FOREIGN BODIES IN EAR 63 NOSE* GEORGE L. RICHARDS, M.D., P.A.C.S.

FALL RIVER, MASS.

LL chiIdren tend to put smaII objects

A in the mouth about as soon as they can handIe anything. The reason

is evident since the mouth is the young child’s organ of information as to the character of externa1 objects.

done under a reAected Iight. If it is found that the child is restIess, fearfu1 and wiI1 not remain quiet it is better to give at once and before any manipuIation a genera1 anesthetic.

OIder children have a tendency to put foreign bodies in the ear and nose as we11 as in the mouth. The reason for this is not quite as cIear but possibly is due to the chiId’s habit of feeIing the skin with various objects, especiaIIy smooth ones.

FOREIGN BODIES IN THE EAR

The foreign bodies pIaced in the ear consist of any smaI1 objects which a chiId can handIe and which may be put in the ear. Common ones are peas, beans, beads, smaI1 pieces of stone, bits of rubber, chaIk, pieces of nut, pencil tips, bits of cotton, bits of wood and the Iike. In addition and more often in oIder persons flies and other insects occasionaIIy make their way into the externa1 ear cana1.

Sudden deafness in chiIdren, pain Iimited to one ear without apparent cause or inffammation with or without a history shouId make one think of the possibiIity of a foreign body and an examination shouId be made. In young children both the examination and the removal may be diffIcuIt on account of the fear of the chiId that he is going to be hurt.

Good iIIumination from a forehead mirror or from some source of eIectric iIIumination or cIear dayIight is essentia1. If the foreign body is deep in the cana reflected light is absoIuteIy necessary. A good-sized ear specuIum, a pIunger syringe with smaI1 tip or a smaI1 soft rubber syringe, two smaI1 wire curettes, one with smooth edges, the other sharp, and bent at a sIight angIe on the shaft, an ear spoon, such as was formerIy in every physician’s pocket case, a small short hook at nearIy right angIes to the shaft, and ear forceps are the instruments required. There are two types of ear forceps, the smaI1 angular type made so as to be opened as widely as possibIe in the cana and the Sexton type with paraIIe1 bIades. The forceps are onIy to be used when the object has been drawn far enough forward to be readiIy grasped. No Iight ear forceps wiI1 hoId the foreign body if it is firmly packed within the cana1.

A foreign body in the ear cana is seIdom an emergency and no attempt shouId be made at remova unti1 prepared to cope with any situation which may arise. Take time to get ready for its remova if there is any IikeIihood that it wiI1 be at a11 diffIcuIt. ChiIdren do not hoId stiI1 for work on their ears and are frequentIy very much frightened before anything is done. AI1 the procedures for the remova requir a quiet patient and are usuaIIy

The first examination is to ascertain the position and nature of the foreign body and how Iong it has been in place. If very recent, attempt to remove at once. If it has been present for some time and the cana is swoIIen wait for this sweIIing to go down, as much harm can be done by III- advised attempts at remova1. The ear cana readiIy bIeeds if traumatized even sIightIy and this bIeeding is often very persistent and masks the foreign body, hence every care must be taken to prevent this bIeeding.

If the object is smaI1 and not too tightIy packed it can usuaIIy be removed by syringing. Use plain warm water or warm water and boric acid and Iifting the auricle

* Submitted for publication February q, 1929.

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NEW SERIES VOL. VI, No. 4 Richards-Foreign Bodies American Journal of Surgery 5’5

upward so as to straighten the cana as much as possibIe, direct the stream back- ward aIong the ear waII so as to get the water behind the object. If it is a pea or bean or anything that can sweI1 it may be so swoIIen that the water cannot get behind it. Here the spoon-shaped instru- ment or the smaI1 curette or hook may serve exceIIentIy. If the chiId is quiet these instruments can be sIowIy worked around and behind the object. Do not use force from beIow upward but on the anterior and posterior and upper sides of the cana since if the object is at a11 deep, by working from beIow it might be possibIe to push the object into the middIe ear cavity and then into the attic. This has happened. In such a case the extraction becomes very diff%uIt and shouId be done by one trained in aura1 surgery. In using the syringe a considerabIe degree of force is required as it is the pressure of the water behind the object which is going to remove it. In using the short hook aIways introduce aIong the side of the cana in such a way as not to traumatize the cana1. Kerrison has invented a ring curette which can be introduced aIong the cana and behind the object and then brought to any angIe up to a right angIe; it is smooth and does not traumatize. It has the possibIe disadvantage that it has to be so smaI1 that it cannot be made strong enough to bring any appreciabIe pressure on the object and is not as prac- tica as the smaI1 ring curette firmly attached to a smaI1 straight handIe.

A gIass bead is very diff%uIt to remove if impacted but if it has a center hoIe it may be possibIe to so manipuIate it as to get the short hook into the Iumen of the bead.

If unabIe after proceeding in this manner to remove the foreign body and if it is firmIy impacted deep in the cana the patient shouId be sent to a capabIe aurist. In such a case the posterior membranous cana waI1 is detached and brought forward as in the radica1 mastoid operation. The foreign body can then be gotten at from

behind and brought forward and removed under good iIIumination. The wound is then sutured, the cana Iining carefuIIy repIaced and heId in pIace by a gauze pack for a few days, HeaIing is prompt and usuaIIy without incident.

Insects are best removed by syringing. They are very annoying, especiaIIy the buzzing kind. Simple syringing may be tried and if they do not come out readiIy they shouId be kiIIed with oil or chIoroform before further attempts at remova1. FIies have even Iaid their eggs in the ears and maggots have formed there. Do not attempt to remove a ffy with forceps even if visibIe. The insect wiI1 be hard to grasp and there is danger of doing injury with the forceps.

Removal of Cerumen. Many peopIe suf- fer from hardened wax in the ear cana and the technique of its remova1, whiIe as a ruIe simple, may be diffIcuIt of accom- pIishment. Th e reason is that the ear cana is sometimes irreguIar and narrow at the junction of the membranous and bony portions. The wax becomes hard and attempts by the patient to remove it with the finger onIy force it more deepIy into the canal.

Patients often compIain after sea bathing of what they caI1 “water in the ear” when the rea1 troubIe is due to water in the externa1 cana which has caused sweIIing of hardened wax, and the deafness and discomfort that foIIow are due to pressure of this wax against the drum.

For remova of cerumen a soIution of bicarbonate of soda (a teaspoonfu1 in a bow1 of warm water), a syringe and a smaI1 smooth wire ring curette are a11 that are necessary. The bicarbonate of soda wiI1 soften the wax suffIcientIy if the wax is not too hard. If the wax is very hard it may be softened by packing against the mass a cotton pIedget soaked in peroxide of hydrogen. Leave this in pIace for a short time and foIIow with syringing, repeating the peroxide if necessary unti1 the wax is a11 out. Sometimes very rigid masses of cerumen which are resistent to syringing

can be removed by inserting the smooth removed by the person himseIf. It may ring curette aIongside of the mass, which even be forgotten and become lime may then come away as a whoIe without incrusted and carried for a Iong time before dill&&y. reIief is sought.

On the other hand, masses of cerumen The symptoms are referred mostIy to are somet mes very difficult of remova one side and are diffrcuIty in breathing and too Iong efforts shouId not be made at and often fouI-smeIIing discharge. In any one time. Instruct the patient to fil1 chiIdren under seven years of age a one- the ear with peroxide of hydrogen every sided discharge Iasting Ionger than a week morning for two days and then return. At or two should suggest the possibility of a the second sitting IittIe difficuIty wiI1 be foreign body. experienced with removaL When the wax is Reflected Iight and a quiet patient are al1 out the drum will be pIainIy visible. essentia1 for both examination and removal. Inspect and dry the canal afterwards and A nasal speculum, spoon curettes, prefer- be carefu1 not to injure the cana or cause abIy smooth edged, a long silver probe, it to bIeed as this bleeding has a tendency cotton applicators, a stout toothed nasa1 to continue and may be annoying. forceps with a Iong blade and scissor handIe,

and a syringe are the instruments required. FOREIGN BODIES IN THE NOSE If the object is irreguIar a snare may be

Pus discharge in the nose, especiaIIy if helpfu1. CIeanse and cocainize the nose one sided and not readiIy expIainabIe, lirst of all and use adrenaIin or some such should make one think of a foreign body substance to contract the tissues. If the as a possibIe cause. This applies to aduIts supposed foreign body is not readily seen as we11 as chiIdren, though not as often. examine carefuIIy with the Iong siIver Children occasionally put foreign bodies probe. This wiI1 usuaIIy revea1 its presence in the nose which, not producing much and position and give information as to troubIe at the time, are unnoticed and its character. may remain for years. I have twice Syringing may be used but there is the removed meta buttons which had been danger of pushing the object further present in the nose for severa years. backward. It is most efficient when used In one case reIief was sought for an through the opposite nostril but much annoying one-sided discharge and in the force cannot be used on account of the other a diagnosis of nasa1 syphilis had danger of forcing water into the ear. been made and much medicine taken. The forceps and short hook on a long Both cases promptIy recovered when the shaft and smooth-edged curettes are the buttons were removed. The foreign body most usefu1 of the instruments. If the if in pIace any Iength of time will be body is round Iike a bead it is safest to incrusted with Iime saIts and may be put the forefinger of the opposite hand in caIIed a rhinolith. The objects introduced the nasopharynx so as to avoid any are as various as those introduced in the possibiIity of the foreign body going down ear: peas, beans, buttons, beads, smaI1 the bronchi; this is especiaIIy necessary stones of the street, penci1 tips, shoe if an anesthetic has been given. buttons, nuts, erasing rubbers, pieces of The questron of anesthesia must be chaIk, pieces of sponge, cotton tampons and considered in each individual case. It is so on. Nose bIeed is not uncommon in better to give an anesthetic than to struggIe childhood and ad& Iife and any object with a frightened or unruIy chiId who is introduced to stop this may be pushed far afraid, and often with good reason, of backward and may not be abIe to be being hurt.

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5’6 American Journal of Surgery Richards-Foreign Bodies APRIL, ,929