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You may opt-out of email communications at any time by clicking on the unsubscribe link in the e-mail. The management of ear canal foreign bodies (ECFB) in children can be challenging. Many ECFB, including pebbles, beads, and other small objects, are readily removed by general practitioners and emergency physicians. Occasionally an ECFB is difficult to remove and requires the use of specialized approaches and techniques or referral to an otolaryngology service, as the following two cases illustrate. Case data Upon arrival at BCCH the following day, the patient had no nystagmus or facial weakness. After a blood clot was aspirated during examination of the ear with the patient under GA, the bead was found lodged tightly and completely within the middle ear, medial to the handle of the malleus, which had been fractured medially. With much difficulty the bead was tilted away from the stapes in an anteriorinferior direction and removed using a right-angle hook [Figure 1]. This procedure took about 20 minutes. Reinspection showed that 80% of the tympanic membrane was missing. The incus and stapes were obscured by the tympanic remnant, mucosal edema, and blood. The patient was treated with ciprofloxacin and dexamethasone otic (Ciprodex drops). The next day a pure tone audiology assessment revealed a mild to moderate left conductive hearing loss with mild left sensorineural hearing loss. Hearing in her right ear was normal. The patient was examined again under GA 2 weeks later. Microotoscopy revealed a 70% tympanic perforation and a small posteroinferior medial ear canal web, which was then divided. There was no growth of squamous epithelium in the middle ear. The patient experienced intermittent vertigo for 2 months and headaches for 3 months post-op. At that time the patient still had mild to moderate conductive hearing loss in the left ear. A large perforation of the left tympanic membrane was observed, and ossicular chain disruption was suspected. The patient was given a hearing aid and preferential seating in her classroom. Despite water precautions the patient had several episodes of purulent left otorrhea, which were treated effectively with Ciprodex drops. Tympanoplasty was performed 9 months after the initial injury; the middle ear was found to be dry, but there was granulomatous tissue within the posterosuperior ear canal and covering the incus long process, stapes, and oval window. There was also blunting of the posterior annular angle and there were posteroinferior middle ear scar adhesions. Four months after tympanoplasty, the patient was found to have a much smaller tympanic perforation and a slight to mild conductive hearing loss. Her hearing aid has been adjusted and further surgery will be considered if the perforation does not heal completely. In case 2, a 6-year-old female presented to the ER with a popcorn kernel in her ear. Initial attempts to remove the kernel with a curette were unsuccessful. An attempt was then made to remove the kernel by applying cyanoacrylate (superglue) to the wooden end of a cotton-tipped swab and inserting this into the ear canal. Unfortunately, the glue made the kernel adhere to the ear canal skin. Subsequent microotoscopy in the pediatric otolaryngology clinic revealed that the dried glue and popcorn kernel formed a 95% middle ear canal obstruction. There was no space to insert a right-angle hook to extract the foreign body complex. Since the patient already had a surgery date for another elective procedure 9 days later and had no pain or inflammation from the foreign body, ECFB removal was planned for the upcoming GA. The night before the surgery the patient’s father saw a portion of the glue at her auricular meatus, grasped this with his fingers, and removed the glue and popcorn kernel together in one piece [Figure 2]. The next day the residual ear wax was removed under GA and there was no evidence of any foreign body remnants or trauma to her ear canal or tympanic membrane. Discussion The old adage “If at first you don’t succeed, try, try again” certainly does not apply to removing objects from children’s ears. Multiple attempts at ECFB removal are associated with increased risk of pain, bleeding, patient anxiety, loss of cooperation, and serious otologic complications. Uncommon but potential otologic complications of ECFB removal include ossicular chain damage, sensorineural hearing loss, vertigo, facial nerve paralysis, and meningitis. Marin and Trainor found that in 244 ER patients with ECFB, 80% had the foreign body removed successfully by emergency physicians and 12% experienced complications. Failure to remove the ECFB and complications secondary to ECFB removal were both associated with multiple attempts at removal and the use of multiple instruments. Of those patients subsequently referred to an otolaryngology service for removal, 26 foreign bodies were removed in the otolaryngology clinic while 14 were removed in the OR. This study concluded that referral to otolaryngology should be considered when more than one attempt or more than one instrument is needed to remove an ECFB.[2] After examining 738 ECFB cases, Singh and colleagues drew the somewhat radical conclusion that an otolaryngology service should be involved in the management of all ECFB cases.[3] Clearly this conclusion is not compatible with the current standard of practice in BC, where many ER physicians have become skilled at removing foreign bodies in uncomplicated cases. Challenges High-risk ECFB situations appropriate for referral to an otolaryngology service can be identified based on the characteristics of the foreign body, its relative size and location within the ear canal, the presence of trauma to the canal, and the number of attempts already made.[1] While the majority of foreign bodies are removed without serious consequences, complex cases require cautious management given the potential morbidity associated with failed attempts at ECFB removal. Approaches and techniques A voroscope (e.g., LumiView) is a moderate-cost alternative that permits “tunneled” binocular vision with less magnification but with more maneuverability. This is useful for less cooperative patients and for settings outside the otolaryngology clinic. Given the expense and limited availability of magnification and lighting equipment, a relatively low-cost alternative is a standard headlamp from an outdoor equipment store. Techniques for ECFB removal rely on various instruments and aids, including the right-angle hook, otologic forceps, and cynanoacrylate (superglue) on the wooden end of a cotton-tipped applicator. Other approaches that might be considered involve using suction, applying mineral oil, or irrigating the ear canal. Summary Effective identification of high-risk cases and successful treatment of low-risk cases by ER physicians can be facilitated by adopting an individualized treatment approach. This is best based on a rational analysis of multiple variables, including patient characteristics and degree of cooperation, physician comfort and skill level, ECFB characteristics, and the availability of appropriate equipment. Repeated attempts at removal increase the risk of complications and should be undertaken with care, if at all. Because of the potentially serious consequences of failed ECFB removal in pediatric populations, referral to an otolaryngology service should be contemplated in situations involving one or more unfavorable factors for ECFB removal. References1. Heim SW, Maughan KL. Foreign bodies in the ear, nose, and throat. Am Fam Physician 2007;76:1185-1189. Mr Dance will graduate from the University of British Columbia Medical School in 2009. Dr Riley is a pediatrician in the Department of Emergency Medicine at BC Children’s Hospital and UBC. Dr Ludemann is a clinical associate professor in the Division of Otolaryngology at BCCH and UBC. D. Dance, BSc, LLB,, M. Riley, MD, FRCPC,, P. Ludemann, MDCM, FRCSC,. Removal of ear canal foreign bodies in children: What can go wrong and when to refer. BCMJ, Vol. 51, No. 1, January, February, 2009, Page(s) 20-24 - Clinical Articles.Above is the information needed to cite this article in your paper or presentation. The International Committee of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally accepted citation style for scientific papers: About the ICMJE and citation stylesThe ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. 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For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit www.icmje.org Which of the following is a method for removing a foreign object from the ear?If the object is easy to see and grasp, gently remove it with tweezers. Use water. Only wash out the ear canal if you don't think there is a hole in the eardrum and no ear tubes are in place. Use a rubber-bulb syringe and warm water to wash the object out of the canal.
Which instrument is used remove foreign body from ear?For the removal of objects from the ear, you will need specula in several sizes, a handheld operating otoscope, alligator forceps, suction tips, wire loops, right-angle hooks, and curettes (Figure 1). The use of a basic surgical microscope is recommended if one is available.
What is the first aid treatment for foreign bodies in the ear?If the object is easy to see and grasp, gently remove it with tweezers. Use water. Only wash out the ear canal if you don't think there is a hole in the eardrum and no ear tubes are in place. Use a rubber-bulb syringe and warm water to wash the object out of the canal.
How are foreign bodies removed?EAC foreign bodies can be removed via either direct visualisation or with microscopy. Objects that are graspable have higher removal success rates under direct visualisation, which is freely available in the primary care setting.
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