Q-Tip Foreign Body Removal

A six-year-old female presented to the pediatric emergency department (ED) after an ear foreign body was discovered during an urgent care visit. The mother reported her child had a history of ear infections and underwent tympanostomy tube placement three years ago. She developed a fever earlier that day and was brought to the UC where her exam was notable for “something in the ear.” The child denied putting anything in her ear and had no pain, drainage, or other ear complaint. An attempt to remove the object at urgent care was unsuccessful. She was diagnosed with an URI and told to follow-up with ENT for foreign body removal. Her mother did not feel comfortable waiting, so she brought her daughter to the ED for a second opinion. The child is well-appearing with mild nasal congestion. On exam, her right ear had a patent tympanostomy tube in place. Her left ear WiscMed Wispr digital otoscopic exam is shown.

True or False:

This child requires an ENT referral.

Answer: True

This is a tricky question--the child requires a referral to ENT (otolaryngology) regardless of the success in removing the left ear foreign body in the ED. Her right tympanostomy (ear, ventilation) tube is overdue for removal since it has not fallen out on its own—typically within 18 months from insertion.  If ear tubes remain present after two years, an ENT referral is indicated for removal and potential tympanoplasty to repair the resultant perforation.

In this case, an option for deferring the foreign body removal was offered since the child was not experiencing any related symptoms and would likely require ear tube removal soon. The mother preferred an attempt to remove the object, so preparations were taken to ensure the greatest likelihood of success. These included oral midazolam, gently securing the child’s position, adequate lighting, and direct visualization of the object with the Wispr digital otoscope. Utilizing these procedures, the foreign body was removed using micro-alligator forceps (see video below). Upon seeing the piece of cotton-like material, the child recalled using a Q-tip several weeks prior that “came off in her ear”. She was discharged with instructions on follow-up with her ENT for evaluation of TM tube removal.

Here is another case featuring a Q-Tip removal.

Other examples of ear foreign bodies include ants, spiders, tic tacs, beans and earrings.

Key Learning Points:

1. Ear foreign bodies are common, challenging and require an organized approach to improve success and minimize complications. The author’s approach is the following:
1. Appropriate anxiolysis with oral midazolam and child life distraction
2. Have an assistant gently secure the head. In young children, it is helpful to have the child sit on the parent’s lap to secure their hands in a comfortable hold.
3. Have a third assistant provide an additional light source.
4. Use the endoscopic capabilities of the Wispr otoscope to directly visualize the foreign body and add light to the canal. The Wispr tip can also be used to gently move the tragus outward. This further stabilizes the area and opens the external canal to allow the tool to be inserted 
5.  Choose the best tool for removal--typically suction or L hook for solid objects and micro-forceps for soft foreign bodies.
2. Tympanostomy (ear, ventilation)  tubes typically fall out within six to eighteen months from insertion. If present beyond two years, ENT evaluation is appropriate.

Here is the removal video of the left ear Q-tip and the video of the right ear ventilation tube.