Aural search & rescue: Techniques for ear foreign body removal in the emergency department

Ear foreign bodies (EFB) are a common complaint in the emergency department (ED), especially among children and adults with mental disabilities or illness. While the obvious presenting complaint of an object in the ear is often the reason for the ED visit, some patients present with otalgia, otorrhea, or possibly bleeding from the external auditory canal [ ]. Many different types and sizes of items may be inserted into one or both ears [ ]. The diverse nature of the problem has precluded randomized controlled trials, and the medical literature consists mainly of anecdotal case reports. Little scientific evidence regarding the best method of EFB removal exists. The aim of this community-based study was to describe our success rate with various techniques and devices for EFB removal in a large cohort of children and adults presenting to the ED in West Michigan.

We conducted a retrospective cohort analysis of patients presenting to the EDs of 12 affiliated hospitals in West Michigan with a diagnosis of EFB. Spanning 19 counties in Michigan, affiliated institutions included four rural medical centers, three community hospitals, four university-affiliated hospitals, and a children’s tertiary care facility. All eligible cases were seen between December 2011 and December 2021 (120 months). We excluded foreign bodies of the outer ear (pinna), patients with associated ear trauma or suppurative condition, those with no evidence of FB on otoscopic examination, or if the patient appeared systemically ill. Patient demographics, type of EFB, treatment in the ED, complications, and final disposition were recorded using a standardized abstraction form. The main outcome criteria were the first attempt success rate of each technique. Descriptive statistics (mean, SD) and 95% confidence intervals (95% CI) were used to describe key demographic and outcome variables. One investigator performed a blinded critical review of a random sample of 10% of the medical records to determine inter-rater reliability using the Kappa statistic.

During the study period, 1186 patients presented to the ED with a total of 1216 EFBs. The mean age was 24.4 years; range 1 to 94 years. Overall, 50.8% were children (< 13 years) and 10.7% were elderly (> 64 years). Sixty-five different types of EFBs were identified, typically located in the right ear (56.3%), with a mean duration of insertion at 19.0 ± 8.6 h. Elderly and adult patients often presented with a piece of a hearing aid or an ear bud/plug, an insect or cotton swab that had become lodged in their ear canal. Children more often presented with items such as food, beads, earrings, insects, rocks, or small toys that had been inserted into their ear canal.

Overall, 47.5% of the EFBs were not visible without direct instrumentation. Fifteen different extraction techniques were documented during the study period. First-attempt success rates varied based on the technique utilized and were documented in Table 1 . Overall, 64.5% (95% CI, 61.7 to 67.1%) of EFB were removed on the first attempt; 9.6% (95% CI, 8.0 to 11.4%) on the second attempt; and 7.6% (95% CI, 6.1 to 9.2%) required three or more attempts. Based on the chart documentation, the choice of extraction technique used depended on several factors. These included the location of the EFB, the shape and consistency of the foreign body, the clinician’s comfort with the removal method, the age of the patient, the need for restraint/sedation, and the equipment readily available.

Table 1

First-pass success rates for extraction techniques used in EFBs.

Technique	# Attempts	First-pass Success Rate
Forceps ^a	488	78.3%
Tweezers	99	70.7%
Saline irrigation	256	65.2%
Schuknecht FB remover	11	63.6%
Ear curette	130	61.5%
Curved hemostat	7	57.1%
Magnet	6	50.0%
Suction catheter ^b	94	48.9%
Hooks/curved, right angle	5	40.0%
Cyanoacrylate on Q-tip	21	19.1%
Katz extractor	103	16.5%
Miscellaneous ^c	6	33.3%