Foreign bodies of the outer ear (pinna [auricle] and external auditory canal): Diagnosis and management

INTRODUCTION — This topic discusses the diagnosis and management of foreign bodies of the outer ear (pinna [auricle] and auditory canal). The evaluation and management of lacerations of the ear are discussed separately. (See "Assessment and management of auricle (ear) lacerations".)

FOREIGN BODIES OF THE PINNA (AURICLE)

Clinical anatomy — Foreign bodies of the pinna usually arise from embedded pierced earrings. These may be located in the earlobe or the cartilaginous portions of the pinna (auricle) (figure 1).

Pathogenesis and epidemiology — Earrings or posts may become embedded in a piercing site due to swelling, which may be caused by local contact dermatitis to gold-plated or metal alloy studs, poor hygiene, or constant pressure caused by fixing clips. Subsequently, skin ischemia, inflammation, and decubitus ulcer formation develop along with penetration of a portion or the entire earring into the pinna [1,2].

Embedded earrings are most common in girls under 10 years of age and young adolescents who are less likely to perform appropriate hygiene and more likely to frequently handle the earring [3].

Clinical manifestations and diagnosis — Embedded earrings are diagnosed based upon clinical features in patients who have undergone ear piercing and commonly present with [2]:

●Ear pain

●Swelling

●Redness

●Purulent drainage from the piercing site

In cases where neither the earring nor the clip are visible, the earring may be palpable, especially when embedded in the earlobe. However, palpation of the external ear is often exquisitely painful. Alternatively, plain radiographs can confirm the diagnosis when the earring is not visible.

Piercing through the cartilage of the helix or fossa triangularis can lead to infection, perichondritis, and permanent disfigurement (picture 1 and picture 2).

Removal — Jewelry portions that have embedded in the subcutaneous tissues should be removed promptly to avoid infection. Analgesia for this procedure is typically accomplished by local infiltration or field block. In younger patients, procedural sedation may be needed. Local anesthesia of the ear and procedural sedation in children are discussed separately. (See "Assessment and management of auricle (ear) lacerations", section on 'Local anesthesia' and "Procedural sedation in children: Approach".)

●Equipment

•Antiseptic solution (eg, povidone iodine)

•Sterile gauze

•Two mosquito hemostats

The steps in removing an embedded earring depend upon what part of the earring or post is embedded and are as follows [4]:

●Wound preparation – Prepare the wound site with antiseptic solution and use sterile technique in the event that an incision is necessary for removal.

●Anesthesia and analgesia – Provide local anesthesia via local infiltration or field block (see "Assessment and management of auricle (ear) lacerations", section on 'Anesthesia and analgesia'). Procedural sedation may be necessary in young or otherwise uncooperative patients. (See "Procedural sedation in children: Approach", section on 'Performing procedural sedation' and "Procedural sedation in children: Selection of medications", section on 'Moderately or severely painful procedures'.)

●Earring front or post visible, with embedded backing (clip)

•Apply posterior pressure to the decorative front of the earring or post, until the backing or clip becomes visible behind the pinna.

•Clamp a hemostat to the backing (clip) and disengage it from the earring or post by pulling the clip posteriorly while holding the earring or post anteriorly.

•If the above technique fails, make a small incision on the posterior portion of the pinna over the piercing site to maintain cosmesis of the anterior pinna and gently spread the skin using a hemostat until the clip comes into view.

•Clamp the hemostat to the clip and remove it from the earring or post as described above.

●Backing (clip) visible, with embedded earring front or post

•Push the earring or post backing (clip) anteriorly until the decorative front or post is visible.

•Clamp a hemostat to the decorative earring front or post.

•Clamp a hemostat to the backing (clip) and disengage it from the earring front or post as described above.

•Alternatively, make a small incision with a #11 blade scalpel on the posterior portion of the pinna over the piercing site to maintain cosmesis of the anterior pinna and gently spread the skin using a hemostat. Grasp and remove the earring (picture 3).

●Neither earring front or post or backing (clip) visible

•Make a small incision on the posterior portion of the pinna over the piercing site and gently spread the skin using a hemostat until the backing (clip) comes into view.

•Grasp the backing and then proceed as described for an embedded earring front or post with backing (clip) visible.

•Dress the wound with antibiotic ointment (eg, triple antibiotic ointment) and allow it to heal by secondary intention.

Treatment of infection — The site of the piercing determines further treatment of infection:

●Cartilaginous piercing – Piercing of the cartilaginous portion of the pinna has been associated with perichondritis and chondritis [5,6]. Signs of perichondritis or chondritis in patients with an embedded earring are similar and include pain, swelling, and erythema of the overlying skin. Consultation with an otolaryngologist is advised.

Fluctuant swelling indicates an abscess that must be drained with culture of purulent fluid and is typically associated with chondritis. Pseudomonas aeruginosa is the pathogen in up to 95 percent of cases [7]. Antibiotic options should cover P. aeruginosa and methicillin-resistant Staphylococcus aureus and include initial treatment with parenteral antibiotics that cover these two pathogens (eg, vancomycin or clindamycin and ceftazidime), which is subsequently adjusted based upon culture results (see "Principles of antimicrobial therapy of Pseudomonas aeruginosa infections", section on 'Antibiotics with antipseudomonal activity' and "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Treatment of skin and soft tissue infections", section on 'Antibiotic selection'). Even with timely and proper antibiotic treatment, these infections may result in cartilage necrosis and cosmetic disfigurement (picture 4).

●Earlobe piercing – After removal of embedded earrings in the earlobe, local care and topical antibiotics are typically sufficient to treat swelling and redness that is confined to the immediate piercing site. However, extensive redness or swelling warrants culture of drainage and treatment as previously described for perichondritis.

FOREIGN BODIES OF THE EXTERNAL AUDITORY CANAL

Clinical anatomy — The ear canal is divided into an outer cartilaginous and inner bony portion (figure 2) and is innervated by the facial, glossopharyngeal, and vagus nerves. Most of the canal is cartilaginous in young children. As the bony tympanic ring grows, the external auditory canal (EAC) becomes roughly one-third cartilaginous and two-thirds bony with a narrow isthmus separating the two zones. The cartilaginous portion is superficial and has thick lining skin, subcutaneous tissue and hair structures. The skin of the deeper bony part of the ear canal is thin, tightly attached to underlying periosteum, and free of hair. Manipulation of foreign bodies in the deep, hairless portion of the ear canal can lead to pain and bleeding, while the superficial portion is less sensitive.

Epidemiology — Most aural foreign bodies are found in children six years of age and younger with a smaller portion occurring in older children and adults, especially those with cognitive or behavioral differences [8-10]. They are also more common in children with irritating conditions of the ear (eg, cerumen impaction, otitis externa, or otitis media), pica, or attention deficit hyperactivity disorder [10-12].

The foreign body is frequently located in the right ear, corresponding to the predominant handedness in children [13]. The most common objects removed include beads, pebbles, tissue paper, small toys, popcorn kernels, and insects [10].

Clinical manifestations and diagnosis — Patients with foreign bodies of the EAC are frequently asymptomatic. Common presentations include:

●Caregiver concern of EAC foreign body based upon witnessing placement or seeing something in the ear

●Incidental finding during routine otoscopy

●Decreased hearing or ear pain

●Purulent or bloody ear drainage (rare)

●Chronic cough or hiccups (rare) [10,14]

Visualization of a foreign body in the EAC on otoscopy confirms the diagnosis. The other ear and both nostrils should also be examined closely for additional foreign bodies.

Differential diagnosis — In most patients, history and visualization by otoscopy are sufficient to identify a foreign body in the EAC and to exclude other diagnoses. Other lesions may rarely mimic foreign bodies of the ear canal as follows:

●Cholesteatoma – A cholesteatoma (abnormal accumulation of squamous epithelium within the middle ear and mastoid) may have the appearance of a round white foreign body (picture 5A-B). It typically is seen in the anterosuperior quadrant of the ear drum and is located within the middle ear. (See "Cholesteatoma in children".)

●Acute otitis media with spontaneous perforation – In the unusual circumstance in which the foreign body causes ear drainage, other causes of otorrhea warrant consideration (table 1). The most common of these is acute otitis media. History of ear pain and fever and physical examination demonstrating a clear or whitish discharge from the ear strongly suggest acute otitis media with tympanic membrane perforation. Suction of the drainage and visualization using otoscopy or otomicroscopy may also be helpful. Evaluation and diagnosis of other causes of otorrhea are discussed separately. (See "Evaluation of otorrhea (ear discharge) in children".)

Removal

Objects requiring urgent removal — The type of foreign body determines the timing for removal. Button batteries, live insects, and penetrating foreign bodies warrant urgent removal for the following reasons:

●Button batteries – Button batteries are found in toys, hearing aids, and household electronics. Once in the EAC, they cause destruction because of strong electrical currents (rather than leakage of battery contents) and pressure necrosis. Maximum destruction typically occurs at the negative battery pole because electrolysis at that site generates hydroxide ions, which cause alkaline tissue necrosis [15]. Damage to the ear canal skin, tympanic membrane, facial nerve, and ossicles have been reported (picture 6) [15-17]. Permanent hearing loss has also been described.

●Insects – A variety of insects may take up temporary residence in the EAC (picture 7). Cockroaches are most commonly found, especially among children living in dense urban areas; they enter the ear because they prefer warm, dark environments. A live insect moving in a child's ear canal can cause considerable discomfort and occasionally may damage the tympanic membrane and middle ear [18]. Insects should be killed with mineral oil [19], ethanol, or lidocaine [20] prior to attempted removal to prevent excess insect movement during retrieval.

●Penetrating foreign bodies – Foreign bodies that might have penetrated the tympanic membrane and caused damage to middle ear structures require immediate attention. Cotton-tipped applicators (eg, Q-tips), pencil points (picture 8), tree branches, and hair pins are frequent culprits [21,22]. Worrisome signs that warrant prompt specialty consultation with an otolaryngologist include:

•Ear pain

•Vertigo

•Nystagmus

•Ataxia

•Otorrhea

•Facial nerve paralysis

•Hearing loss

Weber and Rinne tuning fork tests may help to identify hearing loss and differentiate a conductive loss (from tympanic membrane or ossicular disruption) from a sensory-neural loss (from damage to inner ear structures) (table 2 and figure 3). The clinical features and management of middle ear trauma are discussed in detail separately. (See "Evaluation and management of middle ear trauma", section on 'Evaluation' and "Evaluation and management of middle ear trauma", section on 'Management'.)

For other EAC foreign bodies (eg, round beads, paper, or foam rubber) removal can be deferred until necessary equipment and personnel are available as long as the patient is asymptomatic.

Indications for specialty consultation — Urgent referral to an otolaryngologist prior to any removal attempts is indicated for patients with the following EAC foreign bodies:

●Button battery

●Potentially penetrating foreign bodies (eg, pencil, bobby pin, cotton-tipped applicators)

●Foreign body with evidence of injury to the EAC, tympanic membrane, or middle ear as indicated by otorrhea, vestibular symptoms (eg, nausea, vomiting, nystagmus, vertigo, or ataxia), or marked pain

Elective referral to an otolaryngologist within a few days is warranted for asymptomatic patients with the following types of EAC foreign bodies:

●Glass or other sharp-edged foreign body

●Spherical or other foreign body that is tightly wedged in the medial EAC

●Foreign body that is up against the tympanic membrane

Based upon large case series, successful removal by other clinicians is unlikely in these instances and attempts may potentially cause complications such as ear canal laceration, tympanic membrane perforation, middle ear damage, or conversion of an easily removable foreign body to one that requires advanced techniques or general anesthesia for extraction [10,23-25].

In addition, referral is warranted if the EAC foreign body is not easily removed upon the first attempt or in settings that lack proper instrumentation or staff available to restrain or sedate an uncooperative patient [10].

Removal by nonspecialists — Many EAC foreign bodies can be removed in an emergency department or primary care provider's office using commonly available instruments (eg, irrigation setup, headlight without magnification, otoscope, alligator or bayonet forceps, or plastic or metal cerumen curette) as long as adequate restraint is assured [24,26,27]. As an example, successful removal of EAC foreign bodies such as paper, cotton, erasers, and Silly Putty occurred in 85 to 97 percent of cases in one review from a children's hospital emergency department [24]. Success rates were highest for insects and superficial EAC foreign bodies that were easily grasped or manipulated in children older than four years of age.

If otomicroscopy, proper equipment, and sufficient personnel are available, then successful removal of EAC foreign bodies by experienced clinicians, other than otolaryngologists, is enhanced, even for some complex foreign bodies. As an example, the availability of a dedicated otomicroscope in an inner-city emergency department was associated with successful extraction of 76 percent of foreign bodies in 85 children, including those touching the tympanic membrane, present for more than 24 hours, or that failed prior attempts at removal [28].

Procedure

Irrigation — This technique is used for small inorganic objects or insects. Irrigation is often better tolerated than instrumentation and does not require direct visualization [4]. However, this technique is contraindicated in patients with:

●Tympanostomy tubes or perforated tympanic membranes

●Vegetable matter (eg, a bean; vegetable matter swells as it absorbs water, leading to further obstruction)

●Button batteries (irrigation of a button battery enhances current flow and increases the potential for caustic injury)

●Equipment – The following equipment should be assembled [29]:

•20 to 50 mL syringe.

•Irrigation solution at body temperature (eg, lukewarm tap water, warmed sterile water or normal saline).

•Plastic butterfly needle tubing or 14- to 16-gauge plastic intravenous catheter.

•Mineral oil or 1 percent lidocaine (to kill live insects); although 95 percent ethanol is most effective for killing insects in vitro, it should be avoided in most patients unless a perforated tympanic membrane can be excluded [20].

•Alternatively, an electronic ear syringe with tips specifically designed for ear irrigation may be substituted. In contrast, dental irrigation devices should not be used because they produce an excessively forceful water stream that can cause tympanic membrane and middle ear damage [30].

●Technique – Irrigation is performed as follows [29]:

•Perform otoscopy to ensure that the tympanic membrane is intact and that tympanostomy tubes are not present.

•Place the patient in a supine position with the affected ear up and restrain as needed using a papoose (picture 9) or sheet wrap (eg, young children or older patients with intellectual disability). Cooperative older patients may lie on a stretcher with the head up 30 to 90 degrees or remain seated in a chair.

•If removing an insect, instill mineral oil or 1 percent lidocaine to kill it prior to irrigation [20].

•Place a towel, chuck, or basin under the patient's head to catch the irrigant solution as it flows out of the ear.

•Place the catheter or plastic tubing approximately 1 to 1.5 cm into the EAC.

•Direct the irrigation stream along the posterior and superior margin of the EAC (figure 4) and briskly depress the syringe. Repeat until the foreign body is expelled.

•In some instances, the object is moved towards the auditory meatus but still requires extraction by instrumentation.

Instrumentation under direct visualization — Instrumentation permits EAC foreign body removal under direct visualization and examination of the tympanic membrane and EAC after removal. Adequate restraint, appropriate illumination, and proper equipment are essential to success. Instrumentation can be painful and frequently warrants procedural sedation in young children or other uncooperative patients [31]. On occasion, general anesthesia may be required to ensure safe removal. (See "Procedural sedation in children: Approach".)

●Equipment – The specific instruments required depend upon the type of foreign body (picture 10). The following list provides the range of equipment that is frequently used to remove EAC foreign bodies [29]:

•Headlight or operating microscope – These light sources free the operator to brace both hands against the head, enhancing safety, and are preferred (picture 11); an operating head otoscope is acceptable but provides less control during the procedure.

•Ear speculum – Although not used for superficial EAC foreign bodies, a metal operating ear speculum directs light into the EAC and helps protect the lining from injury when retrieving objects that are deep within the EAC (picture 11).

•Alligator forceps (good for insects, foam, or paper) (picture 10).

•Gruenwald bayonet nasal dressing or Lucae forceps (foam or paper).

•Schuknecht foreign body extractor (picture 12) with suction tubing attached to wall suction (freely mobile round objects). A similar device may be constructed by cutting a 5 to 6 cm length of respiratory suction catheter of a width that is slightly less than the diameter of the foreign body. The cut should be curved to permit better attachment of the round foreign body.

•Right-angle ball or Day hook (round or breakable objects) (picture 10).

•Plastic or metal cerumen curette (round or breakable objects).

•Cyanoacrylate glue and wood or plastic swab stick (petroleum ointment, round or smooth wedged object).

•Mineral oil or 1 percent lidocaine (to kill live insects; although 95 percent ethanol is most effective for killing insects in vitro, it should be avoided in most patients unless a perforated tympanic membrane can be excluded [20]).

●Techniques

•Place the patient in a supine position with the affected ear up.

•Restrain (picture 9) and, if needed for pain control and safety, sedate the patient.

The procedure is continued with specific instrumentation determined by the type of foreign body as follows:

•Insect – If removing an insect, instill mineral oil, ethanol, or lidocaine to kill it prior to removal with alligator forceps (figure 5).

•Soft object – Soft objects (eg, foam rubber or paper), those with protruding surfaces or irregular edges, and insects may be removed with alligator or bayonet forceps (figure 6).

•Round or breakable object – Objects that are round or breakable can be removed using a right-angle hook, angled wire loop, or angled cerumen curette that is slowly advanced beyond the object and carefully withdrawn (figure 7). Freely mobile spherical objects are best removed with suction using a Schuknecht foreign body extractor (picture 12 and figure 8).

•Wedged smooth or round object – Cyanoacrylate adhesive (eg, Super Glue) has been used to remove wedged, smooth, round foreign bodies [32]. First, petroleum ointment may be carefully applied to the EAC to mitigate the risk of gluing the cotton swab to the skin. The glue is applied to the blunt end of a cotton swab and then introduced into the ear canal and placed into contact with the bead. This technique requires the child to remain still while the glue dries (approximately 60 seconds) [33]. Care must be taken to avoid contact between the glue and the EAC.

Cyanoacrylate glue occlusion — Cyanoacrylate glues (eg, Super Glue) that have been instilled in the ear can be removed by applying acetone-soaked cotton balls to the glue mass for 5 to 10 minutes until debonding from the skin has occurred followed by gentle extraction with alligator or bayonet forceps [34]. If acetone is not available, 3 percent hydrogen peroxide is an alternative solvent [35].

Complications — EAC abrasion or laceration is the most common complication of foreign body removal and occurs in up to 50 percent of patients [24,36,37]. The risk of this complication is increased in patients who undergo multiple attempts at foreign body removal. Treatment consists of topical antibiotic ear drops (eg, ofloxacin otic drops).

Tympanic membrane perforation and middle ear damage have been reported but occur much less commonly. These more serious complications are associated with complex foreign bodies, especially button batteries, and warrant prompt consultation with an otolaryngologist [15,36].

Tearing or abrasion of the tympanic membrane has been described following removal of cyanoacrylate glues from the EAC [34]. Tearing of the tympanic membrane may be more common when appropriate solvents (eg, acetone) are not used. (See 'Cyanoacrylate glue occlusion' above.)

ADDITIONAL RESOURCES — The reference provides a video that demonstrates techniques for removal of foreign bodies from the external auditory canal [38].

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Removing objects stuck in the ear (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Embedded piercings in the pinna

•Presentation – Foreign bodies of the pinna usually arise from embedded pierced earrings. These may be located in the earlobe or the cartilaginous portions of the pinna (figure 1). (See 'Clinical anatomy' above.)

Patients with embedded earrings commonly present with ear pain, swelling, redness, and purulent drainage from the piercing site. On inspection, the earring clip behind the pinna is typically not seen while the post and decorative portion of the earring is often visible. In extreme cases, the entire earring may not be visualized. (See 'Clinical manifestations and diagnosis' above.)

•Removal – Jewelry portions that have migrated into the subcutaneous tissues should be removed promptly to avoid infection. Analgesia for this procedure is typically accomplished by local infiltration or field block. In younger patients, procedural sedation may be needed. The technique for removal is described. (See 'Removal' above.)

•Complications – Perichondritis and chondritis may complicate pinna foreign bodies, especially for piercings through cartilage. When present, these infections warrant systemic antibiotics with activity against Staphylococcus aureus and Pseudomonas aeruginosa, and consultation with an otolaryngologist is advised. (See 'Treatment of infection' above.)

●Objects in the external auditory canal

•Presentation – Foreign bodies of the external auditory canal (EAC) frequently occur in children six years of age and younger and consist of a variety of objects including round beads, pebbles, tissue paper, small toys, and insects (picture 5B and picture 7). (See 'Epidemiology' above.)

Patients with foreign bodies of the EAC are often asymptomatic. Visualization of a foreign body in the EAC on otoscopy confirms the diagnosis. The other ear and both nostrils should also be examined closely for additional foreign bodies. In most patients, clinical findings are sufficient to identify a foreign body in the EAC and to exclude other diagnoses. (See 'Clinical manifestations and diagnosis' above and 'Differential diagnosis' above.)

•Indications for specialty consultation – Patients with the following EAC foreign bodies require urgent removal by an otolaryngologist prior to any removal attempts (see 'Indications for specialty consultation' above and 'Objects requiring urgent removal' above):

-Button battery (picture 6)

-Potentially penetrating foreign bodies (eg, pencil, bobby pin, cotton-tipped applicators) with evidence of injury to the EAC, tympanic membrane (picture 8), or middle ear as indicated by otorrhea, vestibular symptoms (eg, nausea, vomiting, nystagmus, vertigo, or ataxia), or marked pain

Elective referral to an otolaryngologist within a few days is warranted for asymptomatic patients with the following types of EAC foreign bodies:

-Glass or other sharp-edged foreign body

-Spherical or other foreign body that is tightly wedged in the medial EAC

-Foreign body that is up against the tympanic membrane

•Removal by nonspecialists – With adequate illumination, proper equipment, and sufficient personnel, many EAC foreign bodies (eg, insects, foam, paper, and round foreign bodies) can be removed by clinicians other than otolaryngologists (see 'Removal by nonspecialists' above). Live insects require urgent removal because of patient discomfort. (See 'Objects requiring urgent removal' above.)

Techniques for removal for specific types of foreign bodies in the EAC are described (see 'Procedure' above):

-Insect (figure 5)

-Soft object (figure 6)

-Round or breakable object (figure 7)

-Freely mobile spherical object (picture 12 and figure 8)

-Wedged smooth or round object – After petroleum ointment is applied to the EAC, remove with blunt end of cotton swab thinly coated with cyanoacrylate adhesive (requires child to be still for 60 seconds)