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Answer: Pediatric Aural Foreign Body

Background:

• Foreign bodies are a common presenting complaint in pediatric emergency departments.
• Typically begin after development of the pincer grip (9 months).¹
• ADHD is considered an important risk factor for auricular foreign bodies due to increased impulsivity and inatentiveness.²

Epidemiology:

• Foreign bodies account for approximately 11% of all pediatric ENT emergencies.²
• 38% of all pediatric foreign bodies will be aural.²
• 22% of patients with a foreign body of the ear, nose, or throat will have a subsequent episode.²
• Beads are the most common aural foreign body (21.2%).¹
• Typically presents in ages 9 months – 8 years.^1-3
• More common in boys (1.48 to 1 ratio).¹

Clinical Presentation:

• Clinical manifestation can vary widely based on the characteristic of the foreign body and the timing since insertion.
• Symptoms can include otalgia, hearing loss, bleeding, dizziness/vertiginous symptoms.²
  • Animate foreign bodies like insects may cause excoriations of the auditory canal.⁴
  • Organic materials are more likely to cause local tissue reactions.⁴
• Much like esophageal and nasal presentations, button batteries require emergent removal due to risk of corrosion and liquefactive necrosis.^4-6

Evaluation/Diagnosis:

• Diagnosis typically made by direct visualization of foreign body.
• Important to evaluate both ears as well as nares as it is not uncommon to have foreign bodies in multiple orifices.
• Must attempt to rule out tympanic membrane (TM) rupture prior to attempted removals.^6,7

• Evaluate position of foreign body and condition of auditory canal.
• Assess for risk factors which make successful removal less likely.
  • Age < 5, non-graspable foreign object, comorbid behavioral disorders.⁸
• Inquire about previous episodes of foreign bodies.
  • Although uncommon, repeated foreign bodies may be a manifestation of Factitious Disorder Imposed on Another.⁶

Management:

• Success rate of removal by ED providers varies heavily in the literature (ranging from 7-85%).^1,8,9
• Factors that decrease rate of successful removal include round object, previous removal attempts, present for greater than 24 hours, touching the TM.^9,10
• Organic objects (such as peas or beans) are more urgent for removal than inorganic objects (like beads).^4,5
  • More likely to cause local inflammatory reaction leading to tissue/canal swelling.^4,5
  • Should not be irrigated due to risk of expansion.⁶
• Animate Objects (insects)
  • First step is asphyxiation with mineral oil or viscous lidocaine.^4-6
  • Successful complete removal in only 65% of cases.⁹
  • After removal, important to re-examine for retained pieces as insects frequently removed in piecemeal fashion.
    • May require gentle irrigation for removal of small components like legs/wings.
•  Disk batteries
  • Should not be irrigated as this can increase corrosive effect.^4,6,7
  • Similarly, attempted removal that causes bleeding may increase corrosive effect.⁶
  • Early consultation to ENT if difficulty with removal is encountered.
• Sharp objects should prompt ENT consultation and/or referral.^6,10
• Tightly packed objects near the TM should be referred to ENT in the outpatient setting for removal via otomicroscopy.⁶
• After removal, re-examine the ear for canal irritation/lacerations, retained foreign bodies, TM ruptures, underlying otitis media.
  • As many as 5.3% of patient will have an underlying otitis media.¹⁰
• Removal Techniques
  • Most common ED approach is direct visualization with otoscope and removal with alligator forceps.¹⁰
  • Hooks, curettes, or loops may be used in objects that are not graspable by forceps.
    • Increased risk of perforation due to need to pass these beyond the visualized foreign body.⁷
  • Otomicroscope increases rate of successful removal over direct visualization in one retrospective study (83% vs 64%).
  • Irrigation
    • Contraindicated with TM rupture.
    • Should be completed with body temperature water aiming at the superior portion of the canal.⁷
      • Body temperature water decreases the risk of inner ear stimulation inducing vertigo, nystagmus, and nausea.⁷
    • If no dedicated equipment can use a 20cc syringe attached to 14-16 gauge angiocath or butterfly tip with needle removed.^6,7

• Suction can be utilized but may be difficult due to loud noise limiting patient cooperation.⁷
• Balloon tipped catheters may be utilized though carry risk of perforation of TM.
• Glue tipped cotton tipped applicators may be used if object is visualized and dry.⁷
  • Higher rate of complication and damage to the canal.¹
• Otic antibiotics should only be given if auditory canal is inflamed, lacerated/excoriated, or TM rupture is present.⁶
  • May also consider prophylactic if the patient has high risk features such as immunodeficiency, diabetes, etc.
  • Coverage for otitis externa, including pseudomonas coverage.

• Consider procedural sedation to aid in removal if needed.

Complications:

• Minor complications include: excoriations, bruising, minor lacerations/bleeding from the external auditory canal.^1,8
• Major complications include TM rupture, ossicle damage.^1,8
• Most common complication is canal excoriation/lacerations (47%).
• Rate of TM rupture 4.2%.¹⁰
• Rate of complication from attempted removal in the ED is approximately 6-20%.^8,10
  • Majority of these will be minor complications.
• Factors that increase risk of complication include previous removal attempt (47% vs 20% in one study), increased duration of foreign body presence, proximity to TM.^1,9,10

Pearls:

• Disc batteries should never be irrigated due to the risk of increasing corrosive effects.
• Antibiotics should only be initiated if signs of inflammation/lacerations are present after removal.
• Live insects should be asphyxiated with mineral oil or viscous lidocaine prior to removal.
• Organic objects such as peas or beans should not be irrigated due to risk of expansion.