David M. Lang discusses how a health care providers may view foreign body removal as a "personal challenge," as well as the consequences of accepting that challenge.
Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
Eardrum Perforated During Attempted Bug Removal
A small boy was taken to a Utah emergency department with a live bug stuck in his left ear canal. He was examined by the defendant emergency physician, who attempted to remove the bug using a surgical instrument. The child’s tympanic membrane was perforated.
A dispute arose as to whether the perforation was the result of the defendant’s procedure or some other cause.
A defense verdict was returned.
In the case presented, a jury concluded that evidence of negligence or compensable damage (or both) was insufficient to warrant recovery. That said, the case raises certain points worthy of discussion.
The first step to managing aural foreign bodies is to determine whether a true emergency exists. Button batteries lodged in the ear represent an emergency because they can cause significant tissue destruction through liquefaction necrosis if not removed from the ear within hours. If initial attempts to remove a button battery are unsuccessful, emergent otolarygologic consultation is required. During these initial attempts, no liquid should be used, as moisture may accelerate battery leakage.
However, most aural foreign bodies may be safely left in the ear. Therefore, the clinician should set reasonable expectations and limits for removal efforts. As a matter of good medicine, before any attempt at removal, the patient (or in this case, the parent or guardian) should be informed that some foreign bodies are difficult to remove and may require referral to an otolaryngologist. Explain the plan to the patient, including at what point the clinician intends to cease removal efforts and seek referral. Have a plan, stick to the plan, and if it is unsuccessful, refer to an otolaryngologist or other appropriate clinician for elective removal.
It is difficult not to view foreign body removal as a personal challenge. Immediately removing the object gives the patient a cure and the clinician a trophy to show the patient and anyone else who cares to see it (a number vastly overestimated by the clinician). But approaching the removal of an aural foreign body as a conquistador may build patient expectations unnecessarily and ultimately demoralize the clinician, should initial efforts prove unsuccessful. A demoralized clinician is soon a frustrated clinician, who may become overly aggressive in an effort to “get the job done.” Litigation may follow when the parents believe that the whole child—not just the child’s external auditory canal—has been traumatized in an overly zealous effort to remove an innocuous aural foreign body.
Document what you start with. Be sure to describe any trauma to the canal or bleeding, location of the object, and any observable damage to the tympanic membrane before attempting removal. Make an objective assessment of the patient’s hearing before and after removal attempts. If the patient is uncooperative at any point, removal efforts should stop.
Various techniques may be used to remove foreign bodies. Irrigation is commonly used in patients with an intact tympanic membrane. The object may be removed by suction, using a standard-tip or specialized otoscope speculum (such as a Hognose device). Instrumentation such as alligator forceps, bayonet forceps, or curettes are generally available and frequently used.
Adhesives offer a removal option when the object can be seen and contacted but not grasped. For example, liquid skin adhesive may be applied to the stick end of a swab and placed in contact with the foreign body under direct visualization. The adhesive may be left in contact for 30 to 60 seconds before the stick and attached object are slowly removed. Irrigating with a topical anesthetic may have only a partial effect, in many cases limiting mechanical instrumentation efforts.
Live insects within the external auditory canal can cause a patient impressive and understandable anxiety. A squirming insect can be euthanized using mineral oil or lidocaine. Mineral oil is safer than lidocaine when the integrity of the tympanic membrane is in question, and—surprisingly—it kills insects more rapidly (as demonstrated by a study in which death times were compared among cockroaches immersed in oil, 2% lidocaine, 4% lidocaine, or viscous lidocaine). The insect can then be removed by irrigation, an alligator forceps, or a suction tip.
In sum, document the patient’s condition before and after removal efforts. Relish your successes, but have no shame when circumstances require an operating microscope, anesthesia, and/or specialized experience. Protect the patient’s interests, and remember primum non nocere: first, do no harm. —DML