Items such as pencil lead or sand may often be removed simply by flushing the canal with water. However, irrigation should be avoided in cases: (1) where tympanic membrane rupture is suspected or tympanostomy tubes are in place; (2) when organic foreign bodies such as food particles are lodged, as the fluid may cause swelling of the foreign body; (3) a button battery is to be removed.

In adults, cotton swabs are the most common foreign body. In pediatric patients, paper is also frequently found. These are often easily removed with alligator or Tobey forceps. Caution should be used to avoid grasping a fragile object too firmly and tearing it apart. Organic objects that break apart easily may be removed by gently maneuvering a wax loop or curette behind the foreign body to pull it out.

Objects with smooth surfaces may require a range of instrumentation. A loop or curette may be used to pull the object out from behind. A sharp Rosen pick may also be advantageous to poke into
the side of a semifirm object for removal (eg, an eraser), while avoiding insertion of the pick into the center of the object and pushing it deeper into the canal. Suction may also work if the object is not tightly wedged in the canal.

A patient reporting the sensation of movement or abnormal noise may suggest the presence of an insect. A noninvasive removal technique may be attempted by turning off the room lights, then introducing a light source adjacent to the external ear to motivate the insect to extricate itself from the canal.² If this fails, application of mineral oil or a lidocaine solution should first be used to euthanize the insect, followed by removal, commonly by alligator forceps or suction.

After an object is removed from the ear canal, the external auditory canal and the eardrum should be inspected for trauma and for additional foreign bodies. If there is significant trauma and/or edema, ototopical drops with either an antibiotic or antibiotic-steroid combination may be indicated. If tympanic membrane perforation is suspected, neomycin or gentamicin drops should be avoided because of their potential ototoxic effects on the inner ear via absorption through the round window membrane.

Although most ear foreign bodies present a low potential for infection or damage if removal is delayed by days to weeks, a few special circumstances warrant urgent or emergent ENT consult. Although button batteries in the ear do not cause the same tissue damage as in the nose or esophagus, they should still be promptly removed, and ENT should be consulted if emergency department (ED) provider attempts are unsuccessful. Additionally, sharp foreign bodies or those suspected to have penetrated the tympanic membrane should be removed semiurgently by ENT without attempts by an emergency medicine (EM) provider; most small perforations will heal thereafter without the need for surgical intervention. Finally, semiurgent ENT follow-up is indicated in circumstances in which removal attempts by an EM provider are unsuccessful or predicted to be difficult.

Sponges and tissue are typically best removed with alligator forceps.

Beads and other smooth objects can be removed by passing a small ring curette behind the object and moving it forward. Alternatively, the balloon of a device such as a Katz extractor (Figure 23.2) or an infant foley catheter may be advanced beyond the foreign body, then pulled out after the balloon is inflated.