Management of foreign bodies in the ear: a retrospective review of 123 cases in Nigeria

Foreign bodies in the ear are relatively common in emergency medicine. However, attempts at removal made outside the healthcare setting by untrained persons can result in complications of varying degrees. We conducted a 3-year retrospective review of 123 cases of aural foreign bodies at our hospital in Nigeria. Our patient population was made up of 80 males and 43 females, aged 2 to 67 years (mean: 13.2); almost three-fourths of these patients were aged 15 years or younger. Only 40 of them (32.5%) presented to an otolaryngologist within 12 hours of foreign-body insertion. A total of 30 patients (24.4%) had initially undergone removal attempts by a non-otolaryngologist prior to receiving trained ENT care, and 23 of them experienced a total of 41 complications: 17 cases of canal abrasion, laceration, and/or bleeding, 8 cases of otitis externa, 6 cases of tympanic membrane perforation, 5 cases of impaired hearing, 3 cases of chronic suppurative otitis media, and 2 cases of middle ear involvement. Of the 93 patients who were seen by an otolaryngologist initially, only 6 (6.5%) developed a complication: 4 cases of canal abrasion, laceration, and/or bleeding and 2 cases of otitis externa. The difference in overall complication rates between patients treated by otolaryngologists and non-otolaryngologists was statistically significant (p < 0.001). We conclude that attempts at removal by non-otolaryngologists can result in a high incidence of preventable complications.     

External auditory canal foreign body removal: management practices and outcomes

OBJECTIVES/HYPOTHESIS: The purpose of the study was to evaluate the effectiveness of external auditory canal foreign body removal attempts by health care practitioners and to explore outcomes of patients with unsuccessful initial removal attempts. STUDY DESIGN: Retrospective case series. METHODS: A case series of patients presenting with external auditory canal foreign body to the emergency department of the authors' institution (Strong Memorial Hospital, University of Rochester Medical Center) over a 3-year period was studied retrospectively. Medical records were reviewed, and information including age at presentation, type of foreign body, side of presentation, length of time in place, signs and symptoms at presentation, management practices, and outcomes was recorded. RESULTS: One hundred sixty-two patients with a diagnosis of external auditory canal foreign body were identified. Emergency personnel successfully managed 67% of patients using direct visualization techniques, and 33% required otolaryngological consultation. Otolaryngologists used otomicroscopy with standard otological instruments as their mainstay of management. Analysis of successfully managed emergency department cases revealed that 82% of foreign bodies were irregularly shaped objects with soft, graspable parts. Conversely, 72% of foreign bodies in otolaryngology referrals were firm, rounded objects such as beads and beans. Analysis of patients referred to otolaryngologists revealed a requirement for removal under anesthesia of 19%. Patients with a history of one or more removal attempts before emergency department evaluation universally failed further direct visualization techniques. A disproportionate number of these patients eventually required operative intervention and/or had tympanic membrane perforation. Patients with a history of previous removal attempt(s) who were referred directly to otolaryngologists were more likely to be successfully managed without general anesthesia. CONCLUSION: Emergency room personnel successfully manage the majority of patients with foreign bodies of the external auditory canal. For patients with firm, rounded objects, direct otolaryngology consultation without further manipulation should be strongly considered. Patients who have had previous removal attempts should not undergo further manipulation in the emergency department but rather should be referred directly to an otolaryngologist.     

Healthcare givers' skill and foreign bodies in the ears of children in the tropics

OBJECTIVE: The aim is to find out the place of clinical skill in the management of foreign bodies in the ear of children by various healthcare givers. METHOD: Case files of children with foreign bodies in the ears seen in the Otorhinolaryngology Department of University College Hospital, Ibadan, Nigeria from 1996 to 2005 were reviewed for all essential clinical data. RESULT: Of 323 patients studied, 171 (53.00%) males and 152 (47.00%) females, 168 (52.01%) had prior removal attempts done by anxious caregivers or general practitioners before referral; 154 (91.67%) of these had complications. Only 10 (6.45%) of the 155 (47.99%) with removal by ENT registrars had complications. CONCLUSION: Complications found appear to be related to level of clinical skill of individual health caregiver. Wherever possible, first attempt at removing aural foreign bodies should be done by an otorhinolaryngologist. Anxious parents must be discouraged from attempts but if they must attempt to remove ear foreign body, it must be by a safe ear syringing. General practitioners must be aware of their limitations and ENT registrars must be supervised by senior registrars with help of operating microscope to remove foreign bodies from the ears.     

Management of complicated airway foreign body aspiration using extracorporeal membrane oxygenation (ECMO)

ObjectivesSuccessful removal of an airway foreign body can be very challenging. We present three patients with airway foreign body aspiration successfully treated using extracorporeal membrane oxygenation (ECMO). Their clinical presentation and findings will be reviewed to determine when ECMO should be considered for treatment.Study designRetrospective multi-institutional review of a case series of patients with airway foreign body who underwent successful treatment using ECMO.MethodAfter institutional review board approval, the use of ECMO during airway foreign body procedures in children was reviewed from the pediatric research in otolaryngology (PRO) network. This network comprises of over 20 Children's hospitals to improve the health of and healthcare delivery to children and their families with otolaryngology conditions. Specific parameters were recorded for each patient.ResultsThree children presented with airway foreign body and required ECMO for successful removal. Mean age was 18 months. Presenting symptoms included severe and worsening respiratory distress. Indications for ECMO included an inability to perform rigid bronchoscopy due to the child's unstable respiratory status and an airway foreign body lodged in the trachea that could not be removed without potential loss of airway support. All three children underwent successful removal of their airway foreign bodies. There were no complications from ECMO or bronchoscopy.ConclusionECMO may be a useful adjunct in cases of life threatening airway foreign body aspiration.     

Intravenous sedation vs general anesthesia for pediatric otolaryngology procedures

OBJECTIVE: To compare efficacy, safety, and hospital charges for common pediatric otolaryngology procedures with the use of intravenous sedation (IVS) vs general anesthesia (GA). DESIGN: Retrospective chart study. SETTING: Hospital-based pediatric otolaryngology practice. PATIENTS: Patients younger than 18 years who underwent tympanostomy tube removal and/or patch myringoplasty with absorbable gelatin sponge, nasal ciliary biopsy, fine-needle aspiration, or other minor procedures between September 1, 1998, and August 31, 2001. INTERVENTIONS: Procedures performed in 2 settings: outpatient clinic with IVS or operating room with GA. MAIN OUTCOME MEASURES: Procedure completion rate, tympanic membrane perforation rate after ear procedures, complications, and hospital charges. RESULTS: Of 103 procedures, 54 were performed with IVS and 49 with GA. Within the GA group, 32 of 49 patients had additional operations performed and were excluded from analysis of safety and hospital charges. Procedure completion rate was 100% in both groups. The most common procedure was tympanostomy tube removal with patch myringoplasty (IVS, 52 ears; GA, 42 ears). The rate of persistent tympanic membrane perforation was similar between these groups (IVS, 7 [16%] of 45 ears; GA, 5 [15%] of 33; P =.96). All complications were minor and occurred at similar rates (IVS, 10 [19%] of 54 ears; GA, 3 [18%] of 17; P =.94). These events included hypoxia, airway obstruction, and bradycardia, all of which resolved spontaneously or responded to noninvasive interventions such as oxygen or repositioning. Average hospital charges were significantly higher for the GA group (IVS, $356.22; GA, $1516.55; P<.001). CONCLUSION: Various procedures can be performed safely, effectively, and with decreased hospital charges with the use of IVS administered by a pediatric sedation service.     

Ear and nose foreign body removal in children

The removal of foreign bodies in children is very common in the otolaryngologist's daily routine. We present a prospective series of 187 cases of ear and nose foreign bodies removed from children aged 0-12 years old in a 6-month period--95 females (50.8%) and 92 males (49.2%); 78 children (41.71%) aged from 1 to 2 years, 66 (35.29%) from 3 to 5 years. There were 93 cases (49.73%) of ear foreign bodies, in which a bean was the most common (24.73%), and 94 cases (50.27%) of nose foreign bodies, in which sponge fragments predominated (36.17%). In 82 cases (45.85%), the removal was performed within the first 24 h after the foreign body insertion, and 86 (45.98%) of the patients had previous attempts to remove it. Thirteen cases with complications (external ear canal lacerations, tympanic membrane perforation) were observed in patients in whom these previous attempts had been made, but there were no sequelae. This corresponds to one of the largest reports of ear and nose foreign body removal in children in the literature; we conclude that younger children are more prone to insert foreign bodies, which are objects usually found at home. Complications may occur as a result of attempts to remove the foreign body without the help of specialised personnel or proper conditions.     

Ear foreign-body removal: A review of 98 consecutive cases

Although patients with external auditory canal foreign bodies present frequently, there is scant literature on the topic other than case reports. A study of 98 consecutive patients referred over a 1-year period to otolaryngologists at a large urban county hospital was undertaken. Fifty-seven percent of these patients were over 12 years of age. A data form was completed by the otolaryngology resident removing the foreign body. Fifty-three percent of the cases had undergone one or more previous attempts at removal prior to the otolaryngologist's attempt, usually by an emergency room physician. Method of removal included use of a microscope in only 6% of previous attempts, while otolaryngologists used a microscope in 91%. Canal wall lacerations were present in 48% of patients following previous attempts at removal by other health-care professionals, but were found in only 4% of removals by an otolaryngologist. Recommendations include use of a microscope for removal and referral to an otolaryngologist if the foreign body is not readily removed by the primary-care physician.     

Acute otalgia: a case report of mature termite in the middle ear

Acute otalgia during childhood is one of the most common complaints in general ENT practice. It may occur as a result of acute otitis externa, otitis media or a foreign body. Animate foreign body in the ear canal or in the middle ear usually results in otalgia and hearing loss. We present a rare case of a living mature termite in the middle ear of a 9-year-old girl complaining of intermittent attacks of otalgia associated with a loud cracking sound in the left ear. In this case, a small perforation of the tympanic membrane without a history of previous trauma, infection, or evidence of a foreign body in the external ear raises a suspicion. A careful, time-consumed microscopic examination could show the living creature in the middle ear. Immediate immobilization and removal of the living foreign body are imperative. In conclusion, tympanic membrane perforation and intermittent severe otalgia without history of otitis may lead to a suspicion of any insects in the middle ear.     

Foreign bodies of the nose and ears in children. Should these be managed in the accident and emergency setting?

OBJECTIVE: This study reviews the management of children with foreign bodies in the nose or ear in an attempt to see whether these children can be successfully managed in the Accident and Emergency (A & E) Department or whether they should be directly referred to the Otolaryngology service. METHODS: The records of all children with a foreign body in either the nose or ear who presented to the Accident and Emergency Department at The National Children's Hospital over a 2-year period were reviewed. RESULTS: 82 children presented with a foreign body in the nose and 53 (65%) were successfully managed in the A & E Department. In contrast, of the 58 children with a foreign body in the ear only 4 (7%) were successfully removed in the A & E Department. CONCLUSION: Most foreign bodies in the nose can be successfully removed in the Accident and Emergency Department. In contrast there is a high failure rate in removal of foreign bodies from the ear in the A & E Department and these should be referred directly to the ENT service.     

Complication from hearing aid mold material: A case report and review of legal matters

Ear mold impression middle ear foreign bodies are a rare complication of hearing aid fitting. Only a small number of cases have been reported; however, the actual incidence is unknown and likely much higher than expected. We present the case of a 77-year-old man with a history of preexisting tympanic membrane perforations who presented with an ear mold impression middle ear foreign body that required surgical removal. We explore the state and federal laws that guide the interaction between patients, hearing aid sellers and otolaryngologists. We highlight steps that can be taken to reduce the incidence of this complication.     

Role of aerating mastoidectomy in noncholesteatomatous chronic otitis media

OBJECTIVE: To assess the success rate of revision tympanoplasty with aerating mastoidectomy in patients with noncholesteatomatous chronic otitis media who had failed at least one prior tympanoplasty. STUDY DESIGN: Retrospective chart review. METHODS: Data were analyzed from 135 patients available for clinical and audiometric studies with a minimum of 18 months' follow-up. All patients had failed at least one prior tympanoplasty and presented with: 1) a persistent tympanic membrane perforation with intermittent drainage, or 2) a wet draining ear, unresponsive to systemic antibiotic and topical management. All patients underwent 1.5-mm, high-density, bone window computed tomography (CT) scanning to assess middle ear, epitympanic, and mastoid air cell pneumatization. All patients underwent revision tympanoplasty with aerating mastoidectomy via a postauricular approach. Patient charts were reviewed for information regarding preoperative radiographic findings, mucosal and ossicular findings at the time of surgery, and success or failure of revision tympanomastoidectomy. RESULTS: The tympanic membrane graft take rate for the entire group of 135 patients was 90.4% (13 grafts failed). A majority of the patients were found to have radiographic and intraoperative evidence of middle ear/mastoid disease. CONCLUSION: For patients with noncholesteatomatous chronic otitis media who have failed prior tympanoplastic reconstruction, an aerating mastoidectomy may be indicated and may improve the success rate of the surgery.     

Timpanoplastias: factores asociados al resultado anatómico y auditivo

IntroductionTympanoplasty is a frequent surgery in otolaryngology. Its main indication is tympanic perforation, followed by adhesive otopathy. Its main and (or) anatomic objective is to restore the tympanic membrane's integrity, preventing infections, and its secondary or audiometric objective is to preserve or improve hearing.Material and methodRetrospective study of all patients submitted to tympanoplasty at our hospital. Biodemographic, ear pathology and surgery characteristics were registered, and anatomic and audiometric success rates were analyzed.ResultsA total of 182 patients were included, most female (57.1%), with average age of 36.1 years. The main surgical indication was tympanic perforation (89.0%), followed by adhesive otopathy (7.1%). Most tympanoplasties were primary surgeries (84.1%), type I (62.6%), performed by endoaural approach (83.5%) using medial or Austin technique (90.1%). Compound cartilage-perichondrium grafts were most frequently used (87.9%). The anatomic success rate was 84.6%, and the audiometric success rate was 66.8%. Patients who underwent myringoplasty (without raising of tympanomeatal flap) presented a better audiometric result (p = .003). No factors associated with better anatomical results were identified.ConclusionsOur anatomic and audiometric results are comparable to those previously published. Further prospective studies are required to define factors associated with improved anatomic and audiometric results.     

Transoral management of pharyngeal ballistics

ObjectiveTo present a case of a ballistic foreign body in the pharynx after a gunshot wound to the maxillofacial area, an accompanying review of relevant literature, and our approach to management.MethodA 68-year-old male with no prior medical history presented to our trauma center with gunshot wounds to the left chin, left wrist, right chest, and sternum. A CT Angiogram of the neck revealed a bullet fragment left neck and additional fragment adjacent to the L hypopharynx at the level of the hyoid. The patient was taken to the operating room for direct laryngoscopy with foreign body removal and esophagoscopy.ResultsWe document our workup and successful surgical removal of the pharyngeal ballistic foreign body via our video abstract, compiling preoperative imaging, intraoperative imaging, and video. Literature review of the subject accompanying our video abstract highlights the extensive complications that can occur from a retained foreign body in this area, supporting surgical removal of the foreign body if safely possible.ConclusionGiven the demonstrated feasibility and success of endoscopic foreign body removal from the pharyngoepiglottic space, in addition to overwhelming support for removal in the literature we recommend surgical extraction of ballistic foreign bodies located in the upper aerodigestive tract in stable patients to avoid early and long-term complications that can impact swallowing function, airway stability and the vital structures contained within the neck.     

Relationships between facial canal dehiscence and other intraoperative findings in chronic otitis media with cholesteatoma

ObjectiveWe investigated the relationship between facial canal dehiscence and intraoperative middle ear and mastoid findings in patients operated on for cholesteatoma.MethodsWe examined retrospectively 334 patients who had been operated on for cholesteatoma in Izmir Katip Celebi University, Ataturk Research and Training Hospital, ENT Clinic, between April 1997 and April 2010. The patients were examined for facial canal dehiscence according to age, gender, side of the ear, surgery type, first or revision surgery, localization of the facial canal dehiscence, spread of the cholesteatoma, with the presence of lateral semi-circular canal (LSCC) fistula and any defect in the ossicle chain, and destruction in the posterior wall of the external auditory canal(EAC).ResultsOf the patients, 23.6% had facial canal dehiscence and detected most commonly in the right ear 28.9% and tympanic segment, 83.5%. Facial canal dehiscence was found to be 24.2-fold more common in patients with LSCC fistula and 4.1-fold more common in patients with destruction in the posterior wall of the (EAC). In patients located cholesteatoma in tympanic cavity + antrum and the tympanic cavity + all mastoid cells and with incus and stapes defect, increased incidence of dehiscence. Age, first or revision operation and canal wall down tympanoplasty (CWDT) or canal wall up tympanoplasty (CWUT) did not affect the incidence of dehiscence.ConclusionsThat the likelihood of facial canal dehiscence occurrence is increased in patients with LSSC fistulas, destruction in the posterior wall of the EAC, or a stapes defect is important information for surgeons.     

Results of middle ear ventilation with Goode's tubes

The results of a retrospective study of the effect and outcome of middle ear ventilation by Goode's tubes are presented. 83 ears from 50 patients were analyzed both as a group and in age-related sub-groups over a mean follow-up period of 1.83 years. The mean period of ventilation by Goode's tubes before removal or extrusion was 18.4 months. The tubes became infected in 70.4% and were spontaneously extruded in 44.9% of patients. Permanent perforation of the tympanic membrane ensued in 47.5% of patients and significantly more often in those aged between 10 and 20 years (P less than 0.002). Patients aged less than 10 years were significantly less likely to develop a retraction of their tympanic membranes after removal of the Goode's tube than those older (P less than 0.02). No significant relationship was found between the development of these complications and the period of ventilation, past experience of otitis media, consistency of effusion, degree of tympanosclerosis or the preoperative presence of tympanic retraction.     

Effect of artificial airway on ear complications from hyperbaric oxygen

Hyperbaric oxygen treatment is associated with an increased risk of barotrauma to the tympanic membrane and middle ear. An artificial airway may compromise normal eustachian tube function and equilibration of middle ear pressures. This retrospective study was designed to evaluate the risk of middle ear complications in 267 patients receiving hyperbaric oxygen (HBO) therapy and to compare those with and without artificial airways. Charts of all patients were reviewed for middle ear and tympanic membrane complications and myringotomy tube placement. Eighteen of the 267 patients had artificial airways. Seventeen (94%) of these 18 patients developed middle ear or tympanic membrane complications, and 11 (61%) required tympanostomy tubes for pain, hemo-tympanum, or serous otitis. In contrast, 114 (45.8%) of the 249 patients without airways developed ear complications, and 53 (21.3%) required tympanostomy tubes. These results suggest that patients with an artificial airway who are receiving HBO therapy are at greater risk for developing tympanic membrane and middle ear complications than nonintubated patients. Similarly, patients with artificial airways receiving HBO frequently require placement of tympanostomy tubes.     

先天性外中耳畸形的诊断和治疗

目的：探讨先天性外、中耳畸形的特点,术前评估和治疗效果。方法：分析2000年6月～2005年6月接受手术治疗的先天性外耳道闭锁中耳畸形患者21例（22耳）的临床资料,全部患者均行外耳道鼓室成形术。结果：术中发现鼓室腔狭小16耳（72．7%）;听骨链畸形20耳（90．9％）,其中锤砧骨畸形19耳（86．4％）,镫骨畸形7耳（31．8％）;面神经畸形8耳（36．4％）;鼓室隔板1耳（4．5%）;垂直外耳道1耳（4．5％）。术后1个月平均语频听力提高〉15dB15耳（68．2％）,其中提高≥30dB9耳（40．9％）。随访6个月～5年,听力保持在术后水平或有轻度提高者17耳,下降3耳,失访2耳。并发外耳道闭锁1耳,狭窄3耳,鼓膜外侧愈合2耳。结论：先天性外、中耳畸形表现复杂多样,术前详细的影像学和听力学评估是保证手术成功的前提,成形一个宽敞的外耳道、预防术后感染是防止外耳道再闭锁和狭窄的关键。     

Surgical management of complications after hearing aid fitting

OBJECTIVES: Standard procedures for hearing aid fitting performed in accordance with established guidelines are well tolerated, safe, and effective. In this article, we present unusual complications after hearing aid fitting that required surgical management. METHODS: Four otologists at a major university center with a combined 65 years of experience performed a retrospective analysis of their surgical practice. Six patients were identified that had encountered severe complications from improper earmold fitting that required surgical intervention. RESULTS: One patient had a perforation of the tympanic membrane with earmold material found to have migrated into the middle ear cleft. The tympanic membrane healed spontaneously, resulting in persistent otalgia and a maximum air-bone gap. The earmold cast was successfully removed by means of a tympanomastoidectomy. Two patients with presbycusis and normal ear canals developed eardrum perforations and conductive hearing deficits. In both patients, earmold material was found partially occupying the middle ear cleft and removed by way of a transcanal approach. Three patients with prior canal wall down mastoidectomy defects and narrow external ear canals required microtoscopy under general anesthesia or canaloplasty for removal of impacted material. CONCLUSION: Proper fitting of hearing aids performed by well-trained medical professionals results in a very low incidence of significant complications. Perforation of the tympanic membrane with impaction of earmold material in the middle ear or mastoid bowl may occur and can be successfully managed by standard otologic surgical techniques.     

Komplikationshäufigkeit bei der ambulanten Zerumenentfernung

Background

Cerumen impaction is known as a frequent problem both in general practice as well as in community based ENT surgeries. The aim of the present review was to describe the frequency and types of complications due to different methods of ear wax removal.

Methods

A systematic review of the literature was carried out (Pubmed, Cochrane, Scopus) and data from the arbitration board for medical liability were evaluated.

Results

Controlled studies addressing the complications of ear wax removal are lacking in the literature and absolute risks could not be reported. Perforation of the tympanic membrane was observed in up to 1% of the cases. Syringing seems to result in a greater number of complications than mechanical removal using a curette.

Conclusions

Complication rates were found to be higher than previously assumed. However, none of the publications had initially been intended to detect adverse events. It can be concluded that syringing can be delegated to trained staff members only if pre-existing defects of the tympanic membrane have been excluded.     

Unidad de Atención al Paciente Traqueostomizado. Una solución innovadora desde Otorrinolaringología con carácter transversal para el hospital

Background and objectiveThe care of tracheostomized patients are high risk skills and low incidence. Strategies for improvement of health care in hospital wards and specialties other than otolaryngology based solely on training have not been able to offer an adequate solution. A tracheostomized patient unit is presented directed by the otolaryngology service to attend all tracheostomized hospitalized patients of all specialties.Material and methodsBackground: Third level public hospital with 876 hospitalization beds and 30 ICU beds for 481,296 inhabitants. Unit model: Transversal unit for the hospital providing attention to all tracheostomized patients, adults, and children, of all specialties, with dedication of 50% of a ENT nurse of hospitalization that moves to the hospitalization bed of the specialty of each patient and 50% of another office ENT nurse for ambulatory patients care, with the consultancy of an ENT specialist and coordinated by the ENT supervisor.Results572 patients between 2016 and 2021, 80% men, aged 63 ± 14 years, were attended in the unit. 14.7 ± 2 tracheostomized patients daily and 96 ± 4 complication annual consultations were attended, rising up to 19 tracheostomized patients daily by 2020 and 141 ± 8.4 consultations by complications in 2020 and 2021, during the COVID-19 pandemic. The mean stay of the non-ENT specialties was reduced in 13 days, increasing the satisfaction of the ENT and non-ENT professionals and the satisfaction of the users.ConclusionsA Tracheostomized Patient Care Unit proactively directed from the Otorhinolaryngology Service to transversally care for all tracheostomized patients improves the quality of health care by reducing stay, complications, and emergencies. Improves the satisfaction of non-otolaryngological professionals by reducing the anxiety of facing care of patients who lack knowledge and experience and that of ENT specialists and nurses by reducing unplanned extemporaneous demands for care. Improves user satisfaction by perceiving adequate continuity of care. The Otorhinolaryngology Services provide their experience in the management of laryngectomized and tracheostomized patients and in teamwork with other specialists and professionals without the need to create new structures outside otorhinolaryngology.