Foreign bodies in the ear are more difficult and dangerous to remove than those in the nose[md]the dangers include a perforated drum, total deafness, and a facial palsy, or all three. So refer the patient if you can. The middle (isthmus) of the auditory canal is narrower than either its outer, or its inner end. If a foreign body is impacted outside the isthmus, removing it should not be difficult. Try syringing first. If this fails and you cannot refer him, and you have to use instruments, be sure to anaesthetize him first, especially if he is a child. The foreign body may be a seed, a live cockroach, a piece of paper or a broken matchstick. Two-thirds of patients are usually under five years.
MOHAMMED ASLAM (10 years), the son of a local VIP was admitted with a ball-bearing in his ear. The consultant ENT surgeon was on leave, and so a junior took the case over. It seemed a pity to give the child a general anaesthetic, and as he seemed co-operative, it was decided to remove the ball-bearing with a wax hook. Unfortunately, after two unsuccessful attempts, during which the ball-bearing was driven deeper in, some bleeding began, which rather obscured the view, but the ball-bearing was eventually removed. However, in the blood clot were found the remains of his malleus, his incus, and his stapes. LESSONS (1) If you are inexperienced, simpler methods may be safer, even if they are less dramatic. Syringing is not clever, but it is ''brilliant' compared with inadvertent stapedectomy. (2) The less experienced you are, the more necessary is it to remove a foreign body under general anaesthesia. A struggling child is no subject for delicate surgery. Fig. 25-4 REMOVING A FOREIGN BODY FROM THE EAR. Start by trying to syringe it out. If this fails, and if you don't have the proper hook, you can use a bent paper clip. Bend it exactly as shown and hold it in mosquito forceps. Be sure you anaesthetize the patient first.
FOREIGN BODIES [s7]IN THE EAR First try to syringe the patient's ear, if necessary under ketamine, as if you were removing wax. Use a 20 ml syringe, or an ear syringe containing water at body temperature. Pull his ear upwards and backwards, and direct the stream of water up along the roof of his ear canal, so that it gets behind the foreign body and pushes it out. Syringing will remove most foreign bodies.
If syringing fails (rare), try gentle suction with a piece of catheter on the end of the sucker. If this too fails, refer him.
If you cannot refer him, admit him and always anaesthetize him. Ketamine is ideal. A foreign body is seldom urgent, so you have time to starve him.
Lay him down, and use a forehead mirror, and a good source of light. Or use an auriscope with a large speculum and an open lens. Rest your hand on his head. Use an aural hook, a cerumen hook, or a paper clip bent exactly as shown in Fig. 25-4, smoothed with a file or on a stone, and held in mosquito forceps. Put the hook into his auditory canal, so that it lies against the wall. Then, when it is past the foreign body, twist it, so that it lies behind it, and allows you to pull it out.
CAUTION ! Be very gentle so as: (1) Not to push the foreign body beyond the isthmus of his auditory canal, and (2) not to damage his tympanic membrane. (3) Don't try to use dissecting forceps.
If it has gone beyond the isthmus, so that you cannot remove it with a hook, make a small vertical incision from the back of his pinna at its attachment to his mastoid, through into his ear canal; hold his pinna forwards, and remove the foreign body under direct vision. An incision like this does not get you a long way in, but it may help. Inspect his drum and close the incision with 2 monofilament sutures. Then pack his canal with ribbon gauze to prevent oedema and granulations. If possible impregnate the gauze with ''BIPP' (Bismuth and Iodoform Paste). Remove the pack in 5 days.
DIFFICULTIES [s7]WITH FOREIGN BODIES IN THE EAR If there is an INSECT IN HIS EAR, put a few drops of oil into his ear to kill it, then try syringing it out. If this fails, which is seldom, anaesthetize him.
If a VEGETABLE FOREIGN BODY SWELLS, and jams in the canal, leave it and try again later.
If his TYMPANIC MEMBRANE IS RUPTURED, try to prevent infection, and let it heal spontaneously. Keep it completely dry for 6 weeks. Don't dust it with antibiotics, or pack the canal. Mopping is unnecessary, unless his middle ear discharges; if so treat him as for otitis media. A drum may rupture during unskilled attempts to remove a foreign body, or as the result of an explosion, or a blow, or by penetration with a sharp object.
CAUTION ! Don't syringe a ruptured drum, and do as few manipulations as possible.