Not ’just' a foreign body in the ear canal

Abstract

Foreign bodies are commonly seen by the Ear, Nose and Throat emergency team with cotton wool being the most common aural foreign body seen in the adult population. Most complications secondary to aural foreign bodies described in the literature are minor and rarely require any surgical intervention. Here, we present two cases with impacted cotton wool as aural foreign bodies which resulted in suppurative labyrinthitis and osteomyelitis causing profound sensorineural hearing. These cases highlight the importance of considering aural foreign bodies in the differential diagnosis in those presenting with unilateral symptoms as significant complications, although rare, can occur, particularly in those with delayed diagnosis.

Background

Foreign bodies of the ear, nose or throat are reported to account for 11% of cases seen by Ear, Nose and Throat (ENT) emergency teams.^{1 2} The range of objects which can present as aural foreign bodies varies depending on geographical location, however, common objects include beads, beans, seeds, cotton tips, foam insects, metallic objects and pebbles.^1–3 Indeed, management varies depending on the foreign object present with live insects being killed with olive oil ear drops prior to attempted removal, or button batteries requiring urgent removal prior to the onset of liquefactive necrosis.

In general, foreign bodies are more common in the paediatric cohort or those with learning difficulties.¹ However, it is important to be mindful that many adult patients use cotton buds regularly for relief of auricular pruritus or for the purposes of wax removal. In fact, studies of the aetiology of ear, nose and throat foreign bodies have shown that 13%–18% of all foreign bodies seen by the ENT surgeon are cotton wool and that this is the most common foreign body type seen in adults.^{4 5} The current literature suggests that 75% of patients with aural foreign bodies are asymptomatic at presentation. Of those who are symptomatic, unilateral otalgia, bleeding from the ear, otorrhoea, hearing loss or a feeling of fullness in the ear represent the most common presenting complaints.^{1 3}

The consequences of foreign bodies vary from mild disturbances to significant complications. It has been shown that both increased duration of foreign body impaction and higher number of attempts at removal carry an increased risk of complications.^{1 2} Complications commonly documented in the literature include bleeding, lacerations of the ear canal, tympanic membrane perforation, otitis externa and acute otitis media.^{1 2} In this case series, we present two cases of non-button battery foreign bodies impacted within the ear canal who subsequently developed significant complications rarely reported in the current literature. It is hoped that this article will help to raise awareness of the potentially serious consequences of aural foreign bodies.

Case presentation

The first case involved a female patient in her 50s with a background of asthma and bilateral meatoplasty for chronic otitis externa. She represented to her general practitioner with left-sided otalgia and yellow otorrhoea which was initially managed in the community with gentamicin and hydrocortisone acetate ear drops. One week later, she was referred to her ENT department as she had developed left-sided perichondritis and complaints of left-sided hearing loss which required admission for parenteral antibiotics and, following clinical improvement, was discharged. On outpatient follow-up, her otalgia had improved. However, she complained of significant hearing loss as well as tinnitus and vertigo. She was therefore admitted for further investigation and treatment with intravenous antibiotics.

The second case was a man in his 60s with type 2 diabetes and atrial fibrillation who presented with a 6-week medical history of severe left-sided hearing loss, otorrhoea and post-auricular swelling which did not resolve despite oral antibiotic treatment. On examination, he had a left-sided, fluctuant, erythematous post-auricular swelling with a discharging sinus. On otoscopy, an oedematous ear canal was visible and a polypoidal lesion was noted obscuring the tympanic membrane. He had no medical history of otological surgery on that ear.

Investigations

For the first case, blood test results are shown in table 1. Swabs sent for culture on admission showed light growth of anaerobic organisms. Following clinic review and the development of tinnitus and vertigo, a CT scan of the head with contrast to include a temporal bone window cut was also performed. This revealed an abnormal left mastoid with lateral semicircular canal erosion (figure 1) and a degree of bony loss at the margin of the carotid canal adjacent to the superior eustachian tube (figure 2) with ongoing inflammatory changes around the external auditory canal. There was no intracranial involvement. MRI of the mastoid with gadolinium contrast was also performed to clarify the soft tissue involvement. Pure tone audiogram revealed profound sensorineural hearing loss on the left (figure 3).

Table 1.

Blood results for case 1

	C reactive protein	White cell count (109/L)	Neutrophils
On admission	5	7.1	3.9
On transfer to tertiary centre	11	11.1	6.7
On discharge	8	17.6	14.8

Figure 1.

Coronal view CT temporal bones of case 1; green arrow showing left-sided lateral semicircular canal dehiscence.

Figure 2.

Axial view CT temporal bones of case 1; green arrow showing left-sided bony loss of the carotid canal margin.

Figure 3.

Pure tone audiogram of case 1 showing profound left-sided sensorineural hearing loss.

Meanwhile for the second case, blood results are shown in table 2. Ear swabs taken on admission showed no significant growth. CT head with contrast from admission showed subcutaneous infiltration extending inferiorly from the level of the external auditory meatus around the left parotid gland with erosion of the basal turn of the cochlea, temporomandibular joint erosion and a pocket of post-auricular gas but no intracranial involvement (figures 4 and 5). Pure tone audiogram showed profound hearing loss on the left and moderate-severe hearing loss on the right (figure 6).

Table 2.

Blood results for case 2

	C reactive protein	White cell count (109/L)	Neutrophils
On admission	62	10.2	8.0
On discharge	4	11.0	8.3

Figure 4.

Axial view of CT temporal bones of case 2; green arrow showing erosion of left temporomandibular joint.

Figure 5.

Coronal view of CT temporal bones of case 2; green arrow showing erosion of the left basal turn of cochlea.

Figure 6.

Pure tone audiogram of case 2 showing profound left-sided sensorineural hearing loss.

Differential diagnosis

Both of these patients presented with unilateral otorrhoea and hearing loss with or without tinnitus and vertigo despite initial antibiotic therapy. This presentation should alert clinicians to the possibility of cholesteatoma or a more sinister infective causes such as skull base osteomyelitis or a malignant lateral skull base tumour. In addition, the vigilant clinician should include the differential of an aural foreign body in any patient presenting with unilateral ear symptoms.

Treatment

The first case received regular aural toileting, intravenous antibiotics (co-amoxiclav and clindamycin) and gentamicin and hydrocortisone acetate ear drops at their regional centre prior to transfer to the tertiary centre for mastoid exploration with biopsy consideration due to the bony erosion pattern. Following transfer, she received IV flucloxacillin and metronidazole as well as oral ciprofloxacin. Intraoperatively, a narrow external auditory canal was noted and a cotton wool was found within the canal with a large pars tensa perforation. Further mastoid exploration was performed via a combined approach tympanoplasty to access the middle ear. There was dense inflammatory tissue filling both the tympanic cavity and mastoid with erosion of the long process of incus as well as two defects in the tegmen tympani and a defect in the external auditory canal. The incus was removed and inflammatory tissue biopsied and sent for pathology. Ribbon gauze soaked in betamethasone and clioquinol ointment was inserted, and intravenous antibiotics were continued postoperatively.

For the treatment of the second case, the patient was admitted from clinic as an emergency for broad spectrum intravenous antibiotics. Following 48 hours of treatment, there was subsequent improvement in his inflammatory markers and swelling. However, the decision was made to proceed with mastoid exploration due the presence of a polyp in the external auditory canal in order to exclude a malignancy. Examination under anaesthesia revealed an aural polyp laterally within the external auditory canal arising from the postero-inferior quadrant with a cotton bud foreign body found medial to this polyp, both of which were removed. A large central tympanic membrane perforation was noted intraoperatively. Ribbon gauze soaked in betamethasone and clioquinol ointment was inserted at the end of the procedure.

Outcome and follow-up

Histopathology result from the first case middle ear biopsy reveals focal chronic inflammation with foreign body granulomatous reaction. Patient was discharged to complete a 7-day course of oral ciprofloxacin and was followed-up 5 days postoperatively. This revealed a well-healed post-auricular wound and the sutures were removed. On disclosing the intraoperative findings and further medical history review, patient then recalled an incident of impacted cotton wool prior to the onset of her symptoms. Further follow-up at 6 weeks postoperatively showed some improvement in the patients balance with an ongoing tympanic membrane perforation. Repeat CT at 4 months post-procedure showed a degree of resolution. Unfortunately, the patient has persistent tympanic membrane perforation with constant left ear discharge. The patient has therefore been scheduled for blind sac closure of the external auditory canal.

The second patient was discharged on day 2 post-procedure with a 6-week course of oral clindamycin and ciprofloxacin on advice of the infectious diseases team due to the degree of bony involvement. Postoperatively, the patient’s medical history was reviewed and subsequently, the patient also recalled an incident of dislodged cotton wool in the ear canal which he had initially used to control his otorrhoea. The incident was thought to be insignificant by the patient, thus it was not disclosed to the clinicians initially. Histopathology results of the external ear canal polyp revealed an 8×3×2 mm lesion with squamous mucosa with hyperkeratosis in keeping with an inflammatory aural polyp. Follow-up at 2 weeks postoperatively showed no ongoing otalgia with a dry subtotal tympanic membrane perforation. Further follow-up is planned at 3 months.

DISCUSSION

Here, we have presented two cases of aural foreign bodies, both of which suffered serious sequelae (table 3) leading to suppurative labyrinthitis and profound sensorineural hearing loss. Both cases also depicted that the public view of cotton bud usage in their ear canal as being harmless. Subsequently, dislodgement episodes secondary to its using will most likely be downplayed by patients and might not be voluntarily disclosed to the clinicians if not directly pursued.

Table 3.

Case series summary

Case	Sex	Foreign body	Foreign body sequela	Intervention	Pure tone audiogram
1	F	Cotton wool	Necrotising otitis external suppurative labyrinthitis	Intravenous antibiotics, combined approach tympanoplasty, blind sac closure	Profound sensorineural hearing loss on affected side
2	M	Cotton wool	Acute mastoiditis post-auricular sinus suppurative labyrinthitis	Intravenous antibiotics, removal under general anaesthetic

Most complications secondary to aural foreign bodies documented in the current literature are mild and require no intervention, such as lacerations to the ear canal or bleeding. Tympanic membrane perforations secondary to aural foreign bodies are thought to occur in the region of around 1% of cases.⁴ More severe complications are rarely reported. To the authors' knowledge, our first case represents the first documented case of a patient having developed suppurative labyrinthitis and necrotising otitis externa secondary to aural cotton wool foreign body dislodgement. However, there are previous documented cases in the literature of uncomplicated otitis externa occurring as a complication of a foreign body in the ear with a prevalence of around 0.5%, with the earliest cases occurring 8–14 days following foreign body insertion.⁵ It is well known that the risk of non-iatrogenic complications related to ear foreign bodies increases with duration following insertion.^{1 2} In this case, the diagnosis of a foreign body was not made until 5 weeks since the onset of symptoms and so it is likely that this delay contributed to the severity of the complication seen.

Our second case of mastoiditis with post-auricular sinus secondary to a cotton wool foreign body dislodgement medial to the external ear canal polyp represents another rare complication of aural foreign body dislodgment. Indeed, there has only been a single reported case of mastoiditis secondary to a metal stud foreign body in a 10-year-old patient.⁶ Here, our patient has a background history of diabetes mellitus type 2 and the foreign body had probably been present for more than 6 weeks due to the bony erosion pattern. Acute mastoiditis with subperiosteal abscess in the presence of tympanic membrane perforation is unusual. A possible explanation is that the cotton wool medial to the polyp acted as a nidus of infection. The combination of the cotton wool and aural polyp in the ear canal could have also obstructed the outflow of pus from the middle ear into the external acoustic canal, subsequently causing acute mastoiditis and post-auricular sinus formation. Removal of the foreign body alone with the aural polyp excision to allow drainage through the perforated tympanic membrane was deemed adequate here based on the fourth author’s previous experience from the first patient. Subsequently, cortical mastoidectomy was also not performed as the mastoid collection size had also improved following 48 hours treatment with intravenous antibiotics.

Both significant infective complications reported in this case report occurred secondary to cotton wool, likely from cotton bud use. Classically, the most serious foreign body is a button battery which requires urgent removal prior to the development of liquefactive necrosis of the surrounding soft tissue and bone. The mechanism behind infection via ear foreign bodies is poorly understood, however, it may act as a nidus for infection or may impede squamous migration in the external auditory canal resulting in stasis and susceptibility to infection. The most common bacteria resulting in infection in the vicinity of a foreign body are thought to be Staphylococcus aureus, S. epidermidis and Escherichia coli.⁷ Given the significant complications highlighted in this case series secondary to cotton wool impaction, ENT surgeons should be vigilant in questioning patients regarding cotton bud use and discouraging future use.

Interestingly, the CT imaging completed for the two complicated cases described above were unable to identify the existence of the aural foreign bodies. Instead, it appears isodense with the soft tissue inflammatory process on this imaging modality. It is more likely that metallic foreign bodies would have been detected with the CT scanning. This again reinforces the need for ENT surgeons to consider the possibility of a foreign body in patients presenting with unilateral symptoms.

In summary, these cases demonstrate the potentially destructive nature of aural foreign bodies due to the inflammatory response it can cause. Cotton bud use in the ear canal is often perceived as harmless by patients and the public, thus any dislodgment episode in the ear canal secondary to this might not be voluntarily disclosed by the patients to the treating clinician unless prompted. We therefore encourage all clinicians to consider the possibility of aural foreign bodies in all adults with unilateral ear symptoms and one should also bear in mind other destructive processes which may result in a similar presentation, such as cholesteatoma or malignancy.

Learning points.

• Cotton wool foreign bodies are the most common foreign bodies seen in the adult population and are frequently used by the general population—screening patients for cotton bud use on initial assessment and discouragement from future use should be a routine part of our clinical practice.

• Although rare, significant complications from aural foreign bodies can occur.

• Early identification and removal of foreign bodies reduces the risk of complications.

• Always consider foreign body in patients with unilateral aural symptoms, regardless of age.