Author: Charlotte Davies and Olu Adenugba / Editor: Nikki Abela / Codes: PAP8 / Published: 13/03/2018
Children (mainly), and even some adults, like to put a range of objects in any orifice they can find. Once they’re in, they come to us in the ED to sort out whether they’re really there, and how best to extract them. Here is some collective wisdom on how to remove foreign bodies from the ears and nose.
As with anything, remember to start by building a good rapport with the child and their parent. Whichever method you use to retrieve a foreign body, it will be significantly easier if the child is relaxed, and trusts you. If they require sedation for removal of a foreign body, consider referral to ENT to maximise the chance of a first pass success.
Extracting foreign bodies from the ear can be very painful, and it is easy to accidentally cause impaction where the auditory canal narrows. 75% of patients with ear foreign bodies are younger than eight, and children most frequently have food and inorganic matter in their ears. Adults most often present with living insects in their ears.
Children don’t always know that a foreign body is present – symptoms may be ear pain, fullness, or impaired hearing. Or they may not present until later with an associated otitis externa and purulent discharge. Tinnitus, vertigo, significant hearing loss or bleeding should also raise suspicion, though these are uncommon.
To start with:
- Position the patient comfortably and securely
- Check whether you should be removing this. ENT should help with button batteries, sharp objects, tightly wedged foreign bodies, and foreign bodies you are unable to remove after a few attempts.
Button batteries cause tissue necrosis very quickly, so if I didn’t have ENT in my hospital, I think I’d have a single attempt at removing the battery before referring, as a lot of damage can be caused if there is a delay in getting definite treatment.
- Check if there’s a tympanic membrane perforation. If you can’t see whether there is or not because the foreign body is obstructing, that makes things trickier. If there is a perforation, still proceed, but don’t put any liquids in the ear, and then refer to ENT as per your local pathway. If you’re not experienced at removing foreign bodies, refer these patients to ENT as there is a risk of pushing the object into the perforated tympanic membrane, and therefore the inner ear. If you’re not sure, proceed with caution – you don’t want to extract anything that is embedded in the tympanic membrane.
- Consider anaesthetising the ear – some lignocaine dripped in may well help, although the rate of success of topical anaesthesia is low.
Nerve blocks could be considered. However if the patient won’t stay still for ear retrieval, they’re unlikely to stay still for a nerve block.
If a standard approach fails, consider referral for general anaesthesia or sedation.
- When successfully removed, double check you’ve removed the whole thing, and there is nothing remaining. Check the other ear just in case!
- Discharge the patient with appropriate safety net advice.
- Consider prophylactic antibiotic drops if there has been an abrasion of the skin.
- If you can’t remove the foreign body, an ENT review the next day is appropriate unless the patient has severe pain, suspected tympanic membrane rupture or button battery entrapment.
If the FB is “graspable” then you could use a crocodile forcep to attempt removal. I often find that if you’re using forceps you need to hide them from the patient’s vision as they look at them, and think they’re a scary option. I like using forceps for organic matter, as raisins are often “graspable”.
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). Don’t aim the water directly at the TM- as this can cause perforation. Aim at the side of the ear canal and it will swirl around the canal, which dislodges the FB more successfully.
3. Modified Suction
Most emergency departments don’t have micro-suction 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.
The standard yankauer suction catheters are too big for the ear.
The pressure should be set at 100-140mmHg. Remember to warn the patient that it will be noisy as otherwise they may jolt!!
4. Glue (a risky strategy!)
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 have to be pretty convinced that you’re going to get the foreign body out, and not just stick the FB further to the ear canal! If you are using this technique, 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. [Editor’s note: this method should only be used by those experienced in using it – if you’ve never done this before – this is not for you]
5. Magnets (a riskier strategy!)
Theoretically, a small magnet may help to remove a magnetic foreign body. Who has a magnet in their emergency department? Yes, I know we should all have them in resus for turning off our internal defibs – but I’m not sure they’re small enough for an ear. (Also, make sure you don’t drop the magnet into the ear).
Nasal foreign bodies are surprisingly common. The removal technique is not too dissimilar to that of removing auricular foreign bodies. In theory, they might be hidden behind a turbinate and tricky to see – and therefore tricky to remove. So if you can’t see a foreign body, but have a high clinical suspicion, refer to ENT for a naso-endoscope. Most nasal foreign bodies rest on the anterior or middle third of the nose, and are unlikely to show up on x-ray.
Like with ears, patients don’t always tell you they have a nasal foreign body, so maintain a high index of suspicion in patients who present with unilateral purulent discharge, unilateral sinusitis or recurrent unilateral epistaxis. Like in ears, button batteries must be removed as soon as possible as they can cause significant injury within hours to days.
1. Mother’s Kiss
This works in 60% of cases. Occlude patent’s other nostril. Get Mum (or Dad) to blow into the patient’s mouth. You can do the “kiss” with a bag valve mask if needed – but be careful the pressure isn’t too high. Older children might be able to “blow their own nose”.
One textbook suggests this should be used with Sellick’s manoeuvre too (cricoid pressure) to prevent air passage into the oesophagus. I suspect that the forced pressure causes the epiglottis to do this more effectively.
Like with foreign bodies in the ear, gentle suction can help and remember to suction slowly and start from the inferior part of the nostril.
3. Curved Probe
A jobson horne probe is useful if your department has it. If you can’t find one, as we can never find them in the ED, you can get a paperclip, open it up and form a small loop with one end so you can use it as a scoop.
A small foley catheter size 6-8 (if you can get hold of one) should be used. First, check that the balloon is functional. Insert the catheter with balloon deflated past the foreign body, then inflate the balloon with 1-3mls of air and pull gently, being sure not to cause any trauma to the nose. The foreign body comes out with the catheter.
You should refer nasal foreign bodies immediately to ENT if you can’t remove it, and not wait until the next day like with ear foreign bodies- as there is a risk of aspiration of the foreign body in the sleep!
Good luck trying to get your foreign bodies out. Remember – a calm, happy patient and parent makes your job easier. It’s well worth investing the time at the beginning of your consultation to do this.