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Thursday, 6 July 2017

Ear Foreign Bodies

Extracting foreign bodies from the ear can be very painful, and it is easy to impact them where the auditory canal narrows. 75% of patients with ear foreign bodies are younger than eight.

To start with:
- Check if there's a tympanic membrane perforation. If you can't see whether there is or not, that makes things trickier.
- Position the patient comfortably and securely
- Consider anesthetising the ear - some lignocaine dripped in may well help. Blocks don't tend to be too helpful - if this fails, think about general anaesthesia or sedation.
- Check whether you should be removing this. ENT should help with button batteries, sharp objects, tightly wedged FBs, and FBs you can't remove after multiple attempts.
- When successfully removed, double check you've removed it. Consider prophylactic antibiotic drops.

Potential Methods: 
1. Forceps Removal
If the FB is "graspable" this can be useful.

2. Irrigation
This is especially useful if there is a live insect in the ear. The insect must be killed with alcohol, 2% lignocaine or mineral oil - but hopefully you can check there is no tympanic membrane perforation first. Once the insect is dead, suction might remove it more effectively than grasping or forceps as this can cause shedding. Until the insect is dead, remember it might try to fly towards the otoscope light - this can be uncomfortable for the patient!
Don't irrigate button batteries in the ear.
Don't irrigate organic matter that might swell, and get wedged.
Don't forget to use warm water - as the patient won't thank you if the water is cold, as it can cause vertigo and vomiting. If you're having trouble directing the irrigation, think about getting a cannula (needle out) connected to a syringe (that you can gently flush).

3. Modified Suction
We don't have microsuction like ENT do, but cutting a 12Fr suction catheter short, and then applying gentle suction, may help. Equally, cutting the soft tubing from a butterfly needle, and using that for suction may help.

4. Glue
A bit of wound glue on the end of a syringe or Q tip can adhere to the foreign body and pull it out. You're going to have to be pretty convinced you're going to get the Foreign Body out, and not just stick the FB further to the ear canal! If you do this, it might be worth putting an ear speculum on the foreign body, then guiding the glue in that way - it protects the rest of the ear canal. You really do need a compliant patient.

5. Magnets
A small magnet may help remove a magnetic foreign body.

References
https://www.aliem.com/2017/05/pem-search-rescue-ear-foreign-bodies/
http://www.bcmj.org/article/removal-ear-canal-foreign-bodies-children-what-can-go-wrong-and-when-refer
https://www.aliem.com/2011/06/trick-of-trade-mini-suction-device/
https://www.aliem.com/2015/08/trick-of-the-trade-ear-foreign-body-removal-with-modified-suction-setup/
http://www.emdocs.net/ear-nose-throat-foreign-bodies/ 
AFP
https://www.aliem.com/2014/10/trick-of-trade-insect-removal-from-the-ear/ 
https://www.aliem.com/2016/08/trick-of-trade-ear-irrigation/ 
https://www.aliem.com/2012/05/trick-of-trade-ear-foreign-body-2/ 
http://pedemmorsels.com/ear-foreign-body/
http://emj.bmj.com/content/17/2/91 
http://www.pemed.org/blog/2014/4/9/anyone-seen-my-corn-pediatric-foreign-bodies.html
http://emj.bmj.com/content/22/4/266
https://wikem.org/wiki/Ear_foreign_body 
http://emblog.mayo.edu/2017/04/04/stick-glue-and-cone-for-ear-foreign-bodies/
https://entsho.com/removing-foreign-bodies/

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