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ORIGINAL ARTICLES

Foreign bodies in the nose and ear: a review oftechniques for removal in the emergencydepartment

P H Davies, J R Benger

Patients frequently present to the emergencydepartment for removal of foreign bodies fromthe nose or ear. Early descriptions of foreignbody removal from Roman times include Aninsect must first be killed with vinegar and thenremoved with a probe; the patient should beencouraged to sneeze or better still he shouldbe bound to a table with the aVected ear down-

wards and the table struck with a hammer sothat the foreign body may be shaken out of theear.1

Little scientific evidence regarding the bestmethod of foreign body removal exists. Thediverse nature of the problem has precludedrandomised controlled trails and the medical lit-erature consists mainly of anecdotal case re-ports. Unfortunately it sometimes seems as ifthe cavalier attitude to these problems haschanged little from those 2000 years ago. Thefollowing review attempts to provide a logical,up to date approach to this common complaint.

Methods

Medline 1966 to August 1998 was searchedusing the OVID interface and the search terms[{exp foreign bodies OR foreign body.mp}AND {exp nose OR nose.mp OR exp ear ORear.mp}] LIMIT to human and English lan-guage. All appropriate articles were retrievedand further searched for relevant references,which were in turn followed up until a completepicture of all previous literature was assembled.These papers were supplemented by infor-mation from major ear, nose, and throat (ENT)and emergency medicine textbooks.

Aetiology and epidemiology

Patients presenting with foreign bodies in the

nose or ear are predominantly children in the 2to 8 age group.2 Foreign bodies in the nose areless common than those in the ear and occuralmost exclusively in children. The earliestpresentation is likely to be around the age of 9months when a child develops a pincer grip,allowing easy manipulation of small objects.3

Patients are more likely to be male and of lowsocioeconomic status.4 Although presentationfor removal is generally immediate, in Tongsseries of 147 patients,5 25% of patientspresented after 24 hours. The presence of aforeign body should always be suspected inpatients with a chronic unilateral discharge,

unexplained pain or suggestive symptoms suchas sneezing, snoring or mouth breathing.

One series from India6 has shown that inser-tion of foreign bodies into the ear is associatedwith pre-existing irritative disease (most com-monly chronic otitis externa), although thisfinding has not been substantiated in otherstudies.2 5

Animal, vegetable or mineral?

The range of nasal and aural foreign bodiesthat present to the emergency department islimited only by the imagination.7 A usefulclassification is animal, vegetable or mineral,8

as removal techniques will vary according tothe composition of the foreign body. Animals(for example, ants, moths, flies, etc) are themost common foreign bodies in the adult earand often require immediate attention as theycause pain and agitation in the patient.9 Theyshould generally be killed before attemptedremoval, which then becomes less urgent. Veg-etable matter (for example, paper, beans, peas,and cotton buds) tend not only to cause aninflammatory reaction, but also to swell inmoist conditions resulting in further impactionand diYculty in removal. The most commonlyinserted mineral foreign bodies include beads,rubber erasers, and small toy parts.10

Patient preparationWriting in the ABC of Otolaryngology,11 Lud-man states On initial inspection, the foreignbody may be seized and removed with forcepsbefore the child is aware of the result. Whilethis may be true, an unsuccessful attemptsignificantly jeopardises subsequent eVorts.

The first attempt is likely to be the mostsuccessful,9 as repeated tries not only causefurther swelling and bleeding but also compro-mise patient cooperation.12 As previously men-tioned, children form a large part of thispatient group and a careful approach isespecially important.

While attitudes are changing there is probablystill over-reliance in the emergency departmenton restraining methods such as papoose strap-ping boards or mummy techniques involvingsheets and tape.13 14 Providing adequate re-sources are available, sedation in the emergencydepartment may now be a more favoured

J Accid Emerg Med2000;17:9194 91

Emergency

Department, Frenchay

Hospital, Bristol

P H DaviesJ R Benger

Correspondence to:Dr Davies, SpecialistRegistrar, EmergencyDepartment, Bristol RoyalInfirmary, MarlboroughStreet, Bristol BS2 8HW(e-mail:carophil@primex.co.uk)

Accepted 28 September 1999

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option, although this will not prevent thewriggling caused by a sudden painful stimulus.

AnaesthesiaLocal anaesthesia before foreign body removalis likely to facilitate eYcient retrieval. Nasallocal anaesthetics are probably best appliedusing a spray as the foreign body will hamperpacking with pledgets. Four per cent lignocaine(lidocaine) is a common choice, althoughcocaine is a more traditional possibility and isuseful for its vasoconstrictor properties.3 Un-fortunately the use of cocaine in children islimited by possible toxicity, and in this instanceadrenaline (epinephrine) 1:200 000 may besubstituted.15

Adequate local anaesthesia within the audi-tory canal is rather harder to achieve. Topicallyapplied local anaesthetic tends to have a partialeVect at best, and although a four quadrantblock has been described, even this may notproduce complete anaesthesia, particularly of

the tympanic membrane.15

Furthermore, fourinjections of local anaesthetic will do little forcompliance in the paediatric population. Forthis reason a general anaesthetic is to bepreferred where the patient is uncooperative orremoval of a foreign body proves diYcult.16

Visualisation

Adequate visualisation is essential for thesuccessful removal of foreign bodies from thenose and ear. One study has shown that canallacerations occurred in 48% of patients whereremoval was attempted without the use of amicroscope, compared with only 4% where amicroscope was used.9

The traditional equipment for viewing for-eign bodies in the emergency room is the oto-scope. Although this provides an adequate lightsource it is less likely to be of use in retrieval,because of difficult instrumentation through oraround the small speculum end. The use of aspecialised ENT speculum allows more spacefor instrumentation. A headlamp or an illumi-nated magnifying glass probably provide thebest form of light source, as they leave bothhands free. A pair of magnifying loopes willprovide useful hands free magnification. Thisequipment is not expensive and will prove use-ful for other practical tasks in the department.

Techniques for removal

GENERAL CONSIDERATIONS

The choice of technique for removal should berelated to the exact location, shape, and

composition of the foreign body. Removal israrely an emergency, and the problem canoften waiteither for more senior advice orreferral to a specialist. The main danger inremoving a foreign body from the nose is aspi-ration, particularly in an uncooperative andcrying child who may inhale the object into theairway.17 In the ear the risk of drum perforationeither before insertion of the foreign body, as aresult of its presence or arising from over-zealous attempts at removal must always beborne in mind. Finally it is essential tore-inspect the nose or ear after successfulremoval to ensure that there is not a secondforeign body still present.3 It is also prudent tocheck the contralateral orifice, especially in thepaediatric population.

The techniques described are summarised intable 1, and their applicability to removal fromthe nose, ear or both orifices is indicated. Table2 lists the authors suggestions for a set ofequipment to ease foreign body removal in theemergency department.

IRRIGATION

This technique is useful for a small foreignbody close to the tympanic membrane. Irriga-tion fluid (tap water or normal saline) shouldbe of body temperature to decrease the risk ofinner ear stimulation. Perforation of theeardrum or a foreign body composed of

vegetable matter, which would swell, arecontraindications.9 The flow should be briskand aimed at the superior aspect of the earcanal.15 Although specialised irrigation cath-eters can be used, a butterfly cannula with theneedle cut oV is soft, flexible, non-traumaticand easily available in the emergencydepartment.4 Specialised machines providing apulsed flow have recently been shown toimprove the success rate for removal.18

POSITIVE PRESSURE TECHNIQUES

Various techniques have been proposed forraising the pressure in the upper airway to

Table 1 Advantages and disadvantages of removal techniques

Technique Orifice Advantages Disadvantages

Irrigation Ear E ase of use Contraindicated in tympanicperforation and for vegetablematter

Po si ti ve p res sur e N os e N on -t ra um at ic R is k o f b ar ot ra um aNegative pressure Both Ease of use Need solid seal

Anterior FBs Posterior FBs diYcultGood for small, round FBs May frighten children

Glue Both Ease of use FB must be visualisedN on -t ra um at ic A dh es io n o f g lu e t o p at ie nt

Catheter techniques Nose/both

Good for awkward andposteriorly placed FBs

Cost and availability of catheterPossible traumaNeeds good anaesthesia

Impressionmaterials

Ear Ease of use Cost and availabilityContraindicated in perforation

Surgicalinstruments

Bot h Ava ilabilit y Trauma w ith metal object sPosterior displacement of FBs

Manufacturedinstruments

Both Instrument can be designedto fit the shape of the FB

TraumaPosterior displacement of FBs

*FB = foreign body.

Table 2 List of recommended equipment for aural andnasal foreign body removal

Access to (with appropriate protocols, equipment, monitoringand safety measures):SedationLocal anaesthesiaVasoconstrictors

Visualisation equipment:OtoscopeNasal speculaeENT speculumIlluminating magnifying glass

HeadlightLoops

Specific instruments:Wire loopBlunt right angle hookCerumen curettesAlligator forcepsHartmans forcepsCurved hookJobson Hor ne probeNasal dressing forcepsSuction and catheters of various sizesIrrigation equipment

Foley and Fogarty catheters

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propel the foreign body out of the nostril. Allrequire the opposing (unaVected) nostril to beoccluded before the attempt. Parents may havetried nose blowing before attending the depart-ment, but further eVorts may prove successful,especially if vasoconstrictors are first used toreduce mucosal oedema.15 Sneeze inductionwith pepper1 3 1 9 is now unlikely to meet withthe approval of either the parent or the patient!

There have been numerous descriptions of

the magic kiss or positive pressure techniquewhereby upper airway pressure is raised,forcing the foreign body through thenostril.2024 This procedure is thought to havebeen first described by a New York generalpractitioner, Vladimir Ctibor in the 1960s.25

Pressure can be raised either by blowing intothe patients mouth, or by the use of abag-valve-mask system.26 While most of thearticles describe a 100% success rate, it is theauthors experience that this technique isviewed with suspicion by children, even if theparent is blowing, and has provided lessimpressive results. Although there is a theoreti-cal risk of barotrauma to the tympanic

membrane or lower airway, there are no reportsof this complication in the literature.

NEGATIVE PRESSURE TECHNIQUES(SUCTION)This technique is supposedly well suited toround objects that are diYcult to grasp withforceps.27 Suction is easily available in theemergency department and needs to providebetween 100 and 140 mm Hg of negative pres-sure to be of use.28 29 Commercial suction cath-eters tend to be metal, increasing the risk oftrauma. They can be protected with plastic tips(umbrellas)29 or alternatively a soft and flexibleendotracheal suction catheter can be used tominimise this risk.15 Soft catheters can also bemodified with a flanged tip to increase the

chance that a smooth, spherical object will besuccessfully held and withdrawn.30 One signifi-cant drawback in the paediatric population isfear associated with the noise created bysuction devices. The use of play before the pro-cedure may allay a childs fears.

GLUE

The first recorded use of glue was in India in1977 when a gum based glue was used toretrieve a foreign body.31 This has been super-seded by faster setting cyanoacrylate super-glues and is now in common use.3234 It is mosteVective in removing smooth, round objectsthat are diYcult to grasp. The foreign body

must be dry and easily visualised so that therisk of accidental contact with the mucosa ortympanic membrane is avoided. Care needs tobe taken to limit the amount of glue introducedinto the ear. Although patient compliance isrequired the technique has been found to begenerally acceptable to children.

CATHETER TECHNIQUES

Both Foley35 and Fogarty3638 balloon cathetershave be used to remove foreign bodies. Thetechnique entails sliding an uninflated balloonpast the foreign body and then inflating theballoon before pulling back on the catheter.

Described for use in both the nose and ear thismethod seems to have found most favour innasal foreign body removal. It is useful whenthe foreign body is posteriorly placed, and notamenable to instrumental removal. The appli-cation of a local anaesthetic and vasoconstric-tor agent is generally required. Balloon cath-eters may also be used to prevent posteriormigration of a foreign body while othermethods of removal are used.

IMPRESSION MATERIALS

This method was first described in 1977 byStassen and Hilding but has since had littlepublicity.39 Semiliquid materials such asacrylic, dental alginate, and silicone werepoured into the external meatus encompassingthe foreign body and allowed to set. Foreignbody and impression material were then bothremoved. A success rate of 92% was reportedin cases that had been referred from the emer-gency department. Problems were found relat-ing to the length of drying time, but it wouldappear that the materials were well tolerated.Perforation of the ear drum is a contraindica-

tion to this technique.

SURGICAL INSTRUMENTS

Many surgical instruments have been designedor adapted to assist in the removal of foreignbodies.40 41 Their use is commonly associatedwith abrasions and bleeding,9 and more rarelywith perforation of the tympanic membrane.This technique should therefore only beattempted under direct vision in a compliantpatient. The choice of instrument depends onthe type of foreign body. Alligator or other for-ceps are useful for irregular objects with aneasily visible edge that can be grasped. Hooks,curettes and loops are required when theforeign body is smooth or spherical and impos-

sible to grasp. In the nose, insertion along thenasal floor or side of the nasal septum allowspositioning behind the foreign body beforeremoval by traction. These techniques are oflittle value with friable foreign bodies, whichtend to tear on removal.

MANUFACTURED INSTRUMENTS

A number of instruments manufactured fromvarious pieces of equipment have been de-scribed in the literature, though these generallymimic equipment already in service. The paperclip seems a popular item, from which is fash-ioned a wire loop or hook to assist inretrieval.42 43 If using this method, care should

again be taken to ensure that there is minimaltrauma to the patient.

UNIQUE TO THE TYPE OF FOREIGN BODY

The ingenious suggestion of using a magnet forremoval of ferrous items44 45 has not yet beensupported by case reports. The expense ofbuying one that is of suYcient strength forremoval, combined with the relative lack ofuse, is likely to limit this method of retrieval.

The fortuitous discovery that ethyl chloridedissolves Styrofoam beads46 provides anotherunique approach to the removal of a commonforeign body.

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INSECT DROWNING

Live animal foreign bodies in the ear areextremely distressing to the patient and shouldbe killed before removal. This is best achievedby filling the ear canal with a liquid such asolive oil, methylated spirit, or lignocaine.8 15

Removal then becomes an urgent rather thanan emergent procedure. Lignocaine also ap-pears to have a more specific irritant eVect thatdrives insects, specifically cockroaches, from

the ear canal.47

COMPLICATIONS AND REFERRAL

Complications may arise from the foreign bodyitself, the examination or attempted removal(by physician or patient). Reported complica-tions include abrasions, bleeding, infection,aspiration, and perforation of the tympanicmembrane.15 The latter is rare but if suspectedthe patient should be referred for furtherassessment. Failure to remove a foreign bodyalso necessitates non-urgent referral unless thepatient is in pain or is at risk of aspiration.Caustic foreign bodies such as batteries cancause mucosal damage including ulceration

and necrosis, and these cases should bereferred urgently.48 49

FOLLOW UP

No routine follow up is required, except incases of infection, severe trauma, or perforationof the ear drum. It is important to check theother aural and nasal orifices before dischargeto exclude coexisting foreign body. Parentsshould be educated to minimise the exposureof children to potential foreign bodies.27

SummaryRemoval of foreign bodies from the ear or noseis a common problem and can be either a frus-trating or gratifying procedure, depending on

outcome. Previous experience and commonsense are likely to influence the physicianschoice of method, as is the availability ofretrieval equipment. Current evidence showsthat this practice is likely to lead to a high fail-ure and complication rate.

Education of junior doctors is the best wayto increase retrieval rates in the emergencydepartment. Both authors have successfullyincorporated a five minute review of this topicinto departmental teaching programmes onENT emergencies. The information from thesetalks has been reinforced by the creation of aforeign body removal pack, accompanied by asummary card of available retrieval methods.

It is inevitable that some patients will need tobe referred to an ENT specialist and localpolicy will dictate referral routes. A realisationthat diYcult patient groups, such as children,should be referred without an attempt in theemergency department is likely to limit com-plication rates.

Conflict of interest: none.Funding: none.

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