Foreign bodies in the external auditory canal (EAC) are a frequent problem in children. The objects found in children’s ears are diverse and include beads, pebbles, popcorn kernels, paper, toy parts, earring parts, and eraser tips (1,2). Pain from pre-existing otitis media may occasionally prompt children to place foreign bodies in the ear. Although the presence of a foreign object in a body orifice is usually a presentation of inquisitive younger children, older children and adolescents will sometimes present after a cockroach has crawled into the EAC during sleep. The majority of superficially located soft or irregularly shaped objects with graspable parts can be successfully removed without otolaryngologic consultation, while firm, rounded, and/or deeply imbedded objects can be much more challenging and may warrant referral (2,3,4,5).

Objects frequently lodge at the narrow junction between the cartilaginous and bony portions of the EAC (see also Chapter 52). In children, pulling the pinna superiorly and laterally will straighten the external auditory canal for adequate visualization (see Fig. 52.5). Skin over the bony canal lacks subcutaneous tissue and is tightly adherent to the periosteum. The canal is exquisitely sensitive to touch, with sensory innervation supplied by branches of the vagus and trigeminal nerves. Nerve blocks of the external ear canal require painful, four-quadrant injections that are impossible to perform without significant emotional distress in an awake child and are not recommended. Topical anesthesia is minimally effective due to the impermeable keratinized epithelial surface of the EAC. Procedural sedation or analgesia should be considered when instruments are used or patient immobility is essential (see Chapter 33) (6).

Objects may be found on routine examination, or asymptomatic patients may have been observed putting something in the ear. Symptoms consistent with a foreign body in the EAC include ear pain, decreased hearing, cough, and otorrhea. Live insects such as roaches in the EAC often cause extreme discomfort. Triage protocols should facilitate early instillation of mineral oil to kill live insects and to prioritize care for patients suspected of having a button battery in the ear. While urgent removal may be indicated (e.g., in the case of a button battery), most objects are safe to leave in place if necessary until removal can be performed by an otolaryngologist.

Most equipment for foreign body removal is readily available in the office or emergency department (ED) (Table 54.1). The diagnostic-type otoscope head commonly available is not ideal for direct visualization during instrument removal. The operating-type head (see Fig. 53.1) facilitates introduction of an instrument under continuous direct visualization.