A 3 Year Old Girl With A Foreign Body In The Ear

A 3-year-old girl is brought by her parents to an urgent care facility after a day of crying, irritability, scant otorrhea, and frequent pulling of her right ear.
Otoscopy reveals an erythematous, swollen external auditory canal (EAC) where a bead is wedged (Picture shown below). The patient was referred to an otolaryngologist and the bead is removed
using an operating microscope for visualization.

Case Discussion:
Foreign Body In The Ear:

Introduction: Ear Foreign Bodiess are commonly seen in children ages 1 to 6 years. Most common FBs in children include:
~ Inanimate objects such as beads , cotton tips, paper, toy parts, crayons , eraser tips, food, or organic matter, including sand, sticks, and stones as well as sometimes insects.

Pathogenesis: Pathogenesis includes some of the key elements of otitis externa :

~ Initial breakdown of the skin-cerumen barrier (caused by presence of FB).
~ Skin inflammation and edema leading to subsequent obstruction of adnexal structures (e.g., cerumen glands, sebaceous glands, and hair follicles).
~ FB reaction leading to further skin injury.
~ In the case of alkaline battery electrochemical reaction, severe alkaline burns may occur.

Clinical Features: Key signs and symptoms include:
~ Otalgia.
~ Otorrhea or otorrhagia.
~ Mild hearing loss.
~ Irritability, crying.
~ History suspicious for FB insertion or witnessed FB insertion.
• Some children may be asymptomatic.
• Hallmark of diagnosis includes visualization of FB on otoscopy
• Otoscopy may reveal signs of EAC inflammation (e.g., edema,erythema, aural discharge)

Differential Diagnosis:

• Otitis externa—Presents with otalgia, otorrhea, and mild hearing loss, all of which can be present in ear FB. Absence of FB (on otoscopic exam) is the key differentiating factor.

• Acute otitis media (with or without perforated tympanic membrane [TM])—Otoscopy shows absence of FB and presence of middle-ear inflammation and effusion (i.e., bulging, erythematous, cloudy, immobile TM). Patients present with clinical signs or symptoms of acute illness like fever

• Chronic Suppurative Otitis Media—Otoscopy shows absence of FB and presence of TM perforation; history reveals a chronically draining ear and recurrent middle-ear infections with or without hearing loss.

Treatment:

Adequate immobilization of the child (sedation if necessary) and proper instrumentation allow the uncomplicated removal of many ear FBs in the pediatric population.
~ The use of general anesthesia is preferred in very young children and in children of any age with ear FBs whose contour, composition, or location predispose to traumatic removal in the ambulatory setting
• Ear FBs can be removed by irrigation, suction, or instrumentation. The type of procedure depends on the type of FB being removed.
~ Small inorganic objects can be removed from the External Auditory Canal by irrigation.
Contraindication to irrigation includes:
 Perforated TM.
 Vegetable matter—Irrigation causes swelling of the vegetable matter which leads to further obstruction.
 Alkaline (button) battery—Irrigation enhances leakage and potential for liquefaction necrosis and severe alkaline burns.
~ Objects with protruding surfaces or irregular edges may be removed with alligator forceps under direct visualization.
~ Objects that are round or breakable can be removed using a wire loop, a curette, or a right-angle hook that is slowly advanced beyond the object and carefully withdrawn.
~ Cyanoacrylate adhesive (e.g., “superglue”) has been used to remove tightly wedged, smooth, round Foreign Bodies.
~ Live insects should be killed before removing them (by irrigation or forceps). Instilling alcohol or mineral oil into the auditory canal can kill them.