It is important to determine the type of foreign body, the time at and circumstances under which the foreign body entered the ear, and any prior attempts at removal. Evaluate the condition of the auricle, external auditory canal skin, and tympanic membrane. Look for foreign bodies in other accessible orifices, such as the opposite ear canal, nose, and oral cavity. If the tympanic membrane is damaged or if the patient reports a hearing loss, obtain an audiogram, if possible, before attempting to remove the foreign body. This documents any hearing loss and protects the physician should the patient allege that the hearing loss was produced by the attempts at removal. A CT scan is indicated if the tympanic membrane is ruptured and violation of the middle ear is suspected.

The technique used for removal of a foreign body from the ear depends on the type and location of the object and the ability of the patient to cooperate. A microscope, suction irrigation, ring curette, alligator forceps, and right-angled hook must be available. Most adults are able to tolerate removal of the foreign body without anesthesia, unless the canal has been severely injured in previous attempts at removal.

Most patients with foreign bodies in the ear can wait until documentation is complete and optimal conditions are achieved. Young children may need a papoose and nursing assistance to help immobilize the head. Uncooperative children too large for a papoose may benefit from brief sedation with a general anesthetic to avoid injury to the eardrum or canal. The importance of minimizing iatrogenic trauma during removal should be explained to the parents at the outset. Alkaline disk batteries
can cause rapid and extensive tissue destruction from electrochemical injury, and thus should be promptly removed. In this case, incision of the canal skin can be performed with the patient under local anesthetic.

A small foreign body that does not occlude the canal may be removed with a curved ring curette. The instrument is inserted around and behind the foreign body and gently withdrawn as it engages the object, removing it from the canal. Irrigation with a jet of water at body temperature directed behind the foreign body with the tip of a 14-gauge Angiocath catheter may be helpful unless the foreign body is a bean or other hygroscopic object that expands with absorption of water. Such expansion can occlude the canal if removal is not immediately successful. During irrigation it is best to pull the auricle gently upward, outward, and backward to straighten the cartilaginous canal.

If the foreign material completely occludes the canal, it may be possible to use a small right-angled hook inserted along the superior portion of the canal and rotated after it is behind the foreign body. It is important to appreciate the length of the canal through experience before attempting to remove such occlusive foreign bodies. Suction is useful, particularly to remove soft material such as softened cerumen. If the foreign body has a lumen (e.g., a bead), it may be possible to insert an instrument into the lumen and withdraw the foreign body after it is engaged. A tightly wedged round foreign body remains a technical challenge that necessitates use of creative methods of removal. Contact between the object and a cyanoacrylate adhesive on the blunt end of a cotton swab for safe removal has been described, but caution must be taken to avoid causing inadvertent adherence of the foreign body to the ear canal skin.

Live insects should be drowned before attempting removal by instilling water, alcohol, lidocaine, or mineral oil. After the insect is dead, it is usually possible to grasp it with an alligator forceps and remove it. Crushing and fragmentation of the insect should be avoided. Some foreign bodies cannot be removed with the aforementioned techniques, even with the patient under general anesthesia. In these instances, surgical exploration may be necessary. This is especially important when the foreign body has traversed the tympanic membrane and entered the middle ear.

After removing the foreign body, inspect the canal and tympanic membrane and record their condition. Unless there is gross infection, it is generally not necessary to prescribe antibiotic drops. However, a single instillation of antibiotic drops is indicated after foreign body removal to avoid infection from instrumentation. If the patient initially reported hearing loss, or if there is any evidence of damage to the tympanic membrane or ossicles, audiometric evaluation and follow-up therapy are indicated. The patient should be instructed to return for reexamination if pain develops. The patient should be counseled against the insertion of any foreign body into the ear—including cotton swabs.

Referral guidelines for the healthcare practitioner are straightforward. If the foreign body is not readily removed with
an appropriate technique, or if the presentation is complicated (such as the case of a completely occlusive round object medial to the isthmus), the patient should be referred to an otolaryngologist. Recommendations include use of a microscope and appropriate instrumentation for safe, successful removal. The patient’s ability to cooperate also dictates the need for nursing assistance and possible consultation with an otolaryngologist.