Patient Presentation
A 4-year-old female came to clinic after putting some small styrofoam balls into her ears at daycare. They had been part of an art project and she had told the teachers she had done it. They had tried washing her ears with running water but could still see some in her ears so called her mother. She was otherwise well and was not having pain.

The pertinent physical exam showed a happy preschooler with normal vital signs.
Her examination was non-contributory except for her ears. Both ears had styrofoam in them with direct visualization.

The diagnosis of bilateral foreign bodies in the ears was made. Some were removed with a curette easily, but there were several which were closer to the tympanic membrane. During water irrigation several more intact styrofoam balls floated out of the ear with the effluent, and repeat visualization found no retained foreign bodies. There did not appear to be any irritation to the canals and so no additional treatment was recommended. At her next visit she proudly told the doctor, “Nothing in my ears!”

Discussion
Living in the world makes the human body susceptible to foreign bodies. Orifices are particularly inviting for children to explore and see how it feels if the opening is touched by their hands or an object. Small objects are easily inserted or even just retained (such as toilet tissue in the genital area, or tissue in the nose). The mouth is particularly inviting to explore objects with as oral sensations are paramount to survival even at birth. Food can be considered a foreign body and often acts like one when stuck in the respiratory or gastrointestinal tract but is necessary to sustain life.

When someone says foreign body often thoughts of harmful objects predominate. Usually these involve some type of trauma or accident from splinters and retained bee stingers to bullets and schrapnel. Accidents predominate but some can be self-inflicted when mental health problems are concurrently present. Some foreign bodies are intentionally inserted such as jewelry, contraceptives, surgical implants, catheters, etc. These are designed with removal methods in mind. However the objects can be defective, become damaged or migrate making usual removal methods not an option. Most health care personnel have stories of various foreign bodies they have encountered, the circumstances they occurred under, and how they were managed.

Learning Point
Foreign body treatment principles vary according to the organ systems involved.

• Management principles
  • Assess if this is a life-threatening or non-emergency issue and treat accordingly. Removal should be planned and common problems planned for so additional equipment and/or emergency treatment is available if needed.
  • Foreign bodies need to be identified including their type and position (which can change even during the treatment) – direct visualization, wound probing, plain radiographs for radiopaque objects (a review can be found here), ultrasound and computed tomography can be used. Magnetic resonance imaging often cannot or should not be used as a metal foreign body could be dislodged causing additional trauma. Metal detectors have been used but are not very specific for location or identification.
  • Pain and anxiety need to be identified and treated. Immobilization of the area is also needed for removal. For patients of any age this may require anesthesia.
  • Adequate visualization is needed which includes a strong light source, and a means to see the area such as a speculum or even surgical incision to open up the area. Ice sometimes can be used to decrease swelling and help visualization and removal.
  • Removed objects should be inspected to make sure the entire object has been removed. Fragments are common especially for compressible objects.
  • Tetanus prophylaxis requirement should be assessed.
• Removal techniques
  • Foreign bodies usually should be removed to decrease infection risk, improve healing and avoid additional trauma to tissues. The area should be irrigated and debrided and definitively treated. Sometimes foreign bodies need to be left in place because the risk of removal is higher than the risk of the object such as a bullet lodged near a major vessel. Irregularly shaped or sharp objects almost always need to be removed (i.e. glass)
  • The track where the object was inserted or entered is often the best to follow to find the object, remove it and treat it.
  • Common options for removal are:
    • Forceps – non-compressible foreign bodies such as beads, rocks, food, jewelry etc. Special forceps have been developed for common foreign bodies such as rounded forceps to remove beads and other small round objects.
    • Suction – compressible foreign bodies such as sponges, styrofoam, paper
    • Irrigation or lubrication – non-compressible foreign bodies or in a location that is amenable such as an eye or ear
    • Medical adhesive on a stick (less common) – attach to the object and wait before removing being careful to not displace the foreign body.
    • Enblock excision (less common) – uncommon but can be used for old foreign bodies or many small foreign bodies in a discrete area
• Special considerations
  • Airway foreign bodies often need special treatment to manage the airway and prevent dislodging the object or pushing it farther into the respiratory tract.
  • Swallowed foreign bodies depending on their characteristics often pass through the gastrointestinal system without problems once they pass through the lower esophageal sphincter and pylorus. Those that are too large need to be removed usually by endoscopy.
  • Certain objects always need to be removed such as button batteries (can erode the surrounding tissue), and small magnets (they can trap tissue between them and erode or necrose the intervening tissue).
  • Hair, styrofoam and cyanoacrylate glue can be dissolved with acetone but should have intact skin around them.
  • Live insects should be euthanized before removal – lidocaine is one option
  • Nasal foreign bodies can be expelled using a short burst of positive pressure such as parent blowing into mouth with the unaffected nare closed
  • Metallic objects possibly can be removed with a magnet in the right circumstances

Questions for Further Discussion
1. What is your favorite foreign body story?
2. What other techniques have you used for foreign body removal?
3. How do foreign bodies present? A review can be found here

Related Cases

Disease: Foreign Bodies

Symptom/Presentation: Trauma | Foreign Body Ingestion

Specialty: Emergency Medicine | Gastroenterology | Otolaryngology | Surgery | Radiology / Nuclear Medicine / Radiation Oncology

Age: Preschooler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Foreign Bodies

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Saps M, Rosen JM, Ecanow J. X-ray detection of ingested non-metallic foreign bodies. World J Clin Pediatr. 2014;3(2):14-18. doi:10.5409/wjcp.v3.i2.14

Oyama LC. Foreign Bodies of the Ear, Nose and Throat. Emerg Med Clin North Am. 2019;37(1):121-130. doi:10.1016/j.emc.2018.09.009

Couper K, Abu Hassan A, Ohri V, et al. Removal of foreign body airway obstruction: A systematic review of interventions. Resuscitation. 2020;156:174-181. doi:10.1016/j.resuscitation.2020.09.007

Del Cura JL, Aza I, Zabala RM, Sarabia M, Korta I. US-guided Localization and Removal of Soft-Tissue Foreign Bodies. Radiographics. 2020;40(4):1188-1195. doi:10.1148/rg.2020200001

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa