Proficiency at removing foreign bodies is an art, and many times it’s a matter of having the right equipment. Often, having the right equipment, or knowing what equipment works best, is the key to successful extraction of the offending object.
Ear Foreign Bodies
Foreign bodies of the external auditory canal include cotton (most common), insects, paper, beads, seeds, eraser tips, earring parts, toy parts, and button batteries. The most commonly described techniques involve grasping the object with forceps or using a curette to drag the object out of the ear canal. Irrigation is another method used to wash the object out. Irrigation should only be undertaken if the tympanic membrane is intact.
Suction extraction has been described with variable success because of the inability to form a tight seal on certain foreign bodies, as well as a lack of suction strength needed to extract the object. With any attempt at foreign body extraction, there is the risk of pushing the object farther into the canal.
- Trick of the trade #1: A Day ear hook is a useful tool for extracting many different objects, and even impacted cerumen, from the ear (see photo 1). Its thin, short, right-angle tip can navigate into small spaces. Insert the hook parallel to the ear canal and just beyond the object to be removed. Rotate the hook tip 90 degrees behind the object and withdraw. If an ear hook is unavailable, one can be fashioned by using a hemostat clamp to bend the very tip of a paper clip (see photo 2). To provide better control of the paper clip during the foreign body extraction, secure it to the end of a pen, which serves as a longer and more stable handle (see photo 3).
- Trick of the trade #2: Tissue adhesives can also be considered when extracting foreign bodies from the ear canal. Immediately after applying a tissue adhesive to the wooden end of a Q-tip, carefully insert the wooden end into the auditory canal without touching any surface except that of the foreign body. Allow the tissue adhesive to polymerize and adhere to the foreign body for 60 seconds, and pull the Q-tip and object out as a unit. This technique was successfully used to pull a rock out from the ear canal of a patient (see photo 4). (This “trick of the trade” was contributed by Dr. Tushar Kapoor and Dr. Robert Gochman of Long Island Jewish Medical Center’s department of emergency medicine.)
Nasal Foreign Bodies
Nasal foreign bodies most commonly occur in the pediatric patient. In these situations, the key to successful diagnosis and treatment is optimal visualization.
Common objects include beads, plastic toy parts, corn kernels, and beans. Techniques for removal include grasping the object with forceps, dragging the object out using a hook or curette, and direct suctioning. Prior to any instrumentation, vasoconstriction of the mucosa and topical anesthesia should be used. Familiarity with and use of headlamps ease diagnosis and treatment, free the physician’s hands, allow the physician use of both hands, and provide binocular vision and better lighting—all of which facilitate the retrieval of the object. Proper placement of the nasal speculum is critical for patient comfort and maximal visualization.
- Trick of the trade: Lighting is essential to this procedure. If an ENT headlamp is unavailable, a common LED camping headlamp similarly provides adequate lighting, as demonstrated in photo 3. Next, maximize visualization of the foreign body by using a nasal speculum. Hold the speculum vertically to avoid applying pressure on the nasal septum. Rest the handle of the speculum comfortably in the palm of the hand while placing your index finger on the patient’s ala (see photo 5). The Day hook can be used to draw the foreign body forward using the technique described previously. After removal of the object, be sure to re-examine both nares again, because foreign bodies may occur in multiples.
Academic EM Blog Debuts
For more tricks of the trade and an insider’s perspective on emergency medicine in the academic setting, visit Dr. Michelle Lin’s new blog, “Academic Life in Emergency Medicine,” at academiclifeinem.blogspot.com.
Oropharyngeal Foreign Body
Oropharyngeal foreign bodies are another common problem encountered in the emergency department. Upper-airway foreign bodies can be removed in the emergency department in the awake, cooperative patient without signs of airway compromise. Patients complain of a sensation of “something stuck in their throat.” Optimal visualization is the key, and the emergency physician should be comfortable using a laryngeal mirror. A common problem with these mirrors, however, is fogging during the oropharyngeal exam.
- Trick of the trade: Laryngeal mirror fogging is caused when the warm air from the patient’s breath contacts the cool mirror surface. To minimize this fogging problem, warm the laryngeal mirror to body temperature. This may be done placing the mirror in a bath of warm water prior to use. In addition, chlorhexidine, which can reduce mirror fogging, can be applied to the mirror.
Dr. Colina is an emergency medicine resident at Michigan State University. Dr. Dudek is an otolaryngologist at Sparrow Hospital in Lansing, Mich. Dr. Lin is an associate professor of clinical emergency medicine at the University of California, San Francisco, and practices at San Francisco General Hospital. Contact Dr. Lin at Michelle.Lin@emergency.ucsf.edu with comments or suggestions for other “tricks of the trade.”