Foreign Body Removal from the Nose and the Ear

T. S. Lian, MD, FACS
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Subject: Foreign Body Removal from the Nose and the Ear

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Introduction

Foreign bodies in the nose or ear are more commonly found in the pediatric population but also present in the mentally challenged adult. The placement of the foreign body is frequently not witnessed. The foreign body may therefore be present for a relatively long period of time with associated soft tissue edema, erythema, or even frank purulence, reflecting the presence of infection. Expansion or swelling of the foreign body may also have occurred if the foreign body is of vegetable or organic material. 
Foreign bodies typically consist of small household items such as plastic beads or organic material including beans or peas. Small batteries deserve special mention because if left in place, a corrosive injury may result. If the foreign body remains relatively proximal to the respective opening, such as in the nasal vestibule anterior to the inferior turbinate or in the external auditory canal lateral to the bony cartilaginous junction, then foreign body removal can usually be accomplished easily in the clinic setting. Typically, the further away the foreign body is from the external meatus of the ear canal or the nares, the more challenging the removal becomes, and otolaryngology consultation should be considered. Because the nasal mucosa and the cutaneous lining of the ear are relatively fragile, one must exercise caution in instrumenting these areas because problematic bleeding can result. Use of irrigation to extract a foreign body from the ear canal is not recommended, particularly if the integrity of the tympanic membrane is not known. 
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. Use of suction with an appropriate suction tip can rapidly remove most insects without the need to use an anesthetic to kill the insect. Oral, intravenous, or general anesthesia may be necessary in individuals who cannot tolerate instrumentation. 

Equipment

  • Otoscope

  • Day hook

  • Nasal speculum

  • Suction and suction tips

  • Head light

  • Alligator forceps

  • Bayonet forceps

Indications

  • Foreign body in the nasal cavity or external auditory canal

Contraindications (Relative)

  • An uncooperative patient or infant who cannot be restrained

  • Marked bleeding

  • Limited visualization

  • Distal location or displacement of the foreign body

  • Trauma-induced distortion of the normal anatomy

  • Previous ear surgery (because of increased risk of perforation)

  • Known or suspected cholesteatoma

The Procedure

Step 1

Assemble the tools for removal of the foreign object. Blunt hooks, forceps, speculums, and suction are the primary instruments used to remove foreign bodies. 

Step 2

Depending on the cooperativity of the patient, the patient can be placed in either a sitting or supine position. To facilitate a traumatic removal, children should be secured so as to avoid movement. With use of an otoscope, the ear canals should be examined to identify the foreign body, including its shape and position. Similarly, the nasal cavity is inspected with use of a nasal speculum and head light. It is important to examine both ears or both sides of the anterior nasal cavity as a contralateral foreign body may be found. 

Step 3

Once the foreign body has been identified and a decision has been made to attempt removal, the appropriate instrument is selected based on the shape of the presenting aspect of the foreign body. For a foreign body in the ear, use an otoscope and blunt-tip hook. The nondominant hand holds the scope while the dominant hand uses the hook. Note how the nondominant hand stabilizes the scope with the patient’s cheek. 

Step 4

Use a nasal speculum and blunt-tip hook to remove a foreign body. 
  • PEARL: Note how using a headlight frees up both hands so that they can be used for instrumentation.

Step 5

Smooth or rounded objects are best removed with use of a right-angled blunt hook such as a Day hook. The hook is introduced such that the hook remains relatively flush to the soft tissues, allowing the end of the instrument to pass distal to the foreign body. The hook is then rotated 90 degrees and withdrawn along with the foreign body. If the foreign body has a broad flat edge, the object may be grasped with forceps and removed. If the foreign body is an insect, suction can be introduced to rapidly suction the insect out. Similarly if the foreign body is particulate, or falls apart when manipulated with forceps or hooks, use of suction maybe most appropriate. 
  • PITFALL: Regardless of which instrument is being used for removal, if manipulation results in displacement of the foreign body further back in the nasal cavity or further down the external auditory canal, attempts at removal should cease and otolaryngology consultation should be considered.

  • PITFALL: If bleeding occurs such that visualization of the object is obscured, attempts at removal should be stopped and otolaryngology consultation should be initiated.

Complications

  • Bleeding

  • Abrasion

  • Infection

  • Perforation

  • Aspiration

  • Nausea or vomiting with removal of an object in the ear

Pediatric Considerations

In some cases, limited cooperation of the pediatric patient may be such that it is safer to perform foreign body removal in an operating room setting under anesthesia to facilitate an atraumatic removal. 

Postprocedure Instructions

After removal of the foreign body, the nasal cavity or ear canal should be examined again for any further foreign bodies as well as to identify any associated injury. 

Removal of Nasal Foreign Body

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. Recommend saline irrigations three times each day for 1 week if mucosal injury has occurred. Obtain an otolaryngology consultation for severe injuries such as septal and turbinate mucosal injuries in apposition to each other. 

Removal of Ear Foreign Body

Instill three drops of antibiotic drops to the ear three times each day for 7 days if ear canal trauma or tympanic membrane perforation is present. Obtain an otolaryngology consultation for persistent perforations. Audiometry and tympanometry testing need to be done if tympanic membrane injury or perforation is present, with otolaryngology consultation as necessary. 

Coding Information and Supply Sources

ICD-9 Codes

Supplies

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 AllHeart.com–Professional Appearances, Inc., 431 Calle San Pablo, Camarillo, CA 93012 (fax: 805-445-8816; Web site: http://store.yahoo.com/allheart/index.html) or Atlantic Medical Supply, 65-14 Brook Avenue, Deer Park, NY 11729 (phone: 516-249-0191; Web site: http://www.atlanticmedsupply.com). 

Bibliography

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