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Auditory and vestibular disorders, Others
Korean Journal of Audiology 2010;14(1):8-11.
Analysis of the 169 Patients with External Auditory Canal Foreign Bodies in the Eemergency Department
Joong Ho Ahn, Gye Song Cho, Jong Woo Chung, Tae-Hyun Yoon
Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
Analysis of the 169 Patients with External Auditory Canal Foreign Bodies in the Eemergency Department
Joong Ho Ahn, Gye Song Cho, Jong Woo Chung, and Tae-Hyun Yoon
Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
Abstract

Background and Objectives
The purpose of this study was to compare the types and managements of foreign bodies in the external auditory canal (EAC FBs) between the children and adult populations. 



Subjects and Methods
We reviewed the medical records of 169 patients with EAC FBs over a 5-year period retrospectively. We analyzed the age, foreign body type, length of time in place, removal techniques, and the rate of referral to otolaryngologist and complications. Foreign bodies were categorized into six groups according to their own characteristics. We divided patients on the basis of age; patients under 14 years were included in child group and patients over 15 years were included in adult group. We compared the types and managements of EAC FBs between the groups. 



Results
One hundred sixty-nine patients (73 male and 96 female) were brought to the emergency department over 5-year period with a diagnosis of EAC FBs. Their mean age was 21 years (range, 1-62 years). Among the types of foreign bodies, type I (Soft and breakable) and IV (hard with regular surface) were more common in children group while type V (insects) was more common in the adult group (p<0.05). There were also significant differences between children and adult group in gender and the rate of referral to otolaryngologist, direct removal, and complications (p<0.05). 



Conclusions
There were significant differences between children and adult in type of foreign bodies, gender, and the rate of referral to otolaryngologist, direct removal, and complications. Clinicians should keep in mind these differences before treatment of EAC FBs.

Keywords: Foreign body;External auditory canal;Age.

Address for correspondence : Joong Ho Ahn, MD, Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
Tel:+82-2-3010-3710, Fax:+82-2-489-2773, E-mail:meniere@amc.seoul.kr


Introduction

Foreign bodies of the external auditory canal (EAC FBs) are commonly seen in the emergency and otolaryngologic departments. EAC foreign bodies presents with various shapes, sizes, and composition.1) Complication rate of EAC foreign bodies is varied from 5% to 31%, especially much higher in child patients.1,2,3,4,5,6) The proper referral to otolaryngologist is emphasized in the otolaryngology literature because of the high complication rate that occurs when attempts are made to retrieve these objects in less than optimal conditions. There are two distinct clinical presentations dependent on the age of the patients, children and adults.7) There are lots of papers about EAC foreign bodies in children, but relatively small numbers of studies are reported in adult patients.
In order to improve patient care, we review the cases of EAC foreign bodies presenting to the emergency department (ED) of our institution (Asan Medical Center, Seoul, Korea) over a 5-year period and analyses management practices and outcomes. Also, we classified foreign bodies into 6 categories like Cederberg's classification according to their characteristics, and analyzed the differences between children and adult patients in practicing EAC FBs.8) These findings will result in successful removal of EAC FBs and increase overall health care efficiency with few complications.

Subjects and Methods 

A retrospective chart review was completed to evaluate all patients with EAC FBs over a 5-year period at the emergency department of tertiary care hospital. Patients were categorized by sex, age, the type of foreign bodies, length of time before arriving to the emergency department, removal techniques, and the rate of referral to otolaryngologist and complications. 
The foreign bodies were categorized into 6 groups: objects with soft quality with regular or irregular surface, objects with hard quality with regular or irregular surface, insects, and unknown origins (Table 1).
One hundred sixty nine patients, 73 males and 96 females, were brought to the emergency department with EAC foreign bodies between January 2000 and November 2004. Their mean age was 21±16 years (range, 1-62 yr). We divided patients on the basis of age; patients under 14 years were in-cluded in child group and patients over 15 years were in-cluded in adult group (Fig. 1). Then we compare between child and adult group in types and management of EAC FBs. EAC FBs were removed directly using head mirror and otoscope. The patients who had failed direct removal then underwent attempted removal utilizing a microscope. The removal instrument that was most commonly successful was forceps. Other methods like suction, irrigation, hook and curette were successful technique according to the different types of EAC FBs. 
Assessment of statistical significance was completed by Fischer's exact test. p-values for the comparison among types of foreign bodies were corrected for the number of comparisons. p-values<0.05 were considered for significant.

Results

The results of comparison between children and adult group in foreign body type, referral to otolaryngologist, and the rate of direct removal and complications are summarized in Table 2
Most common EAC FB was type V (insects)(51.5%). 
When we compared between children and adult groups, type I (soft and breakable) and IV (hard with regular surface) were more common in child group (corrected p<0.05), while type V (insects) was more common in adult group (corrected p<0.01). Cockroaches are the most commonly specified insect foreign body, type V (67.8%); others include ants, honeybees, beetles, spiders, and unspecified in the type V (insects) groups. Acute otalgia was the most common presenting symptom in the type V (insects), while foreign body sensation and earfullness was the common complaint in the other types.
There were more boys in child group and women in adult group (p<0.05). All patients were referred to otolaryngolog-ist in children group, while 79.2% of patients were referred (p<0.01). Of 169 EAC FBs, 51.5% and 34.7% of foreign bodies were removed directly without microscope in child and adult group respectively (p<0.05). Suction and irrigation was useful method in the type I (soft and breakable) group, but forceps, hook, curette was successful technique in the other types. Several forms of restraints included the parents or nursing staff holing the patient in position were used on 52.9% of the children group. Sedation was utilized in 26.5% of children patients with chloral hydrate, midazolam used with no complications related to the use of sedation. 3 children patients (4.4%) required general anesthesia to remove the EAC FBs: 2 cases had undergone failed attempts with using sedatives, 1 case had undergone failed attempts with using direct method because of severe bleeding.
As for complications, there were two cases of the tympanic membrane perforations (the direct trauma of cotton-tippled applicator) and three cases of the EAC lacerations were found in children group (7.4%), while there was only one case of the EAC laceration reported in adult group (1.0%)(p<0.05). Two cases of EAC lacerations occurred during removal procedure in the children group. Other complications appeared to be caused by direct injury of EAC FBs. The majority of patients presented within 24 hours with suspicion of EAC FBs. Although adult patients arrived to ED more quickly than children after awareness of foreign body, there was no significant difference between two groups (Fig. 2).

Discussion

The EAC can be divided into the cartilaginous and the osseous portions and two areas of acute narrowing occur; one at the junction of the cartilaginous and osseous portion of the canal, and one just lateral to the tympanic membrane.7) The Osseous portion is narrower and is lined with a very vascular and highly sensitive thin layer of skin.5) The minor manipulation to this portion will cause bleeding and pain and even the most cooperative patients do not tolerate more than one or two removal attempts. EAC FBs follow chronic otitis media in frequency as an inflammatory etiology for an EAC polyp and such foreign body may take many forms and are a relatively common problem seen and managed by a variety of otolaryngologists and physicians.8)
Many methods are used to extricate various types of foreign bodies, which have been well described.1,4,7,9,10,11,12,13) Whatever method is used, when the operator has one or maybe two attempts without successful foreign body removal, the patient loses his or her patience and becomes uncooperative, especially children. Further attempts with an uncooperative child patient will inevitably lead to an otherwise avoidable complication. Despite of this importance, the subject of EAC FBs has received little attention in the literature until recently. Studies to date have largely focused on the most commonly encountered foreign bodies, age distributions, symptoms at presentation, and possible management strategies.1,2,3,4,9,11,13)
The type of EAC foreign bodies seems limited only by the size of the canal and, in children, the limits of their imagi-nation. Previous studies reported that the most common type of EAC FBs in child patients was hard with regular surface type, ranged from 26.6% to 51.3%1,3,10,11) and most common type of EAC FBs in adult patients was insects.7) In this study, soft and breakable foreign bodies were also common in children and insects in adults.
Although no statistically significant differences have been reported, male child patients slightly outnumber female child patients in most published studies.1,4,5,10,11) This trend in children agrees with our results, but in this study, female patients outnumber male patients in adult group (p=0.01). We carefully guess the possibility of the relationships between these results and the type of foreign bodies. Insects are usually attracted to the fragrances, and eventually, they tend to incited to female than male patients in adult group.
Lots of reports recommend the direct referral to otolaryngologists, especially for the patient with previous removal failures.1,2,4,5,11,12,13) In our hospital, assigned otolaryngologists are resident for emergency department and when the patient with EAC FB visited ED, an intern of ED primarily examines EAC and then refers to otolaryngologist in most cases, especially when the patients are children. Therefore all children patients were referred to otolaryngologist in this study. The complication rates are varied according to the type of foreign body and the age of the patients and previous studies reported foreign bodies were from 5 to 31% in otolaryngologist-managed situations.1,4,6,11,12) In this study, we could reduce complication rate (7.4% in children and 1% in adult) due to these immediate referral system. Of the 6 cases of complications, there were two cases of the tympanic membrane perforations due to direct trauma of cotton-tippled applicator. Of the four cases of the EAC lacerations, two cases occurred due to direct injury and the other two cases occurred during removal procedure in the children group. This finding emphasize that proper procedural sedation is useful for the uncooperative children patients.
Many methods are used to extricate various types of foreign bodies, which have been well described.1,4,7,11,12,13) In this study, foreign body removals under direct visualization technique were more used in children than adult group. Cooperation in children is highly variable and we removed EAC foreign body with head mirror or diagnostic otoscope for the uncooperative patients with very young age. 

Conclusion

For successful management of EAC foreign body, initial evaluation should be important and the added cost of specialty referral will be well compromised by the decreased rate of complications and treatments related to them. There were significant differences between children and adult in type of foreign bodies, gender, and the rate of referral to otolaryngologist, direct removal, and complication. Clinicians should keep in mind these differences before treatment of EAC FBs. 


REFERENCES

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  3. Balbani AP, Sanchez TG, Butugan O, Kii MA, Angélico FV Jr, Ikino CM, et al. Ear and nose foreign body removal in children. Int J Pediatr Otorhinolaryngol 1998;46:37-42. 

  4. Bressler K, Shelton C. Ear foreign-body removal: a review of 98 consecutive cases. Laryngoscope 1993;103:367-70.

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  6. Dubois M, François M, Hamrioui R. [Foreign bodies in the ear; report of 40 cases.] Arch Pediatr 1998;5:970-3.

  7. Fritz S, Kelen GD, Sivertson KT. Foreign bodies of the external auditory canal. Emerge Med Clin North Am 1987;5:183-92.

  8. Cederberg CA, Kerschner JE. Otomicroscope in the emergency department management of pediatric ear foreign bodies. Int J Pediatr Otorhinolaryngol 2009;73:589-91.

  9. Harris KC, Conley SF, Kerschner JE. Foreign body granuloma of the external auditory canal. Pediatrics 2004;113:e371-3.

  10. Mishra A, Shukla GK, Bhatia N. Aural foreign bodies. Indian J Pediatr 2000;67:267-9.

  11. Schulze SL, Kerschner J, Beste D. Pediatric external auditory canal foreign bodies: a review of 698 cases. Otolaryngol Head Neck Surg 2002;127:73-8.

  12. Mackle T, Conlon B. Foreign bodies of the nose and ears in children. Should these be managed in the accident and emergency setting? Int J Pediatr Otorhinolaryngol 2006;70:425-8. 

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