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Foreign bodies in the ear, nose, and throat are occasionally seen in family medicine, usually in
children. The most common foreign bodies are food, plastic toys, and small household items.
Diagnosis is often delayed because the causative event is usually unobserved, the symptoms are
nonspecific, and patients often are misdiagnosed initially. Most ear and nose foreign bodies can
be removed by a skilled physician in the office with minimal risk of complications. Common
removal methods include use of forceps, water irrigation, and suction catheter. Pharyngeal or
tracheal foreign bodies are medical emergencies requiring surgical consultation. Radiography
results are often normal. Flexible or rigid endoscopy usually is required to confirm the diagnosis
and to remove the foreign body. Physicians need to have a high index of suspicion for foreign
bodies in children with unexplained upper airway symptoms. It is important to understand
the anatomy and the indications for subspecialist referral. The evidence is inadequate to make
strong recommendations for specific removal techniques. (Am Fam Physician 2007;76:1185-9.
Copyright © 2007 American Academy of Family Physicians.)
M
ost patients with ear, nose, membrane can be damaged by pushing the
and throat foreign bodies are foreign body further into the canal or by the
children; intellectually chal- instruments used during removal attempts.
lenged or mentally ill adults Adequate visualization, appropriate equip-
are also at increased risk. Often, family phy- ment, a cooperative patient, and a skilled
sicians are able to remove the foreign body physician are the keys to successful foreign
in the office. Successful removal depends body removal.
on several factors, including location of the In many cases, patients with foreign bod-
foreign body, type of material, whether the ies in the ear are asymptomatic, and in chil-
material is graspable (i.e., soft and irregular) dren the foreign body is often an incidental
or nongraspable (i.e., hard and spherical), finding.1,19 Other patients may present with
physician dexterity, and patient cooperation. pain, symptoms of otitis media, hearing loss,
Table 1 provides an overview of common or a sense of ear fullness. In several large
foreign bodies, removal techniques, and indi- case series focusing on children, research-
cations for referral.1-18 ers found that 75 percent of patients with
ear foreign bodies were younger than eight
Ear Foreign Bodies years.1,2,19 Similar studies on adult patients
The external auditory canal is a cartilaginous are lacking.
and bony passage lined with a thin layer The most common ear foreign bodies
of periosteum and skin. The osseous por- include beads, plastic toys, pebbles, and
tion is extremely sensitive because the skin popcorn kernels.2 Insects are more com-
provides little cushion over the underlying mon in patients older than 10 years. In one
periosteum. Thus, attempts at foreign body series, 30 percent of patients required gen-
removal can be extremely painful. eral anesthesia to facilitate removal of an ear
The external auditory canal narrows at foreign body; the majority of those patients
the bony cartilaginous junction (Figure 1). were younger than seven years.2 Graspable
Foreign bodies can become impacted at this foreign bodies (e.g., foam rubber, paper,
point, increasing the difficulty of removal. vegetable material) have higher rates of suc-
Attempts to remove the foreign body may cess for removal under direct visualization.
push it further into the canal and lodge it at In contrast, nongraspable foreign bodies
this narrow point. In addition, the tympanic (e.g., beads, pebbles, popcorn kernels) have
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SORT: KEY RECOMMENDATIONS FOR PRACTICE
Evidence
Clinical recommendation rating References
lower rates of successful removal and are suction catheters. Live insects can be killed
associated with more complications, par- rapidly by instilling alcohol, 2% lidocaine
ticularly canal lacerations.3 (Xylocaine), or mineral oil into the ear
Many techniques to remove ear foreign canal. This should be done before removal is
bodies are available, and the choice depends attempted but should not be used when the
on the clinical situation, the type of foreign tympanic membrane is perforated.20
body suspected, and the experience of the Irrigation should be avoided in patients
physician. Options include water irrigation, with button batteries in the ear because the
forceps removal (e.g., alligator forceps), electrical current and/or battery contents
cerumen loops, right-angle ball hooks, and can cause a liquefaction tissue necrosis.21
Table 1. Management of Common Foreign Bodies in the Ear, Nose, and Throat
Ear Beads, plastic toys, Irrigation with water Need for sedation
pebbles, popcorn kernels2 Grasping foreign body with forceps, Canal or tympanic membrane trauma
cerumen loop, right-angle ball hook, Foreign body is nongraspable, tightly
or suction catheter wedged, or touching tympanic
Acetone to dissolve Styrofoam foreign membrane
body4 Sharp foreign body
Removal attempts unsuccessful1-3,12
Nose Beads, buttons, toy parts, Grasping with forceps, curved hook, Tumor or mass suspected
pebbles, candle wax, cerumen loop, or suction catheter Removal attempts unsuccessful
food, paper, cloth, button Thin, lubricated, balloon-tip catheter7 Edema, bony destruction, granulation
batteries5,6 Patient “blows nose” with opposite tissue from chronic foreign body12
nostril obstructed
PPV delivered to patient’s mouth with
opposite nostril obstructed8,9,11; PPV
may also be delivered by bag mask10
Throat Plastic, metal pin, seeds, Often need to be removed Inadequate visualization
(pharynx)* nuts, bones, coins, dental endoscopically, requiring sedation14,18 Need for sedation
appliances14-18 and, thus, referral Signs of airway compromise13,14
1186 American Family Physician www.aafp.org/afp Volume 76, Number 8 ◆ October 15, 2007
Foreign Bodies
Acetone may be used to dissolve Styrofoam may be applied to provide analgesia. Tech-
foreign bodies4 or to loosen cyanoacrylate niques include removal with direct visualiza-
(i.e., superglue).22 tion using forceps, curved hooks, cerumen
The first attempt at removal is critical loops, or suction catheters. Additionally, suc-
because success rates markedly decrease after cessful removal has been achieved by passing
the first failed attempt. Accordingly, com- a thin, lubricated, balloon-tip catheter (5 or
plications increase as the number of failed 6 French Foley) past the foreign body, inflat-
removal attempts increases.23,24 Removal ing the balloon, and pulling the inflated
attempts are often painful, can cause bleed-
ing that limits visualization, and can further
wedge the foreign body into the canal. An
Bony cartilaginous junction
otolaryngology referral should be obtained
for patients requiring sedation or anesthe- Osseous portion of ear canal
sia. Other indications for referral include
Tympanic membrane
patients with trauma to the canal or tym-
panic membrane; a nongraspable foreign
body that is tightly wedged in the medial
two thirds of the canal or is suspected of
touching the tympanic membrane; foreign
October 15, 2007 ◆ Volume 76, Number 8 www.aafp.org/afp American Family Physician 1187
Foreign Bodies
1188 American Family Physician www.aafp.org/afp Volume 76, Number 8 ◆ October 15, 2007
Foreign Bodies
October 15, 2007 ◆ Volume 76, Number 8 www.aafp.org/afp American Family Physician 1189