If an otoscope is not available, use an ophthalmoscope to look through any type of speculum into the ear canal. Objects that can substitute for a speculum include a pen casing (cut the tapered point off a little and smooth it), a 1-cc syringe barrel with the end cut off and smoothed, a nasal speculum (be careful not to put it in too far), and similar objects. Note that many late-19th century otoscopes looked no different than modern nasal speculums. They used a direct or an indirect (head mirror) light source.4
Foreign Body/Cerumen Removal
Knowing how to remove foreign bodies from an ear can save time and resources. There is no evidence to support choosing one method over another in most cases, and many different techniques are available. It is also useful to know which cases may need to go to the OR to have foreign bodies removed under sedation. The most difficult foreign bodies to remove from an ear are spherical objects, those in contact with the tympanic membrane, and those that have been in the ear for more than 24 hours.5 Most foreign bodies can be removed from the ear using irrigation, dissolution, suction, glue, or by other physical means. Removing insects and metal objects are special cases.
Current sedation techniques (see "Procedural Sedation" in Chapter 15, Sedation and General Anesthesia) make it safe to administer sedation to both adults and children before undertaking painful, or what may be prolonged, attempts at foreign body removal. Anesthetizing the ear can gain the patient's cooperation, although good anesthesia in the ear canal is difficult to achieve. Topical anesthetic can be dropped into the canal (if the foreign body is neither vegetable matter nor a button battery), although it usually has only a modest effect.
Irrigation is the least traumatic way to remove cerumen and smaller foreign bodies close to the tympanic membrane (TM). If the TM is not perforated, irrigate the ear with clean water at body temperature. (Cold water produces emesis.) For earwax, it may help to put in a softening agent for a few days before trying this.
Use a small piece of tubing connected to a syringe; the catheter from an IV or the tubing from a butterfly cannula—with the needle cut off—works well. An alternative is to use a bulb syringe or a turkey baster. With both, low-pressure volume, rather than a directed stream of water, works better. Other methods that have been used successfully include using oral jet irrigators (this may have too high a pressure, depending on the state of the batteries),6 a recreational water gun,7 and mouthfuls of water instilled (by the patient's nurse-wife) through a cocktail straw.8 Aim the fluid stream at the superior aspect of the ear and, if possible, pulse the fluid for best results. Alternatively, direct the stream along the wall of the ear canal and around the object, flushing it out.
Do not irrigate the ear to remove hygroscopic objects such as vegetables, beans, and other food matter as these may swell. More common in noses than in ears, button batteries should not be irrigated out. That only accelerates the tissue necrosis. Also, avoid nasal and otic drops in these patients.
Styrofoam is a common foreign body found in the ear. It is often compressed and tightly impacted in the ear canal. The friable substance tends to fragment if grabbed with forceps. The best removal method is to instill acetone or ethyl chloride, both organic solvents. This results in rapid and near-complete dissolution of the Styrofoam without any patient discomfort.9
Objects that are light and move easily can often be quickly removed with suction. Use a small soft-rubber suction catheter (e.g., pediatric feeding tube), a standard metal suction tip (e.g., Frazier tip), or a specialized flexible tip. It takes 100 to 140 mm Hg (or higher) negative pressure to attach an object, so using your mouth to suck on a tube won't work.
Mechanically removing an object involves grabbing the object and pulling it out of the ear. This is most commonly done with cerumen, but can often be done with compressible objects by using tiny (alligator) forceps. Alligator forceps are best for grasping soft objects like cotton or paper.
To remove cerumen and small, visualized foreign bodies, fashion improvised spoons by bending the end of a paper clip into a very tiny "U" shape. Don't do this with your fingers—use pliers or a similar tool. This can also be used for removing foreign bodies from the nose.10 If the foreign body is at all irregularly shaped and is not made of organic material, it can often be grasped with any available forceps or hemostat and removed.
Metallic objects, such as the appropriately feared button batteries, can sometimes be removed from the ear using a magnetized screwdriver.11 (Ask your maintenance staff for one to use.) Note that batteries must be removed immediately to prevent corrosion or burns. A delay of only an hour or two, or a missed diagnosis of a battery in a nose or an ear, may lead to a particularly severe outcome. Upon contact with most tissue, this type of alkaline battery is capable of producing a liquefactive necrosis extending deep into tissues. Do not crush the battery during removal. Avoid nasal and otic drops. These electrolyte-rich fluids enhance battery corrosion and leakage, the generation of an external current, and local injury. After removing the battery, irrigate the canal to remove any alkali residue.
If the object is dry and smooth, put a tiny amount of cyanoacrylate (Super Glue) on the wooden end of a tiny swab (e.g., Q-tip) and touch the object. It will dry in about 15 seconds and then both can be extracted. The danger is gluing the stick to the patient. If so, don't fret—it can be removed with acetone or simply by waiting several hours.12
Insects are a special case of organic foreign body. They are the most frequent ear foreign body in adults. Generally, they are alive, and often panic the patient because of both the pain and the noise they generate.
Kill the insect before attempting to remove it. Quickly drop in any liquid that will not injure the ear canal (e.g., mineral or cooking oil, lidocaine, liquid soap, alcohol, etc.) to kill the insect—and to restore the patient to relative calm. Plain water or normal saline usually is ineffective. Most insects die in less than 3 minutes after liquid is put in the ear.13
Patients with edematous otitis externa need a method of getting the medication into the ear canal. This usually requires an ear wick. To improvise an ear wick, use thin ribbon gauze, impregnated at the bedside with antibiotic/anti-inflammatory ointment. This can be removed by patients, is inexpensive, and requires fewer visits than when patients use ear wicks.14
Alternatives to Otic Medications
Acetic acid (10% vinegar) is an amazing, nontoxic, inexpensive, and widely used preventive and treatment for most cases of external otitis. Scuba divers routinely use it. Mix one part acetic acid (vinegar) with nine parts water. Instill enough to fill the ear canal as often as needed. The only side effect is a streak of white where it drips out of the ear. Simply wipe it off. One caveat: diabetic patients and individuals whose ear canals have swollen shut need additional treatment; the latter can be treated with this medication if an ear wick is inserted. While patients with diabetes may be able to temporize with acetic acid, they should also have the appropriate antibiotics or antifungals instilled, if these are available. A mixture of 50% rubbing alcohol, 25% white vinegar, and 25% distilled water can also be used for external otitis. This should only be used QID.15
A myringotomy may need to be done if the patient is in pain from otitis and no analgesic, decongestant, or antibiotic is available. If a myringotomy is necessary, nearly any local anesthetic drops will anesthetize the tympanic membrane if you wait 10 minutes after they are put in. For example, use one spray of 10% lidocaine aerosol directed into the clear external meatus onto the tympanum.16 Another option is to put in 1 drop (only!) of 10% phenol. If phenol is used, start the procedure immediately, since the anesthetic effect lasts only 10 minutes. (Phenol also can anesthetize other areas, such as pilonidal cysts.) To do the myringotomy, insert an 18-gauge needle into the anterior-inferior part of the tympanic membrane. To take a culture, attach a TB syringe. Avoid puncturing the membrane posteriorly. (David Merrell, MD, oral communication, October 2006.)