CASE REPORT

Corpus Alienum Auricular

Presented by:

Afifah Al Azizah 17/421280/KU/20211

Ma Wan Hui 17/421304/KU/20235
Muhammad Ifan Alfian 17/421308/KU/20239
Gavrilo Giardi 17/421297/KU/20228
Azaria N. Paramastri 17/421286/KU/20217
Dinda Ajeng A. 17/421289/KU/20220

Moderator: Dr. dr. Sagung Rai Indrasari, M.Kes., Sp. THT-KL (K), FICS

Departement of Otorhinolaringology, Head and Neck Surgery

Faculty of Medicine Universitas Gadjah Mada
RSUP Dr. Sardjito
2018
INTRODUCTION
The ear is an organ for hearing and
balance, which consists of the external ear,
middle ear and inner ear. The external ear
captures sound waves that are converted
into mechanical energy by the middle ear.
The middle ear converts mechanical
energy into nerve waves, which are then
delivered to the brain. The inner ear also
helps maintain body balance.
The external ear consists of earlobes
(pinna or aurikel) and ear canal (meatus
auditory externa). The outermost part of
the ear which is the auricle is composed
mainly by elastin cartilage and skin. It
consists of: root/crus of the helix, helix,
antihelix, scaphoid fossa, triangular fossa,
crura of antihelix, antitragus, lobule, and
tragus. The external acoustic meatus is an
“S” shaped canal that leads to tympanic
membrane from the auricle. 1/3 of the
outer part of the canal is composed of
cartilage while 2/3 of the canal’s inner part
is made out of bone (temporal), with its
length measured to be around 2.5-3 cm.
The cartilaginous part of the canal
produces cerumen from sebaceous and
ceruminous glands, while 2/3 of the bony
part of the canal has only a few of these
glands compared to the other.
Foreign body (corpus alienum) in the
ear are objects lodged in the ear which
originates from outside the body or even
from within which is normally not present.
The objects themselves are variable,
ranging from beads to insects. Cases are
seen mostly but not exclusively in children
and are a relatively common case in
emergency medicine. Patients may
sometimes realize that a foreign object is
lodged inside their external ear canal,
coming in with the chief complaint the
insertion of a foreign object in their ear.
But some may not even realize the
presence of an object in their ear canal,
leading up to patients presenting with
hearing loss, or a sense of fullness.
Significant discomfort, or complain of
nausea and vomiting may be present if a
live insect enters the ear canal.1
In children, the child does not
complaint before the pain due to infection
in the ear, the ears can be smelled bad if
the foreign body stay for a long time in the
ear canal. If the child’s ear smelled bad,
parents should suspect it as a result of
foreign body in the ear canal. Do not
handle it yourself because the objects may
actually go inside because of the anatomy
of the ear canal that is notched. In the ears
there are many nerves and injuries can
occur. Foreign body in the ear canal
usually can only be evacuated by ENT
doctors using equipment and specific
skills.
Foreign bodies in the ears, nose or
throat are a common occurrence in
otorhinolaryngology (ENT) emergency
services. Foreign bodies have been
estimated to account for approximately
11% of the cases seen in ENT services.2
There are several factors that can
cause foreign objects in the ear that is 3:
 Intentional factor, usually occurs in
children under five.
 Carelessness factors often occur in
adults when using earwashers such as
cotton, a matchstick or sticker left
inside the ear, the latter being accidental
factors in which a foreign object enters
the ear for example insects,
cockroaches, flies and mosquito.
Here are some foreign objects that
often enter the ear canal: water, cotton
bud, small things and insect. The effects of
the entry of foreign matter into the ear can
range in no symptoms until the symptoms
of severe pain and the presence of hearing
loss. Other symptoms that may arise are:
feeling uncomfortable, clogged, impaired
hearing and earache / otalgia.
The entry of foreign objects into the
ear that is to the external auditorius canal
will cause a clogging sensation in the ear,
so the patient will try to remove the
foreign object. However, the actions that
the patient undertakes to expel the foreign
body often leads to further exacerbation of
the foreign body to the external canal
bone, causing skin laceration and injury to
the tympanic membrane. As a result of
laceration of the skin and the wound of the
tympanic membrane, it will cause hearing
loss, ear pain / otalgia and possible risk of
infection.
Severe complications can occur in
22% of the cases found, and the morbidity
associated with foreign bodies, therefore,
foreign matter must be handled correctly.2
Improper handling can lead to bleeding,
trauma to the ear canal, trauma to the
membrane tympanic and hearing bones.
This will increase the patient's morbidity,
so it will require exploratory action with
general anesthesia to remove the foreign
object. Lack of experience in foreign body
management in the ear is one of the factors
causing iatrogenic complications.4
CASE REPORT
A 19 years old female visited RSUD
Tjitrowardojo Purworejo on January 18th,
2018 because she claims an insect-like
thing burrowed itself in her right ear since
this morning. She also complained a
feeling of discomfort in her right ear.
Tinnitus, discharge and itchiness were
denied. There was no history of
swimming, cleaning the ear canal with
cotton bud, and scratching her ear with
nails. She has seen the doctor in primary
health care before going to RSUD
Tjitrowardojo Purworejo. The doctor said
that the insect-like thing were burrowed
deep in the right ear and there were no
adequate equipments to evacuate the thing
so she had to go to the ENT specialist. She
has no history of food allergy as a kid. She
also denied nasal congestion, cough,
hoarseness and upper respiratory infection
before her complaints appeared.
On otoscopic examination, the left ear
was within normal. The external auditory
canal of the left ear was not hyperemic, no
discharge and no swelling. The tympanic
membrane were intact with good light
reflection. The patient felt no pain when
we palpated her left ear and the
paraauricular area.
Compared to the left ear, the right ear
was within normal. The external auditory
canal was not hyperemic, no discharge,
and no swelling but we can see the foreign
body deep in the ear, right in front of the
tympanic membrane. The tympanic
membrane itself were intact. There were
no pain when we palpated her right ear and
paraauricular area. Inspection of the
external nose was normal. From anterior
rhinoscopy examination, both of her
nostril was normal, no edema or
hyperemic concha and no discharge was
seen.
Physical examination on the throat
was within the normal limit.
Tonsilopalatina, pharynx, larynx was in
normal limit, no swelling nor hyperemic
were seen. No granule was seen in
oropharynx. Based on history taking and
physical examination, the patient was
diagnosed with Corpus Alienum Auricular
Dextra. The evacuation of the foreign
body was done, and no drug was
prescribed to the patient.
DISCUSSION
The patient present with a feeling of
discomfort in the right ear. Physical
examination revealed a foreign body deep
in the CAE with no discharge, tenderness,
redness, and swelling on the right ear.
Based on the signs and symptoms we
diagnosed the patient with corpus alienum
auricular dextra. The physical
examination is the main diagnostic tool for
corpus alineum in the ear canal.
Physical examination is done with the
use of an otoscope while retracting the
pinna in a posterosuperior direction. A
head mirror with a strong light source,
operating otoscope, or operating
microscope also may be used. The result
that may be gathered from the examination
are:
• Redness, foul odor and swelling indicate
infection
• The bluish color and cone shaped
indicate a pile of blood behind the
tympanic membrane.
• The possibility of a tympanic membrane
perforation.
There is no specific prehospital
management for the presence of a foreign
body, immediate visit to the hospital is
needed. Occasionally if the patient suffers
from discomfort, pain, or
symptomatic treatment can
administered to the patient.
There are some tools that required for
removal foreign body:
 Otoscope for ensure the located foreign
body.
 Headlamp used for
visualization.
 Curved hook. This tool is ideal for hard,
spherical shaped objects in the lateral
one third of the ear canal.
 Alligator forceps. The most common
tool used for removal of an ear foreign
body. The alligator forceps is ideal for
graspable objects such as paper, erasers,
cotton or tissue. They are not ideal for
hard, spherical shapes such as beads
(unless there is a hole) or seeds.
Alligator forceps are also useful when
the foreign body can be directly
visualized from the external ear canal.
 Irrigation equipment. Syringe
angiocatheter 20 gauge usually is used
for irrigation in the ear canal.
 Suction equipment. One of the tools for
suction is catheter. The catheter is ideal
for hard, round, spherical
objects specifically in the lateral one
third of the ear canal.
visualization of the objectis important
since the catheter must be placed
directly on the object with a good seal
nausea, obtained. The catheter does not work as
be well for foreign bodies in the medial
two thirds of the ear canal where it is
narrower, and it is sometimes difficult
to keep enough suction pressure on
theforeign body for removal.
 Magnet. It is used for metallic foreign
lighting/ bodies.
 Mineral oil or lidocaine 2%. It is used
to kill the insect in the ear canal.
 Sedation (if needed)
There are 3 techniques commonly
used by practitioner to evacuate the foreign
bodies: mechanical extraction, irrigation,
and suction. In this patient, the technique
used was irrigation because the foreign
body was a small accessory located in the
inner two third of CAE, right in front of
the tympanic membrane. Mechanical
extraction and suction techniques are best
used when the foreign bodies had a mushy
consistency. The side effect was minimal
and after the foreign body evacuation, so no
drug was prescribed to the patient.
• Mechanical extraction
Briefly repeat the ear examination
while observing the location and depth of
shaped the foreign body. Move the headlamp for
better visualization and carefully introduce
Direct alligator forceps through ear canal.
Advance the forceps incrementally through
the external auditory canal until the foreign
body is grasped. Gently withdraw the
forceps, with attached foreign body, from
the auditory canal. Always check for
complete removal of the foreign body,
perforation of the tympanic membrane,
and abrasions of the auditory canal.
• Irrigation
To irrigate, first attach a 20-ga
angiocatheter to a 60-mL syringe.
Warming the irrigation fluid (water or
normal saline) greatly enhances patient
comfort. Position the patient comfortably
and drape the area to keep the patient dry.
Position an emesis basin under the affected
ear to collect irrigation runoff. Place the
flexible angiocatheter tip gently in the
external auditory canal. Advancing the tip
too far risks damage to the tympanic
membrane. With the angiocatheter tip held
gently in position, slowly inject irrigation
fluid until the foreign body washes out.
Always conduct a postprocedural ear
examination to confirm complete removal
of the foreign body and to check for
complications.
Irrigation is contraindicated for
organic matter that may swell through
osmosis and enlarge within the auditory
canal. Disk batteries and vegetable matter
are also absolute contraindications to
irrigation.
• Suction
Connect the soft-tipped suction
catheter to low wall suction and position
the patient comfortably. Visualize the
foreign body with the headlamp/otoscope.
Introduce the catheter through ear canal
and gently advance it incrementally until
the foreign body is contacted. Gently
withdraw the suction catheter tip and
attached foreign body from the external
auditory canal. Repeat a postprocedural ear
examination to confirm complete removal
of the foreign body and to check for
complications.
Insects, organic matter and objects
with the potential to become friable and
break into smaller evasive pieces are often
better extracted with suction than with
forceps. Live insects in the ear canal
should be immobilized before removal is
attempted.5 The insect should be killed
prior to removal, using mineral oil or
lidocaine 2%.6-7
Always examine the opposite ear for
additional foreign bodies and the external
auditory canal after the removal of a
foreign body to identify preexisting or
iatrogenic tympanic membrane
perforations or abrasions.
There are some prevention for the
entry of object in the ear, that:
 The habit of using cottonbud to clean
the ears should be stopped because it
can cause some side effects: our ears
 which have fine hairs that are useful for
making sweeping movements of dirt in
our ears will be damaged, so this
natural cleansing mechanism will be
lost. If our skin is blistered there can be
a very uncomfortable outer ear infection
and other possibilities if we are too
deep in pushing cottonbud, it can injure
or penetrate the eardrum.
 Avoid giving toys in the form of seeds
to the children since the children can
put the small toys into the ear or can
also be swallowed. It can be fatal if it
clogged the airway.
Am Fam Physician. 2007, Oct 15;
76(8): 1185-89.
4. Edwad Y, Fitria H. Trauma pada
Tingkap Lonjong Akibat Ekstraksi
Benda Asing di Liang Telinga. 2013.
5. Figueiredo RR, Azevedo AA, Kos AO,
Tomita S. Complications of ent foreign
bodies: a retrospective study. Braz J
Otorhinolaryngol. 2008 Jan-Feb.
74(1):7-15.
6. Antonelli PJ, Ahmadi A, Prevatt A.
Insecticidal activity of common
reagents for insect foreign bodies of
the ear. Laryngoscope. 2001 Jan.
111(1):15-20.
7. Leffler S, Cheney P, Tandberg D.
Chemical immobilization and killing
of intra-aural roaches: an in-vitro
comparative study. Ann Emerg Med.
1993 Dec. 22(12):1795-8.

CONCLUSION
A 19 years old woman was presented
with Corpus Alienum Auricular Dextra.
The evacuation of the foreign body was
done with irrigation and no prescribed
drug was given. The diagnosis was defined
by the clinical presentation of the patient.

REFERENCES
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et al. Foreign-body in External
Auditory Meatus: Evaluation of 462
Cases. Intl. Arch. Otorhinolaryngol.,
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3. Heim SW, Maughan KL. Foreign
Body in the Ear, Nose, and Throat.
University of Virginia School of
Medicine, Charlottesville, Virginia.