Intriguing aural foreign body and algorithm of management of foreign body

Abstract

Foreign body (FB) in the external auditory canal is more common among the paediatric age group compared with adult patients and it may be deposited in various ways. An accidental animate aural FB is reported to be commonly encountered in adults whereas inanimate FBs are likely to be found among adult patients with learning disability. An elderly man presented with accidental penetration of rattan tree stem into his ear while gardening. Removal of a FB from the external auditory canal requires expertise as deep penetration of a FB into the middle and inner ear may lead grave complications, especially when overzealous removal is attempted by nonear, nose and throat (ENT) personnel. This case emphasises on the importance of awareness of meticulous removal of a FB under proper visualisation so as to avoid unnecessary complications. Additionally, we propose an algorithm for proper removal of aural FB in an acute care setting.

Background

Foreign body (FB) is defined as an object or piece of extraneous matter that has entered the body by accident or intentionally. It may be deposited by various means, including traumatic or iatrogenic injury as well as via ingestion. FB incidence may involve all age group. FB in the ear is considered the most common site encountered in otorhinolaryngology practice. This is predominantly seen involving the paediatric population between 2 and 8 years.¹ Aural FB can be classified into organic–inorganic, animate–inanimate, metallic–nonmetallic, hygroscopic or non-hygroscopic, regular or irregular, and soft or hard according to their nature. The most common identified aural FB includes bead, cotton tip, insect and paper.² In adults, accidental animate FB like cockroaches are more common while presence of inanimate FB like cotton wool and cotton bud in adults involves adult patient with learning disability. FB must be removed immediately and its removal requires proper skill and technique depending on the type, location, shape and size of FB. Various techniques like syringing, suctioning, removal by forceps and surgery have been used over the years. Overzealous removal of FB, especially by an untrained medical practitioner, may lead to devastating complications, namely perforation of the tympanic membrane, ossicular disruption, bleeding and even perilymphatic fistula. Herein, we report on an unfortunate man with accidental penetration of rattan tree stem into the ear canal while gardening.

Case presentation

A 60-year-old man with underlying diabetes mellitus and hypertension was referred for accidental penetration of rattan tree stem into the left ear while gardening. The patient claimed he immediately attempted to twist and remove it; however, he failed due to extreme pain and otorrhagia. The patient was brought to a nearby district hospital; however, removal of the stem of rattan tree failed, which led to worsening pain and bleeding. Besides that, the patient had no spinning sensation, facial asymmetry, headache or fever. There were no accompanying tinnitus or reduced hearing.

On examination, the patient was in pain. Vital signs were within normal range. Facial nerve was intact and no nystagmus was seen. There was a long piece of rattan tree seen protruding from the external ear canal, which was embedded in the left external auditory canal with blood stain, obscuring visualisation of the tympanic membrane (figure 1). Multiple tiny thorns were seen along the rattan tree. No clear fluid was seen coming from the left ear. Right ear examination was normal with intact tympanic membrane. There was no skin discolouration, and no preauricular or postauricular swelling.

Figure 1.

Rattan stem tree embedded in left ear canal.

Treatment

FB removal was planned under local anaesthesia using headlight and forceps. Intravenous analgesia was given using ketamine. Initially, attempt was made to gently twist the stem. However, as the tiny thorns were embedded into the ear canal, it was difficult to remove it as a whole. Hence, the stem was removed in pieces gently part by part (figure 2). Post removal, the patient had minimal bleeding, which stopped within minutes. Otoscopic examination revealed superficial laceration wound over the external auditory canal with no active ooze. Tympanic membrane was visualised with no evidence of perforation. He was subsequently discharged with topical antibiotics and analgesia, and was given a 1-week appointment, which he defaulted.

Figure 2.

Rattan tree stem removed in parts.

Outcome and follow-up

Patient defaulted his follow-up.

Discussion

FB in the external ear is a common occurrence in otolaryngology practice and is predominant among the paediatric age group. This has been attributed to high curiosity and desire among these ‘little ones’ to explore the body orifices. On the other hand, accidental entry of FB or intentionally used objects following a pre-existing irritative otological diseases and habitual cleaning of ear with cotton buds has been acknowledged to be the most common underlying cause among adult patients.

Patients with FB in the ear often are asymptomatic and it is thus not surprising when aural FB are found incidentally.³ At times, patients may present with symptoms like otalgia, otorrhoea, hearing loss or aural fullness.⁴ Aural FBs can be divided into organic ones like insects, peas and cotton wool, whereas inorganic FBs include beads, plastic toys and rocks as showed in figure 3. Our patient was an adult with accidental penetration of an organic FB: stem of the rattan tree, which pierced into the left external auditory canal. Removal of impacted FB from the external ear canal is more challenging compared with other craniofacial orifices as the external auditory canal is a cul de sac and is the narrowest among the craniofacial orifices and serpentine in configuration.

Figure 3.

Types of FB in ear and important elements of FB removal. FB, foreign body.

Organic FBs may be hydrophilic and, hence, trigger an intense inflammatory reaction and expand in size. Aim of FB removal is to maintain the integrity of the ear. Despite the various techniques which exist, it mainly depends on the type, size, shape and texture of the FB as shown in table 1. Cooperation of the patient at the time of removal and experience of the attending physician is crucial as to avoid distressing complications.⁵ FB removal can be performed either by direct visualisation or otomicroscopy. Commonly used modalities include water irrigation, forceps removal (alligator forceps), cerumen loops (Jobson horne’s probe), right angle ball hooks and suction catheters.⁶ Usage of otomicroscope is a preferred choice for better visualisation and to minimise complications.³ In our patient, alligator forceps were used to remove the FB under direct visualisation with the assistance of headlight. The algorithm for removal of FB in the home setting and acute care setting is shown in figures 4 and 5.

Table 1.

Foreign body removal techniques and tools in the acute care setting

Techniques	Indication	Contraindication	Tools
Irrigation	Loose small objects (<2 mm)	Perforated tympanic membrane Soft/seed/other vegetable matter that may swell when water added Button battery	Commercial device Elephant ear washer Otoclear Waterpik Improvised Syringe, catheter Syringe, butterfly
Traction	Soft, crumble on palpation, round, smooth, non-graspable	External auricular canal infection Swelling around the object Impacted object	Suction Frazier suction tube Dental suction tip Schuknecht retriever Adhesion Magnets Cotton swab Cyanoacrylate glue Dental impression media
Manual instruments	Wide variety of objects		Forceps Bayonet Alligator Fine tissue Hooks Skin Right angle Wire loop curette Katz extractor Balloon-tip catheter
Insecticidal/disillusion	Living insects		Immersion oil Alcohol 2% lidocaine Viscous xylocaine Acetone

Figure 4.

FB removal at home setting. FB, foreign body; HD, high definition; ORL, otorhinolaryngologist.

Figure 5.

FB removal at acute care setting. FB, foreign body; ORL, otorhinolaryngologist.

With recent advances in modern technology, smartphone and camera adjuncts are capable of enabling the patient or family member to directly visualise FBs in the external auditory canal, potentially facilitating safe self-removal of FB under direct visualisation without the need for medical expertise. Family members can utilise tools like high-definition wireless otoscope with visual ear endoscope camera⁷ or a smart otoscopy⁸ to remove simple FB in the ear although awareness on when to seek medical expertise ought to be exercised with caution.^{9 10}

It is of paramount importance to know when a FB can be self-removed or when to wait for medical professional (figure 4). In case of superficial or externally located FB, especially when it is located close to the meatal opening, not embedded, able to be grasped easily, removal can be attempted provided adequate and proper equipments are available. For example, a part of cotton bud. However, only single attempt is advised as multiple attempts may lodge the FB deeper in the ear canal and lead to perforation of the ear canal. Additionally, following self-removal, it is advisable that patients should ask their primary care physician or local ear, nose and throat (ENT) service to review the ear subsequently to ensure no tympanic membrane perforation or laceration to canal, which may require further management. FB removal in an acute care setting, on the other hand, can be performed under local anaesthesia or under general anaesthesia depending on several factors, including the age of the patient and location of the FB. FB removal can be performed under local anaesthesia in a cooperative patient, superficially or laterally placed FB, graspable FB and if no attempt or only single attempt has been undertaken. Whereas removal under general anaesthesia is opted in an uncooperative patient, deep or medially located FB, following failed or multiple attempts of removal (figure 5).

Although being straightforward, drawbacks ascribed to FB include: nature and composition of FB itself, unsuccessful previous trial, uncooperative patient, delayed referral, the method of removal as well as unskillful physician. Adequate skills and expertise are required for successful FB removal. Numerous authors have emphasised that difficult cases should be managed by an experienced otolaryngologist as non-ENT personnel have a higher prevalence and association with complications, especially in an unequipped setting.

Higher complication rate is attributed mostly following failed first attempt, as most of the time, the patient may not be as cooperative as the first attempt and the success rate is significantly reduced after the first failed attempt. Among the common complications are laceration, bleeding, perforation of tympanic membrane, canal abrasion, ossicular chain destruction and hearing loss. Besides this, the patient also may end up with facial nerve palsy and vestibular disturbances. Penetrating injuries may result in dreaded complications like meningitis following otomastoiditis and perilymphatic fistula. Presence of granulation tissue and malodorous ear discharge are the early warning signs. Fortunately, in our patient, despite having an embedded organic FB, removal was performed successfully under local anaesthesia with minimal laceration wound over the ear canal.

Learning points.

• Removal of aural foreign body (FB) despite appearing trivial requires expertise to avoid unnecessary complications.

• Caution should be taken when dealing with FBs, which are embedded in the ear canal as there is a possibility of damage to the middle and even inner ear structures.

• Post-removal disabilities are miraculously minimal with adequate and appropriate instruments, proper techniques as well as patient’s cooperation.

• FB removal should only be attempted at home in case the FB is superficially located and not embedded in the ear canal, and following removal, it is important to seek a primary care physician or local ear, nose and throat service to review the ear.

• Primary care physician ought to refer when the FB is located deep, the patient is uncooperative and multiple attempts have been made, as the FB needs expertise for removal and may need to be performed under general anaesthesia.

Ethics statements

Patient consent for publication

Obtained.