Exploration is a normal part of childhood. Unfortunately, this may cause the common pediatric problem of small foreign objects placed in the external auditory canal or nasal cavity. Simple removal techniques may be attempted first, such as normal saline irrigation through an 18-gauge catheter or using vasoconstrictive nasal solution to reduce mucosal edema and having the patient blow forcefully. Irrigation is contraindicated if tympanic membrane perforation is suspected.
Attempts to remove foreign bodies should be made under direct visualization. Use care to avoid pushing the object deeper. Hard, spherical objects may be especially difficult to remove because they cannot be grasped and may easily be pushed deeper. Metallic objects may sometimes be removed with a small magnet. Other objects, such as plant materials or seeds, can swell over hours if left in place or if saline is used to flush them out.
If local anesthesia is needed for removal of an object from the auditory canal, place the affected ear in the nondependent position, and instill 2% lidocaine or 20% benzocaine into the canal, allowing it to remain for 10 minutes. This is especially useful with an insect in the ear. Many insects, especially cockroaches, grasp the lining of the canal to resist extraction. Local anesthetic provides anesthesia, and it kills the insect, making it easier to remove. Do not use local anesthesia if the tympanic membrane may be disrupted. Oral, intravenous, or general anesthesia may be necessary in individuals who cannot tolerate instrumentation.
Complications are usually minor. Trauma to mucous membranes with or without associated infection or bleeding is a possibility. The clinician must also be careful not to push the object deeper, making it harder or impossible to extract the foreign body. Care must be exerted to prevent serious trauma to the tympanic membrane or middle ear during removal. Otitis externa is a common sequelae of injury caused by the foreign body itself or by its removal. The patient may experience nausea or vomiting before or after removal of an object in the ear.
After the procedure, instruct the patient to watch for signs of infection. If mucous membrane injury occurs, have the patient return for a follow-up visit in 1 or 2 days. Saline irrigations two to three times each day for 2 or 3 days may be used after nasal foreign body removals.
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INDICATIONS
CONTRAINDICATIONS
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PROCEDURE
If desired, instill a topical anesthetic. Use suction as necessary to remove liquids or debris to visualize the object. With adults, visualization of the external auditory canal is accomplished by pulling the auricle upward and backward to straighten the canal (Figure 1A). In children, the auricle is pulled downward to aid in visualization (Figure 1B). Extending the head and applying upward pressure on the tip of the nose helps to visualize the nasal cavity (Figure 1C).
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(1) The external auditory canal in adults can be visualized by pulling the auricle upward and backward to straighten the canal, and the external auditory canal in children can be visualized by pulling the auricle downward. |
PITFALL: Suction of the auditory canal produces a loud, scary stimulus to children.
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Grasp fibrous objects (e.g., cotton, cloth, gum, insects) with the alligator forceps, and gently extract them. Use local anesthetic to remove insects because it provides anesthesia and kills the insect. Alligator forceps are valuable aids in removing nasal cavity foreign bodies.
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(2) Grasp fibrous objects with the alligator forceps, and gently extract them. |
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Smooth objects that are not tightly blocking the canal, such as beads, beans, seeds, or popcorn kernels, may be removed using a small hook. Steady the operating hand by placing the wrist or hand against the patient. Pass a right-angle hook (i.e., attic hook) beyond the object (Figure 3A), turn the hook 90 degrees (Figure 3B), and gently withdraw the object and the hook (Figure 3C). This same technique is useful for nasal cavity foreign bodies. Alternatively, small objects may be flushed out as described in Chapter 57.
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(3) Smooth objects that are not tightly blocking the canal may be removed with a small (attic) hook. |
A right angle (attic) hook may be made by dulling the tip of an 1½-inch needle and then bending the last 2 mm at a 90-degree angle.
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(4) An attic hook can be made by dulling the tip of a 1½-inch needle and bending the last 2 mm at a 90-degree angle. |
PITFALL: Remove small batteries quickly, because permanent damage to the ear can result if they are allowed to remain for more than a short time.
PITFALL: Insertion of a needle can damage the canal. Make sure the end has no sharp edges before insertion.
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CODING INFORMATION
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INSTRUMENT AND MATERIALS ORDERING
Instruments such as suction tips, alligator forceps, ear curettes, attic hooks, ear speculums, or nasal speculums may be obtained from most national supply houses, such as http://www.AllHeart.com-Professional Appearances, Inc., 431 Calle San Pablo, Camarillo, CA 93012 (fax: 805-445-8816; http://www.store.yahoo.com/allheart/index.html) or MD Depot, 7590 Commerce Court, Sarasota, FL 34243 (phone: 888-355-2606; fax: 800-359-8807; http://www.mddepot.com).
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