous line placement and medication administration and possibly anesthesia or respiratory therapy to assist in airway monitoring. With appropriate team coordination this procedure can be performed safely and rapidly with low risk for complication and minimal stress for the patient.