Diagnosis and management of foreign bodies of the outer ear Authors Glenn C Isaacson, MD, FAAP Aderonke Ojo,

MD Section Editor Anne M Stack, MD Deputy Editor James F Wiley, II, MD, MPH Disclosures All topics are pdated as ne! e"idence #ecomes a"aila#le and o r peer re"ie! process is complete$ Literature review current through: A % &'()$ * This topic last updated: mar (&, &'()$ INT !D"#TI!N + ,m#edded earrin%s in t-e earlo#e or cartila%ino s portions o. t-e pinna and e/ternal a ditory canal 0,AC1 .orei%n #odies are common pro#lems enco ntered #y primary care and emer%ency p-ysicians$ P-ysical e/amination pro"ides t-e dia%nosis in most patients$ S ccess. l remo"al o. .orei%n #odies o. t-e pinna re2 ires appropriate anal%esia sin% local anest-esia or proced ral sedation$ 3ocal in.ection and peric-ondritis .re2 ently complicate t-ese .orei%n #odies$ Proper restraint, ade2 ate ill mination, and appropriate e2 ipment are essential .or s ccess. l e/traction o. .orei%n #odies o. t-e e/ternal a ditory canal$ Comple/ ,AC .orei%n #odies 0e%, # tton #atteries, o#jects p a%ainst t-e tympanic mem#rane, or t-ose associated !it- inj ry to t-e tympanic mem#rane or middle ear1 !arrant prompt re.erral to an otolaryn%olo%ist$ 4-is topic disc sses t-e dia%nosis and mana%ement o. .orei%n #odies o. t-e o ter ear$ 4-e e"al ation and mana%ement o. lacerations o. t-e ear are disc ssed separately$ 0See 5Assessment and mana%ement o. a ricle 0ear1 lacerations5$1 $! EI%N &!DIES !$ T'E (INNA elevant anatomy + Forei%n #odies o. t-e pinna s ally arise .rom em#edded pierced earrin%s$ 4-ese may #e located in t-e earlo#e or t-e cartila%ino s portions o. t-e pinna 0.i% re (1$ 3ocal contact dermatitis to %old6plated or metal alloy st ds, poor -y%iene, and constant press re ca sed #y .i/in% clips create local s!ellin% at t-e piercin% site$ S #se2 ently, skin isc-emia, in.lammation, and dec #it s lcer .ormation de"elop alon% !it- penetration o. a portion or t-e entire earrin% into t-e pinna 7(,&8$ Epidemiology + ,m#edded earrin%s are most common in %irls nder (' years o. a%e and yo n% adolescents !-o are less likely to per.orm appropriate -y%iene and more likely to .re2 ently -andle t-e earrin% 7)8$ #linical manifestations and diagnosis + ,m#edded earrin%s are dia%nosed #ased pon clinical .eat res in patients !-o -a"e recently nder%one ear piercin%$ Patients !item#edded earrin%s commonly present !it- ear pain, s!ellin%, redness, and p r lent

draina%e .rom t-e piercin% site 7&8$ In s c- cases, t-e earrin% may #e palpa#le, especially !-en em#edded in t-e earlo#e$ Ho!e"er, palpation o. t-e e/ternal ear is o.ten e/2 isitely pain. l$ Alternati"ely, plain radio%rap-s can con.irm t-e dia%nosis !-en t-e earrin% is not "isi#le$ Piercin% t-ro %- t-e cartila%e o. t-e -eli/ or .ossa trian% laris can lead to in.ection, peric-ondritis, and permanent dis.i% rement 0pict re ( and pict re &1$ emoval + Je!elry portions t-at -a"e mi%rated into t-e s #c taneo s tiss es s-o ld #e remo"ed promptly to a"oid in.ection$ Anal%esia .or t-is proced re is typically accomplis-ed #y local in.iltration or .ield #lock$ In yo n%er patients, proced ral sedation may #e needed$ 3ocal anest-esia o. t-e ear and proced ral sedation in c-ildren are disc ssed separately$ 0See 5Assessment and mana%ement o. a ricle 0ear1 lacerations5, section on 9Anest-esia and anal%esia9 and 5Proced ral sedation in c-ildren o tside o. t-e operatin% room5, section on 9Per.ormin% proced ral sedation9$1

E)uipment Po"idone iodine sol tion Sterile %a :e 4!o mos2 ito -emostats

4-e steps in remo"in% an em#edded earrin% depend pon !-at part o. t-e earrin% or post is em#edded and are as .ollo!s 7;8<

Prepare t-e !o nd site !it- iodine and se sterile tec-ni2 e in t-e e"ent t-at an incision is necessary .or remo"al$ Pro"ide local anest-esia$ Proced ral sedation may #e necessary in yo n% or ot-er!ise ncooperati"e patients$ 0See 5Assessment and mana%ement o. a ricle 0ear1 lacerations5, section on 9Anest-esia and anal%esia9 and 5Proced ral sedation in c-ildren o tside o. t-e operatin% room5, section on 9Per.ormin% proced ral sedation9$1 ,m#edded earrin% or post #ackin% 0clip1 !it- earrin% .ront or post "isi#le< Apply posterior press re to t-e decorati"e .ront o. t-e earrin% or post, ntil t-e #ackin% or clip #ecomes "isi#le #e-ind t-e pinna$ Clamp a -emostat to t-e #ackin% 0clip1 and disen%a%e it .rom t-e earrin% or post #y p llin% t-e clip posteriorly !-ile -oldin% t-e earrin% or post anteriorly$ I. t-e a#o"e tec-ni2 e .ails, make a small incision on t-e posterior portion o. t-e pinna o"er t-e piercin% site and %ently spread t-e skin sin% a -emostat ntil t-e clip comes into "ie!$ Clamp t-e -emostat to t-e clip and remo"e it .rom t-e earrin% or post as descri#ed a#o"e$ ,m#edded earrin% .ront or post !it- #ackin% 0clip1 "isi#le<

P s- t-e earrin% or post #ackin% 0clip1 anteriorly ntil t-e decorati"e .ront or post is "isi#le$ Clamp a -emostat to t-e decorati"e earrin% .ront or post$ Clamp a -emostat to t-e #ackin% 0clip1 and disen%a%e it .rom t-e earrin% .ront or post as descri#ed a#o"e$ Alternati"ely, make a small incision !it- a =(( #lade scalpel on t-e posterior portion o. t-e pinna o"er t-e piercin% site and %ently spread t-e skin sin% a -emostat$ Grasp and remo"e t-e earrin% 0pict re )1$ ,m#edded earrin% .ront or post and #ackin% 0clip1 !it- not-in% "isi#le< Make a small incision on t-e posterior portion o. t-e pinna o"er t-e piercin% site and %ently spread t-e skin sin% a -emostat ntil t-e #ackin% 0clip1 comes into "ie!$ Grasp t-e #ackin% and t-en proceed as descri#ed .or an em#edded earrin% .ront or post !it- #ackin% 0clip1 "isi#le$ Dress t-e !o nd !it- anti#iotic ointment 0e%, triple anti#iotic ointment1 and allo! it to -eal #y secondary intention$

Treatment of infection + Piercin% o. t-e cartila%ino s portion o. t-e pinna -as #een associated !it- peric-ondritis and c-ondritis 7>,?8$ Si%ns o. peric-ondritis or c-ondritis in patients !it- an em#edded earrin% are similar and incl de pain, s!ellin% and eryt-ema o. t-e o"erlyin% skin$ Cons ltation !it- an otolaryn%olo%ist is ad"ised$ Fl ct ant s!ellin% indicates an a#scess t-at m st #e drained and is typically associated !itc-ondritis@ Pseudomonas aeruginosa is t-e pat-o%en in p to A> percent o. cases 7B8$ Anti#iotic options s-o ld co"er P. aeruginosa and met-icillin6resistant Staphylococcus aureus and incl de oral .l oro2 inolones 0e%, le"o.lo/acin1 in adolescents and ad lts and parenteral anti#iotics 0e%, "ancomycin or clindamycin and ce.ta:idime1 in c-ildren$ ,"en !it- timely and proper anti#iotic treatment, t-ese in.ections may res lt in cartila%e necrosis and cosmetic dis.i% rement 0pict re ;1$ A.ter remo"al o. em#edded earrin%s in t-e earlo#e, local care and topical anti#iotics are typically s ..icient to treat s!ellin% and redness t-at is con.ined to t-e immediate piercin% site$ Ho!e"er, e/tensi"e redness or s!ellin% !arrants treatment as pre"io sly descri#ed .or peric-ondritis$ $! EI%N &!DIES !$ T'E E*TE NAL A"DIT! + #ANAL ,EA#elevant anatomy + 4-e ear canal is di"ided into an o ter cartila%ino s and inner #ony portion 0.i% re &1 and is inner"ated #y t-e .acial, %lossop-aryn%eal, "a% s ner"es$ Most o. t-e canal is cartila%ino s in yo n% c-ildren$ As t-e #ony tympanic rin% %ro!s, t-e e/ternal a ditory canal #ecomes ro %-ly one6t-ird cartila%ino s and t!o6t-irds #ony !it- a narro! ist-m s separatin% t-e t!o :ones$ 4-e cartila%ino s portion is s per.icial and -as t-ick linin% skin, s #c taneo s tiss e and -air str ct res$ 4-e skin o. t-e deeper #ony part o. t-e ear canal is t-in, ti%-tly attac-ed to nderlyin% perioste m and .ree o. -air$

Manip lation o. .orei%n #odies in t-e deep, -airless portion o. t-e ear canal can lead to pain and #leedin%, !-ile t-e s per.icial portion is less sensiti"e$ Epidemiology + Most a ral .orei%n #odies are .o nd in c-ildren si/ years o. a%e and yo n%er !it- a smaller portion occ rrin% in older c-ildren and special needs ad lts 7C6('8$ C-ildren !it- irritatin% conditions o. t-e ear 0e%, cer men impaction, otitis e/terna, or otitis media1 or t-ose !it- pica are predisposed 7(',((8$ 4-e FD is .re2 ently located in t-e ri%-t ear, correspondin% to t-e predominant -andedness in c-ildren 7(&8$ 4-e most common o#jects remo"ed incl de #eads, pe##les, tiss e paper, small toys, popcorn kernels, and insects 7('8$ 4-e type o. .orei%n #odies "aries #y c lt re and economic stat s 0e%, #eads and toys in de"eloped co ntries@ seeds and stones in de"elopin% co ntries1 7(),(;8$ #linical manifestations and diagnosis + Patients !it- .orei%n #odies o. t-e e/ternal a ditory canal 0,AC1 are .re2 ently asymptomatic$ Common presentations incl de<

Care%i"er concern o. ,AC .orei%n #ody #ased pon !itnessin% placement or seein% somet-in% in t-e ear Incidental .indin% d rin% ro tine otoscopy Decreased -earin% or ear pain P r lent or #loody ear draina%e 0rare1 C-ronic co %- or -icc ps 0rare1 7(',(>8

Eis ali:ation o. a .orei%n #ody in t-e ,AC on otoscopy con.irms t-e dia%nosis$ 4-e ot-er ear and #ot- nostrils s-o ld also #e e/amined closely .or additional .orei%n #odies$ Differential diagnosis + In most patients, -istory and "is ali:ation #y otoscopy are s ..icient to identi.y a .orei%n #ody in t-e ,AC and to e/cl de ot-er dia%noses$ Ot-er lesions may rarely mimic .orei%n #odies o. t-e ear canal as .ollo!s<

A con%enital c-olesteatoma 0a#normal acc m lation o. s2 amo s epit-eli m !it-in t-e middle ear and mastoid1 may -a"e t-e appearance o. a ro nd !-ite .orei%n #ody 0pict re >A6D1$ It typically is seen in t-e anteros perior 2 adrant o. t-e ear dr m and is located !it-in t-e middle ear$ Palpation !it- a pro#e d rin% otomicroscopy can di..erentiate a c-olesteatoma .rom a .orei%n #ody !-en otoscopy is not de.initi"e$ In t-e n s al circ mstance in !-ic- t-e .orei%n #ody ca ses ear draina%e, ot-er ca ses o. otorr-ea !arrant consideration 0ta#le (1$ 4-e most common o. t-ese is ac te otitis media$ History o. ear pain and .e"er and p-ysical e/amination demonstratin% a clear or !-itis- disc-ar%e .rom t-e ear stron%ly s %%est ac te otitis media !it- tympanic mem#rane per.oration$ S ction o. t-e draina%e and "is ali:ation sin% otoscopy or otomicroscopy may also #e -elp. l$ ,"al ation and

dia%nosis o. ot-er ca ses o. otorr-ea are disc ssed separately$ 0See 5,"al ation o. otorr-ea 0ear disc-ar%e1 in c-ildren5$1 emoval Timing + 4-e type o. .orei%n #ody determines t-e timin% .or remo"al$ D tton #atteries, li"e insects and penetratin% .orei%n #odies !arrant r%ent remo"al .or t-e .ollo!in% reasons<

&utton batteries F D tton #atteries are .o nd in toys, -earin% aids, and -o se-old electronics$ Once in t-e e/ternal a ditory canal 0,AC1, t-ey ca se destr ction #eca se o. stron% electrical c rrents 0rat-er t-an leaka%e o. #attery contents1 and press re necrosis$ Ma/im m destr ction typically occ rs at t-e ne%ati"e #attery pole #eca se electrolysis at t-at site %enerates -ydro/ide ions !-ic- ca se alkaline tiss e necrosis 7(?8$ Dama%e to t-e ear canal skin, tympanic mem#rane, .acial ner"e, and ossicles -a"e #een reported 7(?6(C8$ Permanent -earin% loss -as also #een descri#ed$ Insects F A "ariety o. insects may take p temporary residence in t-e ,AC 0pict re ?1$ Cockroac-es are most commonly .o nd, especially amon% inner city c-ildren, as t-ey pre.er !arm, dark en"ironments$ A li"e insect mo"in% in a c-ildGs ear canal can ca se considera#le discom.ort and occasionally may dama%e t-e tympanic mem#rane and middle ear 7(A8$ Insects s-o ld #e killed !it- mineral oil 7&'8, et-anol or lidocaine 7&(8 prior to attempted remo"al to pre"ent e/cess insect mo"ement d rin% retrie"al$ (enetrating foreign bodies F Forei%n #odies t-at mi%-t -a"e penetrated t-e tympanic mem#rane and ca sed dama%e to middle ear str ct res re2 ire immediate attention$ Cotton applicators 0H6tipsI1, pencil points 0pict re B1, tree #ranc-es and -air pins are .re2 ent c lprits 7&&,&)8$ Pain, "erti%o, nysta%m s, ata/ia, otorr-ea, .acial ner"e paralysis, andJor -earin% loss are !orrisome si%ns t-at !arrant prompt cons ltation !it- an otolaryn%olo%ist$ We#er and Kinne t nin% .ork tests -elp to identi.y -earin% loss and can o.ten di..erential a cond cti"e loss 0.rom tympanic mem#rane or ossic lar disr ption1 .rom a sensory6ne ral loss 0.rom dama%e to inner ear str ct res1 0ta#le & and .i% re )1$ 4-e clinical .eat res and mana%ement o. middle ear tra ma is disc ssed in detail separately$ 0See 5,"al ation and mana%ement o. middle ear tra ma5, section on 9Clinical .eat res9 and 5,"al ation and mana%ement o. middle ear tra ma5, section on 9Mana%ement9$1

For ot-er ,AC .orei%n #odies 0e%, ro nd #eads, paper, or .oam r ##er1 remo"al can #e de.erred ntil necessary e2 ipment and personnel are a"aila#le as lon% as t-e patient is asymptomatic$

Indications for consultation or referral to a specialist + Lr%ent re.erral to an otolaryn%olo%ist prior to any remo"al attempts is indicated .or patients !it- t-e .ollo!in% e/ternal a ditory canal 0,AC1 .orei%n #odies<

D tton #attery Potentially penetratin% .orei%n #odies 0e%, pencil, #o##y pin, cotton6tipped applicators1 Forei%n #ody !it- e"idence o. inj ry to t-e ,AC, tympanic mem#rane, or middle ear as indicated #y otorr-ea, "esti# lar symptoms 0e%, na sea, "omitin%, nysta%m s, "erti%o, or ata/ia1, or marked pain

,lecti"e re.erral to an otolaryn%olo%ist !it-in a .e! days is !arranted .or asymptomatic patients !it- t-e .ollo!in% types o. ,AC .orei%n #odies<

Glass or ot-er s-arp6ed%ed .orei%n #ody Sp-erical or ot-er .orei%n #ody t-at is ti%-tly !ed%ed in t-e medial ,AC Forei%n #ody t-at is p a%ainst t-e tympanic mem#rane

Dased pon lar%e case series, s ccess. l remo"al #y ot-er clinicians is nlikely in t-ese instances and attempts may potentially ca se complications s c- as ear canal laceration, tympanic mem#rane per.oration, middle ear dama%e, or con"ersion o. an easily remo"a#le .orei%n #ody to one t-at re2 ires ad"anced tec-ni2 es or %eneral anest-esia .or e/traction 7(',&;6&?8$ In addition, re.erral is !arranted i. t-e ,AC .orei%n #ody is not easily remo"ed pon t-e .irst attempt or in settin%s t-at lack proper instr mentation or sta.. a"aila#le to restrain or sedate an ncooperati"e patient 7('8$ Many e/ternal a ditory canal 0,AC1 .orei%n #odies can #e remo"ed in an emer%ency department or primary care pro"iderGs o..ice sin% commonly a"aila#le instr ments 0e%, irri%ation set p, -eadli%-t !it-o t ma%ni.ication, otoscope, alli%ator or #ayonet .orceps, or plastic or metal cer men c rette1 as lon% as ade2 ate restraint is ass red 7&>,&B,&C8$ As an e/ample, s ccess. l remo"al o. ,AC .orei%n #odies s c- as paper, cotton, erasers, Silly P ttyI occ rred in C> to AB percent o. cases in one re"ie! .rom a c-ildrenGs -ospital emer%ency department 7&>8$ S ccess rates !ere -i%-est .or insects and s per.icial ,AC .orei%n #odies t-at !ere easily %rasped or manip lated in c-ildren older t-an .o r years o. a%e$ I. otomicroscopy, proper e2 ipment, and s ..icient personnel are a"aila#le, t-en s ccess. l remo"al o. ,AC .orei%n #odies #y e/perienced clinicians, ot-er t-an otolaryn%olo%ists, is en-anced, e"en .or some comple/ .orei%n #odies$ As an e/ample, t-e a"aila#ility o. a dedicated otomicroscope in an inner city emer%ency department !as associated !it- s ccess. l e/traction o. B? percent o. .orei%n #odies in C> c-ildren,

incl din% t-ose to c-in% t-e tympanic mem#rane, present .or more t-an &; -o rs, or t-at .ailed prior attempts at remo"al 7&A8$ (rocedure Irrigation + 4-is tec-ni2 e is sed .or small inor%anic o#jects or insects$ Irri%ation is o.ten #etter tolerated t-an instr mentation and does not re2 ire direct "is ali:ation 7;8$ Ho!e"er, t-is tec-ni2 e is contraindicated in patients !it- tympanostomy t #es or per.orated tympanic mem#ranes and .or t-e remo"al o. "e%eta#le matter 0e%, a #ean1 or # tton #atteries$ Ee%eta#le matter s!ells as it a#sor#s !ater, leadin% to . rt-er o#str ction$ Irri%ation o. a # tton #attery en-ances c rrent .lo! and increases t-e potential .or ca stic inj ry$

E)uipment F 4-e .ollo!in% e2 ipment s-o ld #e assem#led 7)'8< &' to >' m3 syrin%e Irri%ation sol tion at #ody temperat re 0e%, l ke6!arm tap !ater, !armed sterile !ater or normal saline1 Plastic # tter.ly needle t #in% or (;6 to (?6 %a %e plastic intra"eno s cat-eter Mineral oil, A> percent et-anol, or ( percent lidocaine 0to kill li"e insects1@ et-anol s-o ld #e a"oided in patients !it- a per.orated tympanic mem#rane 7&(8 Alternati"ely an electronic ear syrin%e !it- tips speci.ically desi%ned .or ear irri%ation may #e s #stit ted$ In contrast, dental irri%ation de"ices s-o ld not #e sed #eca se t-ey prod ce an e/cessi"ely .orce. l !ater stream t-at can ca se tympanic mem#rane and middle ear dama%e 7)(8 Techni)ue F Irri%ation is per.ormed as .ollo!s 7)'8<

Per.orm otoscopy to ens re t-at t-e tympanic mem#rane is intact and t-at tympanostomy t #es are not present$ Place t-e patient in a s pine position !it- t-e a..ected ear p and restrain as needed sin% a papoose 0pict re C1 or s-eet !rap 0e% yo n% c-ildren or older patients !it- intellect al disa#ility1$ Cooperati"e older patients may lie on a stretc-er !it- t-e -ead p )' to A' de%rees or remain seated in a c-air$ I. remo"in% an insect, instill mineral oil, A> percent et-anol, or ( percent lidocaine to kill it prior to irri%ation 7&(8$ Place a to!el, c- ck, or #asin nder t-e patientGs -ead to catc- t-e irri%ant sol tion as it .lo!s o t o. t-e ear$ Place t-e cat-eter or plastic t #in% appro/imately ( to ($> cm into t-e ,AC$ Direct t-e irri%ation stream alon% t-e posterior and s perior mar%in o. t-e ,AC 0.i% re ;1 and #riskly depress t-e syrin%e$ Kepeat ntil t-e .orei%n #ody is e/pelled$ In some instances, t-e o#ject is mo"ed to!ards t-e a ditory meat s # t still re2 ires e/traction #y instr mentation$

Instrumentation under direct visuali.ation + Instr mentation permits e/ternal a ditory canal 0,AC1 .orei%n #ody remo"al nder direct "is ali:ation and e/amination o. t-e tympanic mem#rane and ,AC a.ter remo"al$ Ade2 ate restraint, appropriate ill mination, and proper e2 ipment are essential to s ccess$ Instr mentation can #e pain. l and .re2 ently !arrants proced ral sedation in yo n% c-ildren or ot-er ncooperati"e patients 7)&8$ 0See 5Proced ral sedation in c-ildren o tside o. t-e operatin% room5$1

E)uipment F 4-e speci.ic instr ments re2 ired depend pon t-e type o. .orei%n #ody 0pict re A1$ 4-e .ollo!in% list pro"ides t-e ran%e o. e2 ipment t-at is .re2 ently sed to remo"e ,AC .orei%n #odies 7)'8< Headli%-t or operatin% microscope F 4-ese li%-t so rces .ree t-e operator to #race #ot- -ands a%ain t-e -ead, en-ancin% sa.ety and are pre.erred 0pict re ('1@ an operatin% -ead otoscope is accepta#le # t pro"ides less optimal control d rin% t-e proced re$ ,ar spec l m F Alt-o %- not sed .or s per.icial ,AC .orei%n #odies, a metal operatin% ear spec l m directs li%-t into t-e ,AC and -elps protect t-e linin% .rom inj ry !-en retrie"in% o#jects t-at are deep !it-in t-e ,AC 0pict re ('1$ Alli%ator .orceps 0pict re A1 Gr en!ald #ayonet nasal dressin% or 3 cae .orceps Sc- knec-t .orei%n #ody e/tractor 0pict re ((1 !it- s ction t #in% attac-ed to !all s ction$ A similar de"ice may #e constr cted #y c ttin% a .i"e to si/ cm len%t- o. respiratory s ction cat-eter o. a !idt- t-at is sli%-tly less t-an t-e diameter o. t-e .orei%n #ody$ 4-e c t s-o ld #e c r"ed to permit #etter attac-ment o. t-e ro nd .orei%n #ody$ Ki%-t6an%le #all or Day -ook 0pict re A1 Plastic or metal cer men c rette Cyanoacrylate %l e and !ood or plastic s!a# stick Mineral oil, A> percent et-anol, or ( percent lidocaine 0to kill li"e insects@ et-anol s-o ld #e a"oided in patients !it- a per.orated tympanic mem#rane 7&(81 Techni)ues F 4-e proced re is per.ormed !it- speci.ic instr mentation determined #y t-e type o. .orei%n #ody as .ollo!s<

Place t-e patient in a s pine position !it- t-e a..ected ear p$ Kestrain 0pict re C1 and, i. needed .or pain control and sa.ety, sedate t-e patient$ I. remo"in% an insect, instill mineral oil, et-anol, or lidocaine to kill it prior to remo"al !it- alli%ator .orceps 0.i% re >1$ So.t o#jects 0e%, .oam r ##er or paper1, t-ose !it- protr din% s r.aces or irre% lar ed%es, and insects may #e remo"ed !it- alli%ator or Adson #ayonet .orceps 0.i% re ?1$

O#jects t-at are ro nd or #reaka#le can #e remo"ed sin% a ri%-t6an%le -ook, an%led !ire loop, or an%led cer men c rette t-at is slo!ly ad"anced #eyond t-e o#ject and care. lly !it-dra!n 0.i% re B1$ Freely mo#ile sp-erical o#jects are #est remo"ed !it- s ction sin% a Sc- knec-t .orei%n #ody e/tractor 0pict re (( and .i% re C1$ Cyanoacrylate ad-esi"e 0e%, S per %l eM1 -as #een sed to remo"e !ed%ed, smoot-, ro nd .orei%n #odies 7))8$ 4-e %l e is applied to t-e #l nt end o. a cotton s!a# and t-en introd ced into t-e ear canal$ 4-is tec-ni2 e re2 ires t-e c-ild to remain still !-ile t-e %l e dries 0appro/imately ?' seconds1 7);8$ Care m st #e taken to a"oid contact #et!een t-e %l e and t-e e/ternal a ditory canal$ #yanoacrylate glue occlusion + Cyanoacrylate %l es 0e%, S per %l eM1 t-at -a"e #een instilled in t-e ear can #e remo"ed #y applyin% acetone soaked cotton #alls to t-e %l e mass .or > to (' min tes ntil de#ondin% .rom t-e skin -as occ rred .ollo!ed #y %entle e/traction !it- alli%ator or #ayonet .orceps 7)>8$ I. acetone is not a"aila#le, ) percent -ydro%en pero/ide is an alternati"e sol"ent 7)?8$ #omplications + ,/ternal a ditory canal a#rasion or laceration is t-e most common complication o. .orei%n #ody remo"al and occ rs in p to >' percent o. patients 7&>,)B,)C8$ 4-e risk o. t-is complication is increased in patients !-o nder%o m ltiple attempts at .orei%n #ody remo"al$ 4reatment consists o. topical anti#iotic ear drops 0e%, o.lo/acin otic drops1$ 4ympanic mem#rane per.oration and middle ear dama%e -a"e #een reported # t occ r m c- less commonly$ 4-ese more serio s complications are associated !it- comple/ .orei%n #odies, especially # tton #atteries and !arrant prompt cons ltation !it- an otolaryn%olo%ist 7(?,)B8$ 4earin% or a#rasion o. t-e tympanic mem#rane -as #een descri#ed .ollo!in% remo"al o. cyanoacrylate %l es .rom t-e e/ternal a ditory canal 7)>8$ 4earin% o. t-e tympanic mem#rane may #e more common !-en appropriate sol"ents 0e%, acetone1 are not sed$ 0See 9Cyanoacrylate %l e occl sion9 a#o"e$1 IN$! /ATI!N $! (ATIENTS + Lp4oDate o..ers t!o types o. patient ed cation materials, N4-e DasicsO and NDeyond t-e Dasics$O 4-e Dasics patient ed cation pieces are !ritten in plain lan% a%e, at t-e >t- to ?t- %rade readin% le"el, and t-ey ans!er t-e .o r or .i"e key 2 estions a patient mi%-t -a"e a#o t a %i"en condition$ 4-ese articles are #est .or patients !-o !ant a %eneral o"er"ie! and !-o pre.er s-ort, easy6to6read materials$ Deyond t-e Dasics patient ed cation pieces are lon%er, more sop-isticated, and more detailed$ 4-ese articles are !ritten at t-e ('t- to (&t- %rade readin% le"el and are #est .or patients !-o !ant in6dept- in.ormation and are com.orta#le !it- some medical jar%on$ Here are t-e patient ed cation articles t-at are rele"ant to t-is topic$ We enco ra%e yo to print or e6mail t-ese topics to yo r patients$ 0Po can also locate patient ed cation articles on a "ariety o. s #jects #y searc-in% on Npatient in.oO and t-e key!ord0s1 o. interest$1

Dasics topic 0see 5Patient in.ormation< Kemo"in% o#jects st ck in t-e ear 04-e Dasics151

S"//A +

Forei%n #odies o. t-e pinna s ally arise .rom em#edded pierced earrin%s$ 4-ese may #e located in t-e earlo#e or t-e cartila%ino s portions o. t-e pinna 0.i% re (1$ 0See 9Kele"ant anatomy9 a#o"e$1 Patients !it- em#edded earrin%s commonly present !it- ear pain, s!ellin%, redness, and p r lent draina%e .rom t-e piercin% site$ On inspection, t-e earrin% clip #e-ind t-e pinna is typically not seen !-ile t-e post and decorati"e portion o. t-e earrin% is o.ten "isi#le$ In e/treme cases, t-e entire earrin% may not #e "is ali:ed$ 0See 9Clinical mani.estations and dia%nosis9 a#o"e$1 Je!elry portions t-at -a"e mi%rated into t-e s #c taneo s tiss es s-o ld #e remo"ed promptly to a"oid in.ection$ Anal%esia .or t-is proced re is typically accomplis-ed #y local in.iltration or .ield #lock$ In yo n%er patients, proced ral sedation may #e needed$ 4-e tec-ni2 e .or remo"al is descri#ed$ 0See 9Kemo"al9a#o"e$1 Peric-ondritis and c-ondritis may complicate pinna .orei%n #odies, especially .or piercin%s t-ro %- cartila%e$ W-en present, t-ese in.ections !arrant systemic anti#iotics !it- acti"ity a%ainst Staphylococcus aureus and Pseudomonas aeruginosa and cons ltation !it- an otolaryn%olo%ist is ad"ised$ 0See 94reatment o. in.ection9 a#o"e$1 Forei%n #odies o. t-e e/ternal ear canal 0,AC1 .re2 ently occ r in c-ildren si/ years o. a%e and yo n%er and consist o. a "ariety o. o#jects incl din% ro nd #eads, pe##les, tiss e paper, small toys, and insects$ 0See 9,pidemiolo%y9 a#o"e$1 Patients !it- .orei%n #odies o. t-e e/ternal a ditory canal 0,AC1 are .re2 ently asymptomatic$ Eis ali:ation o. a .orei%n #ody in t-e ,AC on otoscopy con.irms t-e dia%nosis$ 4-e ot-er ear and #ot- nostrils s-o ld also #e e/amined closely .or additional .orei%n #odies$ In most patients, clinical .indin%s are s ..icient to identi.y a .orei%n #ody in t-e ,AC and to e/cl de ot-er dia%noses$ 0See 9Clinical mani.estations and dia%nosis9 a#o"e and 9Di..erential dia%nosis9 a#o"e$1 D tton #atteries in t-e ,AC as !ell as penetratin% .orei%n #odies or t-ose associated !it- inj ry to t-e ,AC, tympanic mem#rane, or middle ear !arrant r%ent remo"al #y an otolaryn%olo%ist$ ,lecti"e re.erral to an otolaryn%olo%ist is !arranted .or asymptomatic patients !it,AC .orei%n #odies t-at are %lass or s-arp6ed%ed, sp-erical and ti%-tly !ed%ed, or p a%ainst t-e tympanic mem#rane or !-en clinicians lack proper instr mentation

or personnel to restrain or sedate an ncooperati"e patient$ 0See 9Indications .or cons ltation or re.erral to a specialist9 a#o"e$1

Wit- ade2 ate ill mination, proper e2 ipment, and s ..icient personnel, many ,AC .orei%n #odies can #e remo"ed #y clinicians ot-er t-an otolaryn%olo%ists$ 4ec-ni2 es .or remo"al are descri#ed$ 0See 9Proced re9 a#o"e$1