Fishin for foreign bodies

[nacholibre]

A traumatic experience today has encouraged me to pose a few questions.
My outpatient peds attending decided to go after a large white foreign body today that had been stuck in a Somali kid's ear for "4 months" (the family just got to the states and didn't want to have it taken out in Africa so they waited). The kid was screaming, the doc was shaking and obviously flustered because he yelled "what the hell are you doing" at me when I failed to anticipate the 8 year-old's rapid head movements and keep the light directly in the canal. After digging with forceps and then a curette for a while he got most of what looked like an eraser out. Then he "thought he might have seen something else in there" and decided the procedure wouldn't be cool enough until he drew blood which he did several strokes later.

1)Is foreign body removal ever a good idea without a scope?
2)If something has been in an ear a long time, will it fuse/adhere/encrete?
3)How many screams from the patient should a non-ENT doctor tolerate until he decides to call it quits and refer?

Thanks

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[OtoHNS]

A traumatic experience today has encouraged me to pose a few questions.
My outpatient peds attending decided to go after a large white foreign body today that had been stuck in a Somali kid's ear for "4 months" (the family just got to the states and didn't want to have it taken out in Africa so they waited). The kid was screaming, the doc was shaking and obviously flustered because he yelled "what the hell are you doing" at me when I failed to anticipate the 8 year-old's rapid head movements and keep the light directly in the canal. After digging with forceps and then a curette for a while he got most of what looked like an eraser out. Then he "thought he might have seen something else in there" and decided the procedure wouldn't be cool enough until he drew blood which he did several strokes later.

1)Is foreign body removal ever a good idea without a scope?
2)If something has been in an ear a long time, will it fuse/adhere/encrete?
3)How many screams from the patient should a non-ENT doctor tolerate until he decides to call it quits and refer?

Thanks

Sounds like no fun.

1. Generally no. In smaller kids, it can sometimes be easiest to use an otoscope with an operating head that you can insert instruments through. The reason being that you can move with the patient somewhat doing it this way. A microscope gives the best visualization but it requires a perfectly cooperative and still patient, since any movement will cause you to lose your view.

2. Not that I've seen, but it's definitely possible for an inflammatory reaction or infection to develop under the FB if it sits in there for too long. I guess this could potentially cause some overgrowth of skin onto the foreign object.

3. Everybody is different, but I have a pretty low threshold for taking little kids to the OR for ear FB removal.

 

[DrBodacious]

I think some of us have to much pride about being able to take foreign bodies out using the simplest equipment possible.

For me, if the ER calls about an ear foreign body, the kid comes to clinic. I look at it w an otoscope and make a judgement call about if to make an attempt in clinic. It depends on the childs age with regards to how cooperative and restrainable they are. Usually the ear foreign body kids are are 2-5 yr olds which are probably the most difficult to both reason with or hold down.

The bottom line is, if it doesn't come out very easily, I have a pretty low threshold to take the child to the operating room to avoid any risk, no matter how small the risk is, of trauma to the child's ear, the mother's mental well-being, and therefore my reputation.

I could probably place ear tubes in clinic with a nurse restraining a child, but that's not the point. Old time docs used to do tonsillectomies in clinic, but given the option to have it done under anesthesia, the choice is pretty easy for the mother.

There is a pretty wide range as far as difficulty of removal depending on the foreign body and how it is situated. There are potential situations were you could get one out with a headlight alone, an operating head otoscope or a microscope. By the way you described the above situation, there is no way I would do that in clinic. But, there could be other factors. Like, maybe the attending was doing it pro bono and there would have been problems getting the child in for general anesthesia. Even in that case, you could potentially admit the patient from the ER to have it done.

The down side is cost.

Also, I have seen a TM severely damaged from ER attempts at removing an EAC foreign body.

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