I.

History
A. General Data
C.D., 51 years old, Female, married, Roman Catholic, presently residing at Sta. Ana Manila
came in our institution for ER consult for the first time.
B. Chief Complaint: Foreign body impaction, AD
C. History of Present Pregnancy
1 day PTC, patients daughter saw an insect went inside patients right ear. Patient did not felt
anything, no pain, no discharge and no foreign body sensation noted.
5 hours PTC, patient noted to have right ear pain, 5/10 pain scale associated with moving
foreign body sensation at the right ear. No ear discharge, no ear bleeding noted. There was no ear
manipulation done. No medication taken and no consult done.
1 hours PTC, patient noted that right ear pain progressed now 8/10 pain scale associated with
ear bleeding. Hence, consult.

D. Past Medical History

She is non-hypertensive, non-diabetic and no history of pulmonary tuberculosis, asthma,
cancer, cardiovascular disease and kidney disease. She had no previous history of surgery and
hospitalizations. She had no history of allergy to any medications or any food.
E. Family History
There were no history of hypertension, diabetes mellitus, asthma, cardiovascular disease,
malignancies and kidney disease in her family.
F. Obstetrical History: Gravida 3 Para 3 (3003)
G. Menstrual and Gynecological History
The patient had her menarche at the age of 10 occurring at regular intervals of 29 days lasting
for 3-4 days consuming 3 moderately soaked napkins per day and not associated with dysmenorrhea.
Patient had her menopause at the age of 45 years old. No pap smear done and no history of
contraceptive use.
H. Sexual History
Patient had her first contact at the age 17 years old and had 2 sexual partners. She denies any
history of dyspareunia, postcoital bleeding, leukorrhea and exposure to sexually transmitted infection.
I. Personal and Social History
Patient is non-smoker, non-alcohol beverage drinker and denies illicit drug use. She is a
college undergraduate and a housewife. She is living with her husband and children. Garbage is
collected once a week. Water source is from NAWASA.

II. Review of Systems

General: (-) chills night sweats, fever, change in weight
Skin: (-) scars, lesions, rashes, ulcerations, excoriations
HEENT:
Head: (-) Headache, masses, bruises
Eyes: (-) eye pain, red eyes, eye itchiness, eye discharge
Nose: (-) colds, nasal discharge, epistaxis, trauma
Neck: (+) goiter, (-) neck pain, cervical lymphadenopathy
Throat: (-) throat pain, dysphagia
Respiratory: (-) difficulty of breathing dyspnea, hemoptysis, cough, colds
Heart: (-) cyanosis, edema, heart murmurs, chest pain, palpitations
Gastrointestinal: (-) nausea and vomiting, loss of appetite, abdominal pain, diarrhea, jaundice
Genitourinary: (-) dysuria, frequency, urgency, nocturia, enuresis, hematuria, vaginal discharge and
itchiness
Extremities: (-) swelling bilateral extremities , warmth/erythema, joint pain, muscle pain, cramps
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 Neurologic/Psychiatric: (-) mental status changes, agitation, disorientation, mood change, weakness

III. Physical Examination

A. General Survey: In general, the patient looks healthy, small-framed woman, dressed and groomed
appropriated for her age. She is alert, awake, and responsive to the examiner. She is sitting on the chair,
slightly distressed but ambulatory, not in respiratory distress.
B. Vital Signs and Anthropometrics
Result
Weight = 50 kg
BMI = 21.6 kg/m2 (normal)
Height = 152 cm
BP = 130/80 mmHg Normotensive
PR = 81 bpm, regular rhythm Normal
RR = 16 breath/min Normal
Temperature = 36.9 Celsius (axillary) Afebrile

C. Skin and Appendages: The patients skin is brown, warm to touch and she has good skin turgor. No
raches, no edema, erythema, cyanosis, pallor, masses or lesions noted. The nail beds were not pale and
no clubbing or koilonychias were observed.
D. HEENT:
The patient has medium length, grey hair with evenly distributed volume, pattern and
texture. Her head is symmetrical and normocephalic without lesions, masses, scars and tenderness. The
scalp has no lesions, non-edematous, no parasites nor scales.
Upon inspection, her eyes are symmetrical and not protruding. There were no ptosis or
strabismus noted. The eyebrows are also symmetrical and with equal hair distribution, eyelids were
non-edematous. Lacrimal glands were not swollen or tender. She has pink palpebral conjunctiva with
no inflammation, masses nor ulcerations noted. She has anicteric sclera with no corneal ulcers or
opacities. Her pupils are equally reactive to light, accommodation, consensual reflex. No visible
lesions, masses, ulcerations or serous drainage in the ears.
Her auricles were symmetrical. Tympanic membrane on left ear is intact with retained
cerumen while tympanic membrane on right is not seen due to obstructing clotted blood and insect.
There was no tragal tenderness noted on both ears.
Her nose is symmetrical and nasal septum is in midline. External nares are equal in size
and shape. Vestibule and nasal cavity has no masses, no serous/purulent/blood-tinged drainage. Both
nostrils are patent without watery/mucoid discharge. No nasal flaring was noted.
The lips are symmetrical, no masses or ulcerations. Gums and buccal areas are pinkish
free of lesions, masses or ulcerations. The tongue is pinkish and mobile, free of masses or ulcerations.
The palate is smooth and free of lesions. The floor of mouth is free of masses or ulcers.
Neck has no limitation of motion and any nuchal spasm or rigidity. There was no
lymphadenopathy, no enlargement of parotid and submandibular glands and cervical lymph nodes
noted. Thyroid gland moves with swallowing and trachea is in midline position.
E. Chest and Lungs: Upon inspection, chest is symmetrical; no chest retractions and use of accessory
muscles; no masses, lesions, discolorations or deformities; symmetrical chest expansion. On palpation,
there was no cervical lymphadenopathy. Resonant on all lung fields, no dullness and chest lag noted.

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 Upon auscultation, vesicular on all lung fields and clear breath sounds. No wheezes, crackles, rales and
rhonchi noted.
F. Cardiovascular System: On inspection, no precordial bulging noted. PMI is at 5th ICS LMCL. Upon
palpation, no thrills and no heaves noted. Apex beat at 4th ICS LMCL. Patient had normal rate and
rhythm with no murmurs. At apex, S2>S1 while at the base S1>S2.
G. Breast: Breasts are symmetrical and non-tender.
H. Abdomen: Upon inspection, abdomen is flabby with inverted umbilicus. No engorged or dilated veins,
visible pulsations noted. On auscultation, normoactive bowel sound, no boborygmi noted. There was
no tenderness on light and deep palpation in all quadrants.
I. Extremities: (-) for clubbing, cyanosis, venous engorgement, hemorrhages, contusion; (+) strong
central and peripheral pulses; (+) rapid capillary refill, (-) bipedal edema

IV. Diagnosis: Foreign Body Impaction (Insect), AD

V. Plan and Management

Diet and increase oral fluid intake
For ear irrigation with baby oil
For ear foreign body removal with alligator forceps
Teach Aural Toilette
Take home medications:
1) Ciprofloxacin + Dexamethasone Otic drops, 2-3 drops on both ears TID for 7 days
2) Amoxicillin + Clavulanic Acid (Amoxiclav) 625 mg/tab, TID for 7 days
3) Paracetamol 500mg/tab, one tablet q6 prn for pain
Avoid ear manipulation
To comeback after 1 week

VI. Discussion
Anatomy1
The ear consists of three parts: the outer ear, middle ear and inner ear. The ear canal of the outer
ear is separated from the air-filled tympanic cavity of the middle ear by the eardrum. The middle ear contains
the three small bones called ossicles which involved in the transmission of sound, and is connected to the throat
at the nasopharynx, via the pharyngeal opening of the Eustachian tube. The inner ear contains the otolith organs,
utricle and saccule, and the semicircular canals belonging to the vestibular system, as well as the cochlea of the
auditory system.

The Outer Ear

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 The outer ear is the external portion of the ear and
includes the fleshy visible pinna (also called the Auricle), the ear
canal, and the outer layer of the eardrum (also called the Tympanic
Membrane). The pinna consists of the curving outer rim called the
helix, the inner curved rim called the antihelix, and opens into the
ear canal. The tragus protrudes and partially obscures the ear canal,
as does the facing antitragus. The hollow region in front of the ear
canal is called the concha. The ear canal stretches for about 1 inch
(2.5 cm). The first part of the canal is surrounded by cartilage,
while the second part near the eardrum is surrounded by bone. This bony part is known as the auditory bulla and
is formed by the tympanic part of the temporal bone. The skin surrounding the ear canal contains ceruminous
and sebaceous glands that produce protective ear wax. The ear canal ends at the external surface of the eardrum.
Two sets of muscles are associated with the outer ear: the intrinsic and extrinsic muscles. The ear muscles are
supplied by the facial nerve, which also supplies sensation to the skin of the ear itself, as well as to the external
ear cavity. The great auricular nerve, auricular nerve, auriculotemporal nerve, and lesser and greater occipital
nerves of the cervical plexus all supply sensation to parts of the outer ear and the surrounding skin. The pinna
consists of a single piece of elastic cartilage with a complicated relief on its inner surface and a fairly smooth
configuration on its posterior surface. The symmetrical arrangement of the two ears allows for the localization
of sound. The brain accomplishes this by comparing arrival-times and intensities from each ear, in circuits
located in the superior olivary complex and the trapezoid bodies which are connected via pathways to both ears.

The Middle Ear

The middle ear lies between the outer ear and the inner ear. It consists of an air-filled cavity called
the tympanic cavity and includes the three ossicles and their attaching ligaments; the auditory tube; and the
round and oval windows. The ossicles are three small bones that function together to receive, amplify, and
transmit the sound from the eardrum to the inner ear. The ossicles are the malleus (hammer), incus (anvil), and
the stapes (stirrup). The stapes is the smallest named bone in the body. The middle ear also connects to the
upper throat at the nasopharynx via the pharyngeal opening of the Eustachian tube. The three ossicles transmit
sound from the outer ear to the inner ear. The malleus receives vibrations from sound pressure on the eardrum,
where it is connected at its longest part (the manubrium or handle) by a ligament. It transmits vibrations to the
incus, which in turn transmits the vibrations to the small stapes bone. The wide base of the stapes rests on the
oval window. As the stapes vibrates, vibrations are transmitted through the oval window, causing movement of
fluid within the cochlea. The round window allows for the fluid within the inner ear to move. As the stapes
pushes the secondary tympanic membrane, fluid in the inner ear moves and pushes the membrane of the round
window out by a corresponding amount into the middle ear. The ossicles help amplify sound waves by nearly

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 15
20

times.

The Inner Ear

The inner ear sits within the temporal bone in a complex cavity called the bony labyrinth. A
central area known as the vestibule contains two small fluid-filled recesses, the utricle and saccule. These connect to
the semicircular canals and the cochlea. There are three semicircular canals angled at right angles to each other
which are responsible for dynamic balance. The cochlea is a spiral shell-shaped organ responsible for the sense of
hearing. These structures together create the membranous labyrinth. The bony labyrinth refers to the bony
compartment which contains the membranous labyrinth, contained within the temporal bone. The inner ear
structurally begins at the oval window, which receives vibrations from the incus of the middle ear. Vibrations are
transmitted into the inner ear into a fluid called endolymph, which fills the membranous labyrinth. The endolymph is
situated in two vestibules, the utricle and saccule, and eventually transmits to the cochlea, a spiral-shaped structure.
The cochlea consists of three fluid-filled spaces: the vestibular duct, the cochlear duct, and the tympanic duct. Hair
cells responsible for transduction changing mechanical changes into electrical stimuli are present in the organ of
Corti in the cochlea.

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Blood supply
The blood supply of the ear differs according to each part of the ear. The outer ear is supplied by a
number of arteries. The posterior auricular artery provides the majority of the blood supply. The anterior auricular
arteries provide some supply to the outer rim of the ear and scalp behind it. The posterior auricular artery is a
direct branch of the external carotid artery, and the anterior auricular arteries are branches from the superficial
temporal artery. The occipital artery also plays a role. The middle ear is supplied by the mastoid branch of either the
occipital or posterior auricular arteries or the deep auricular artery, a branch of the maxillary artery. Other
arteries which are present but play a smaller role include branches of the middle meningeal artery, ascending
pharyngeal artery, internal carotid artery, and the artery of the pterygoid canal. The inner ear is supplied by the
anterior tympanic branch of the maxillary artery; the stylomastoid branch of the posterior auricular artery; the
petrosal branch of middle meningeal artery; and the labyrinthine artery, arising from either the anterior inferior
cerebellar artery or the basilar artery.

Ear Foreign Body Removal3

The removal of foreign bodies from the ear is a common procedure in the emergency department.
Children older than 9 months often present with foreign bodies in the ear; at this age, the pincer grasp is fully
developed, which enables children to maneuver tiny objects. In adults, insects (eg, cockroaches, moths, flies,
household ants) are the foreign bodies most commonly found in the ear. Rarely, other objects have been reported
(eg, teeth, hardened concrete sediments, illicit drugs, plant material). Some persons from Mexico and Central
America reportedly insert leaves and other plant material into their ears as a form of native remedy. Also, some
adults with psychiatric disorders present to the emergency department with foreign bodies lodged in their ears as a
form of self-mutilation called ear stuffing. In children, the range of foreign bodies is extensive. Food particles (eg,
candy, vegetable matter, beans, chewing gum) and other organic material (eg, leaves, flowers, cotton pieces) are
commonly encountered. Inorganic objects such as small toys, beads, pencil erasers, and rocks are also common.

Indications
The prompt removal of foreign bodies from the ear is indicated whenever a well-visualized
foreign body is identified in the external auditory canal and an uncomplicated first attempt is anticipated.

Contraindications
The presence of a tympanic membrane (TM) perforation, contact of a foreign body with the
tympanic membrane, or incomplete visualization of the auditory canal are indications for urgent-emergent ENT
consultation for removal by operative microscope and speculum. If button batteries or hearing aid batteries are
involved, emergent ENT consultation is always warranted because time-sensitive liquefaction necrosis may lead to
subsequent tympanic membrane perforation and further complications. In fact, irrigation should never be attempted
in such cases, as it accelerates the necrotic process.

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Anesthesia
Local anesthesia is invasive and is not generally used for uncomplicated ear foreign body removal
because of the complex innervations of the external ear canal. Procedural sedation is sometimes necessary for a
patient who is unable to cooperate with the removal procedure.

Equipment
The equipment required depends on the removal method. Typical equipment includes the following
Otoscope with removable lens
Microscopic otoscope
Nasal speculum
Headlamp
Bayonet forceps
Alligator forceps
Syringe
Angiocatheter, 20 gauge
Emesis basin
Soft-tipped suction catheter and suction equipment
Magnet for metallic foreign bodies

Positioning
A patient's external auditory canal is easily visualized in both seated and lateral decubitus
positions; cooperative patients can choose whichever position is more comfortable. In adults and young children,
gently retract the pinna superiorly and posteriorly to straighten the ear canal for optimal visualization. In infants, the
pinna may have to be gently retracted posteriorly or even downward for optimal view of the external auditory canal.

Technique
Techniques appropriate for the removal of ear foreign bodies include mechanical extraction,
irrigation, and suction. Practitioners should allow the nature of the foreign body to guide the choice of technique.
Irrigation is contraindicated for organic matter that may swell through osmosis and enlarge within the auditory
canal. Insects, organic matter, and objects with the potential to become friable and break into smaller evasive pieces
are often better extracted with suction than with forceps. Live insects in the ear canal should be immobilized before
removal is attempted. Mineral oil, microscope oil, and viscous lidocaine have all been used successfully for this
purpose
Mechanical extraction
Position the patient comfortably. Briefly repeat the ear examination while observing the location
and depth of the foreign body. Move the otoscope lens to one side and carefully introduce bayonet forceps or
alligator forceps through the otoscope lens. Advance the forceps incrementally through the external auditory canal
until the foreign body is grasped. Gently withdraw the forceps, with attached foreign body, from the auditory canal.

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Always check for complete removal of the foreign body, perforation of the tympanic membrane, and abrasions of
the auditory canal.

Irrigation
To irrigate, first attach a 20-ga angiocatheter to a 60-mL syringe. Warming the irrigation fluid
(water or normal saline) greatly enhances patient comfort. Position the patient comfortably and drape the area to
keep the patient dry. Position an emesis basin under the affected ear to collect irrigation runoff. Place the flexible
angiocatheter tip gently in the external auditory canal. Advancing the tip too far risks damage to the tympanic
membrane. With the angiocatheter tip held gently in position, slowly inject irrigation fluid until the foreign body
washes out. Always conduct a post procedural ear examination to confirm complete removal of the foreign body and
to check for complications.

Suction
Connect the soft-tipped suction catheter to low wall suction and position the patient comfortably.
Visualize the foreign body with the otoscope. Maintain the position of the otoscope while retracting its lens to one
side. Introduce the catheter through the otoscope and gently advance it incrementally until the foreign body is
contacted. Gently withdraw the suction catheter tip and attached foreign body from the external auditory canal.
Repeat a post procedural ear examination to confirm complete removal of the foreign body and to check for
complications. See video below.
Abandon attempts to retrieve a foreign body if complications arise. If the object migrates farther into the canal or if
bleeding, edema, or increasing pain develops, consult an ENT specialist. Repeated attempts to remove a foreign
body from the ear may result in infection, perforation, or other morbidity.

Pearls
Consider that an underlying illness may have prompted the patient to insert a foreign body into the ear to relieve
discomfort such as pain or pruritus.
Perform a thorough head, ears, eyes, nose, and throat (HEENT) examination in all patients, since throat pain can
refer to the ears.
Always examine the opposite ear and both nares for additional foreign bodies.
Always examine the external auditory canal after the removal of a foreign body to identify preexisting or
iatrogenic tympanic membrane perforations or abrasions.
Acetone has been used successfully to remove chewing gum, Styrofoam, and superglue from the ear canal.
Ethyl chloride has been used to remove Styrofoam beads from the ear canal.

Complications
Reported acute complications of ear foreign body removal include canal abrasions, bleeding,
infection, and perforation of the tympanic membrane. Presentation of these complications may be delayed. Retained
foreign body particles may cause subsequent formation of granulomas. For the uncomplicated removal of foreign

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bodies from the ear, neither prophylactic antibiotics nor routine ENT follow-up is indicated. Not all complications
are immediately evident. Ensure that the patient or caregiver understands that further treatment is warranted if pain,
redness, fever, or discharge develops.

Source:
1. https://en.wikipedia.org/wiki/Ear
2. Grays Anatomy 3rd Edition
3. Medscape. Ear Foreign Body Removal

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