You Put What Where?
Abstract & Commentary
By John P. Santamaria, MD, Affiliate Professor of Pediatrics, University of South Florida, School of Medicine, Tampa, Florida, is Associate Editor for Urgent Care Alert.
Dr. Santamaria reports no financial relationship to this field of study
Synopsis: A retrospective case series looking at the success and complication rates of otic foreign body removal.
Source: Marin JR, Trainor JL. Foreign body removal from the external auditory canal in a pediatric emergency department. Pediatr Emerg Care. 2006;22:630-634.
Children are often brought to medical attention for removal of foreign bodies lodged in the external auditory canal. Most studies of this topic are found in the otolaryngology literature, emphasizing high ENT referral rates and frequent need for operative removal. Marin and colleague reviewed the emergency department literature, noting wide ranges of successful removal (7-78%) and complications (2-47%).
In this retrospective case series, attempts to remove 254 foreign bodies from 250 children were made. Although there were 55 unique foreign bodies, most were beads, insects, cotton and paper. Fifty patients had unsuccessful removal attempts prior to ED arrival, most having been referred to the ED by a primary care physician or subspecialty clinic.
Only 1 of 250 children received conscious sedation in the ED. Eighty percent of foreign bodies were successfully removed in the ED; the remaining 20% were referred to an otolaryngologist. Half of the referred patients did not have any foreign body removal attempt in the ED owing to prior unsuccessful attempts, prior patient relationship with the subspecialist, refusal to allow ED examination, or ED physician discretion. Of those receiving ENT consultation, almost a third had removal in the operating room.
Complications were mostly minor, including 29 children with canal bleeding and/or laceration. One child had TM rupture, ossicle damage, and subsequent hearing loss. In this case, the child struggled during numerous attempts to remove a piece of styrofoam using suction and alligator forceps.
Multiple attempts, and more than one instrument used for removal, were independently associated with both failed removal and complications. Although contrary to findings in previous studies, Marin et al did not find higher rates of failure in cases involving patients under 4 years of age or patients with foreign bodies present for more than 24 hours.
All batteries, sticks, and rubber objects were removed successfully. Insect foreign bodies were removed in only 65% of cases; Marin et al hypothesize that the success rate may have been higher had irrigation been used. Higher complication rates were found when removing erasers and pieces of foam.
Limitations of this study were cited, including the retrospective design, possible overestimate of the complication rate, and incomplete chart information. The chart did not routinely include documentation of the instrument used to successfully remove the foreign body or the level of physician training and experience.
Commentary
First, anyone practicing medicine in an urgent care center should expect and be prepared to see children with foreign bodies in the ear canal, nose, and GI tract. Although it is a retrospective study with several limitations, this article brings up much food for thought.
- Should otic foreign body removal be attempted in my facility?
- Can we predict success with a screening history and physical examination?
- What additional skills (physician, staff) and equipment are necessary?
- If not, to whom will these patients be referred?
- Will the subspecialist see my patient in a timely manner?
As in most things medical, there is no right answer that fits every situation. Physicians need to know their limitations and not tread in areas where they are more likely to do more harm than good. This requires an honest assessment of one's skills, as well as patient characteristics. The physician without experience or training in this area is no match for the completely uncooperative toddler with a rubber eraser in his ear.
However, this is not an excuse for inaction. It is a call to action. Often, with only a modest amount of training and minimal equipment, the physician can successfully remove many pediatric foreign bodies. An important aspect of preparation is education of the staff in using age-appropriate immobilization and distraction techniques.
Do heed the warnings, though, about multiple attempts and use of a variety of instruments, both of which will increase the chance of bleeding and make removal by the otolaryngologist more difficult. And always review the risks of the procedure with the patient and family, as they may opt for ENT consultation.
One other tip — when a child presents with an otic foreign body, always check the nose and other ear for second, third, and fourth foreign bodies. You and the parents may be surprised by what you find.
Children are often brought to medical attention for removal of foreign bodies lodged in the external auditory canal. Most studies of this topic are found in the otolaryngology literature, emphasizing high ENT referral rates and frequent need for operative removal.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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