The best questions often stem from the inquisitive learner. As educators, we love—and are always humbled—by those moments when we get to say “I don’t know.” For some of these questions, you may already know the answers. For others, you may never have thought to ask the question. For all, questions, comments, concerns, and critiques are encouraged. Welcome to the Kids Korner.

In Children, How Successful Are Emergency Physicians at Extracting External Auditory Canal Foreign Bodies?

Kids stick everything everywhere. In general, the type and the location of the foreign body (FB) dictates the need for a speedy extraction. Airway FBs mostly likely need to be dealt with immediately. Button batteries tend to be the most concerning FBs in any orifice above the level of the stomach (i.e., ears, nose, mouth). But what about those instances of a non-button battery foreign body in the external auditory canal (EAC)? How quickly do they need to be removed? Does it warrant a transfer or a late-night consult to pull a bead out of a kid’s ear? Are we—as emergency physicians—always the best person to go after it?

So how successful are we at extracting the EAC FB? A recent 5-year retrospective study of 1,197 pediatric patients at a single institution studied 759 kids (63.4 percent) primarily presenting to the ED and 438 (36.6 percent) children presenting initially to an outpatient otolaryngology clinic.¹ In the ED cases, the EAC FB was present less than 24 hours in most cases (74 percent), while it was present less than 24 hours in only 11 percent of the outpatient clinic. Overall, FBs had been present for longer when patients presented to outpatient clinics. In ED cases, the EAC FB was successfully removed in 67.9 percent of ED pediatric patients compared to 92.9 percent of the otolaryngology clinic patients. In patients who had a failed ED FB extraction (n=186) the otolaryngology clinic was still able to successfully extract 146/186 (78.5 percent) of these originally unsuccessful EAC FBs. The most common types of FBs that resulted in failed ED attempts were beads, rocks, and popcorn seeds—items with a hard texture and which are notoriously difficult to grasp.

Complications also were more commonly reported in the ED setting (35.7 percent) compared to the outpatient otolaryngology clinic (5 percent). Complications included patient agitation, bleeding, irritation, EAC laceration, swelling, TM perforation, and pushing the FB closer to TM. While some of these complications are clinically significant, others may not be.

A separate retrospective study included 275 pediatric patients and found that emergency physicians were successful at removing most of these EAC FBs (86 percent), but the success rate was still less than in the ENT clinic (94 percent).² Complication rates from the ED setting (6 percent) were still higher than the ENT clinic (2.3 percent), but overall were much lower than the prior study. These complications included minor issues such as bleeding or excoriations of the external canal wall. Only 2.3 percent of ED retrievals required procedural sedation. Broadly, rates of successful extraction range from 53–86 percent by emergency physician and the use of procedural sedation varies from about 2 percent to up to 20 percent.^3–7

Conversely, though, there is an occasional study that suggests that we are not great at successfully extracting EAC FBs. A retrospective study of 366 children found the ED/urgent treatment center success rate to be low at 17.5 percent with a complication rate of 22 percent compared to an ENT clinic with a reported successful extraction rate of 94.5 percent.⁷ Interestingly, the authors did not report a complication rate for the ENT clinic and that study makes no mention of the number of patients that warranted procedural sedation.

Which EAC foreign bodies are we the most unsuccessful at retrieving?

Ultimately, it’s the ones that are hard to grasp. A one-year retrospective study of 36 children with EAC FBs identified a higher success rate in graspable objects (64 percent; n=9) compared to non-graspable objects (45 percent; n=9). The complication rate was also much lower in these graspable (14 percent) versus non-graspable (70 percent) cases. Nongraspable objects were described as “smooth-surfaced objects,” but the specific breakdown was not given aside from saying “beads were the most common.” While the number of cases is small, non-graspable FBs appear to decrease the success rate of a successful EAC FB extraction.

Do EAC FBs need to be emergently removed?

Due to the COVID-19 pandemic we gained some data on the timing of EAC FB retrieval. During this time, outpatient ENT appointments were difficult to obtain. A retrospective study of 34 patients including both children and adults aged 2–78 years, evaluated the duration of EAC FB and its relationship to successful removal as well as complications.⁶ The FBs duration ranged from 1–78 days with a mean of 19 days for those who did not require general anesthesia removal and 34 days for those who required removal under general anesthesia. The study did not find that a prolonged duration of EAC FB led to an increase in complications. However, this study is limited in addressing our question as it included both adults and children and had a low number of total patients.

While we may not plan to leave an EAC FB in place for over 2 months, like this study did, a shorter duration less than 1 week may not be unreasonable. The literature suggests we can remove the EAC FB a majority of the time although certain FB characteristics—like whether it is able to be grasped and its location in respect to the TM—should factor into our decision-making.

Summary

EAC foreign body retrieval in the ED setting is successful a majority of the time with success rates most commonly in the range of 53–86 percent. Hard, smooth-surfaced objects, such as beads, rocks, and seeds tend to have the lowest success rates. Removal of non-button battery EAC FBs is not typically emergent and can likely be done with a reasonable outpatient clinic referral if you cannot easily extract it yourself.

Dr. Jones is assistant professor of pediatric emergency medicine at the University of Kentucky in Lexington.

Dr. Cantor is professor of emergency medicine and pediatrics, director of the pediatric emergency department, and medical director of the Central New York Regional Poison Control Center at Upstate Medical University in Syracuse, New York.

References

1. Karimnegad K, Nelson, EJ, Rohde RL et al. External auditory canal foreign body extraction outcomes. Ann Oto Rhinol Laryngol. 2017;126(11):755-761.
2. Mingo K, Eleff D, Anne S et al. Pediatric ear foreign body retrieval: a comparison across specialties. Am J Otolaryngol. 2020;41(2):102167.
3. Duan M, Morvil G, Badron J, et al. Epidemiological trends and outcomes of children with aural foreign bodies in Singapore. Ann Acad Med Singap. 2022;51(6):351-356.
4. Ngo A, Ng KC, Sim TP. Otorhinolaryngeal foreign bodies in children presenting to the emergency department. Singapore Med J. 2005; 46(4):172-8.
5. DiMuzio J, Deschler DG. Emergency department management of foreign bodies of the external ear canal in children. Otol Neurotol. 2002; 23(4):473-5.
6. Ho GC, Thind R, Yap D, et al. A change in clinical practice for aural foreign bodies—what we learnt from the coronavirus disease 2019 pandemic. J Laryngol Otol. 2021;135(9):825-828. .
7. Shih M, Brock L, Liu YC. Pediatric aural foreign body extraction: comparison of efficacies among clinical settings and retrieval methods. Otolaryngol Head Neck Surg. 2021;164(3):662-666.