Removing earrings embedded in the ear lobe

On occasion you will encounter a patient with an earring stuck in their ear lobe. This most commonly occurs in girls younger than 12-13 years of age and is related to a combination of factors.

  • Younger children tend be less likely to perform adequate hygiene, and they are more likely to irritate the area by playing with their earrings
  • Local contact dermatitis caused by earrings, poor hygiene and pressure on the pinna caused by wearing earrings can all lead to skin ischemia, inflammation and ulcer formation with associated swelling and increased risk of earrings becoming imbedded in the pinna

Patients with embedded earrings often present with ear pain, swelling, erythema and purulent drainage from the site of the piercing. The area is usually quite tender to the touch. Typically at least part of the earring is visible or palpable, however plain radiographs may be needed to confirm the diagnosis.

Suspected embedded earrings should be removed as soon as possible to avoid infection.

It is important to obtain adequate analgesia with either local infiltration or field block prior to removal. Procedural sedation may be required in younger patients.

The area should be prepared/cleaned using sterile technique in case an incision is required for removal

Mosquito hemostats can be used to grasp both the anterior (the decorative front) and posterior (the backing or clip that holds the earring in place) parts of the earring. Use the hemostats to disengage the backing from the post and then pull the earring out of the pinna.

If the front is visible, apply pressure to the front until the posterior backing or clip become visible. Clamp a hemostat to the backing and disengage it from the earring by pulling the backing while holding the earring in place anteriorly. It may be necessary to create a small incision on the posterior portion of the pinna and spread the skin using a hemostat to get the clip in view.

If the backing or clip is visible with the anterior earring embedded, push the earring anteriorly until the decorative front is visible. Clamp a hemostat to the front once visible then disengage the clip/backing and pull the earring out. Again, it may be necessary to create an incision to increase visibility, but incision should be made on the posterior portion of the pinna.

If nothing is visible, start with an incision on the posterior portion of the pinna and spread the skin with a hemostat until the backing or clip becomes visible. Grasp the backing with a hemostat and apply posterior pressure until the anterior decorative portion becomes visible and a hemostat can be used to disengage the two pieces of the earring.

Once the earring is removed, the area should be dressed with antibiotic ointment and left to heal by secondary intention. For the most part, oral antibiotics are not needed after removal of an embedded earring from the ear lobe.

However, piercings in the cartilaginous portions of the ear have been associated with perichondritis, chondritis and occasionally permanent disfigurement. Embedded earrings in the cartilaginous portions of the ear present similarly to those embedded within the ear lobe, with swelling, erythema and tenderness. Given the risks of cartilage necrosis and cosmetic disfigurement associated with cartilage piercings, it is best to involve an otolaryngologist in the management. In these cases, oral antibiotics are often necessary to treat both pseudomonal infections (involved in up to 95% of cases) and staphylococcal infections.

A retrospective chart review published in 2008 by Timm and Iyer examined incidence, age distribution and management of children with embedded earrings presenting to the CCHMC ED between June 2000 and January 2005. It ultimately included 100 patients over the study period. This study found that incidence of embedded earring as a chief complaint was 25 cases per 100,000 visits. Of the 100 patients included in this study, 60% were younger than 10 years of age. In 68% of the cases, the posterior portion of the earring was embedded. In 35% of the cases, there was an associated infection (which was less than reported in previous studies with infections in about 61-65% of patients with embedded earrings). However, 73% of children with piercings outside of the ear lobe or tragus had associated infections, some of which required IV antibiotics. None of the cases required procedural sedation for removal, but 47% of them required the use of an incision to aid in removal (Timm, Iyer 2008).

References

Timm N, Iyer S. Embedded Earrings in Children. Pediatric Emergency Care 2008;24(1):31-33.

Removing foreign bodies in the external auditory canal

External auditory canal foreign bodies are most commonly seen in children under 7. Children with conditions that cause irritation of the ear such as otitis media or cerumen impaction are at higher risk. Additional risk factors include pica and ADHD. Most often, the foreign body is on the right side due to the handedness of the child. The most common foreign bodies found in the external auditory canal include beads, pebbles, pieces of paper, toys, popcorn kernels and insects.

Frequently, foreign bodies of the external auditory canal are asymptomatic and found during routine otoscopy. However, they may cause impaired hearing, pain, purulent or bloody drainage from the ear or chronic cough/hiccups (which is rare).

Timing of removal is dependent upon the type of foreign body

Button batteries should be removed immediately, as the electrical current from the battery can cause destruction of the ear canal skin, tympanic membrane, facial nerve and ossicles. They also cause local pressure necrosis.

Insects should be removed urgently because they can cause damage to the tympanic membrane and middle ear as the insects move in the canal.

Foreign bodies that can penetrate the tympanic membrane and cause damage to middle ear structures should also be evaluated immediately. Such foreign bodies include cotton applicator tips, pencil points, hair pins. A patient with a penetrating foreign body who exhibits vertigo, ataxia, facial nerve damage, or hearing impairment should be urgently evaluated by an otolaryngologist.

Referral to a subspecialist such as an ENT depends upon the type of foreign body, tools available, type of assistance available and behavior of the child. Patients with button batteries, penetrating foreign bodies or foreign bodies with evidence of injury to the ear canal, tympanic membrane or middle ear should be seen by an otolaryngologist. Foreign bodies that may require ENT referral include glass or other sharp edged foreign bodies, hard spherical foreign bodies that are wedged in the canal and foreign bodies touching the tympanic membrane as these have been shown to be difficult to remove without the help of a sub specialist.

Techniques for removal

Irrigation

Can be used for small, inorganic items. Contraindicated in patients with PE tubes or with perforated tympanic membranes. Should not be used to remove vegetable matter or button batteries. Organic matter may swell with water, which leads to further obstruction. Using water with button batteries increases risk of chemical injury.

  • The patient should be in the supine position with affected ear up. Irrigate with body temperature water until foreign body is expelled. May still require instrumentation to grasp the foreign body if it reaches the auditory meatus but is not expelled.

Instrumentation

Commonly used instruments for foreign body removal include an ear speculum, forceps, or curettes. The use of instrumentation can be painful and may be difficult in patients who are unable to remain still for the procedure.

  • soft objects with irregular edges typically can be grasped with forceps
  • round objects are often removed by extending an instrument such as a curette beyond the object then slowly withdrawing it from the ear canal

Special consideration: Insects

Live insects should be killed with mineral oil or 1% lidocaine prior to removal to prevent insect movement during removal. Mineral oil is preferred because though both kill the insect, lidocaine may cause it to writhe and squirm which is, needless to say, uncomfortable for the patient.

Complications

Common complications include laceration or abrasion of the ear canal, which occurs in up to 50% of patients. Additionally, patients are at risk for tympanic membrane perforation and middle ear damage during removal.

A study by Thompson, Wein and Dutcher in 2003 looked at patients presenting to an emergency department over a 3 year period with a chief complaint of external auditory canal foreign body. Of the 162 patients seen with this chief complaint, about 33% required ENT referral, 81% of them after unsuccessful removal attempt in the ED. They found that ED removal was successful for irregularly shaped, soft objects with easily graspable parts such as paper, small toys and insects. Firm, smooth and round objects such as beads, beans, stones and popcorn kernels were more likely to require ENT referral. A wide variety of removal techniques were used in the ED including irrigation, forceps, suction and curette. Overall complication rate was about 1% with 2 patients developing tympanic membrane perforation after multiple attempts at foreign body removal ultimately requiring removal by an ENT (Thompson, Wein, Dutcher 2003).

Another study by Marin and Trainor examined the medical records of patients presenting to a pediatric emergency department with a chief complaint of “foreign body in the ear” between November 1998 and October 2003. In this study, there were 254 foreign body removal attempts in 250 children over 5 years. About 80% of foreign bodies were successfully removed in the ED using a variety of different techniques. Twenty percent of cases were referred to ENT, and 6% required removal in the OR. Complications included canal bleeding and/or laceration in 29 patients. One patient developed a perforation of the tympanic membrane with ossicle damage. Risk of complications increased as number of attempts at removal increased as well as the number of instruments used for removal increased (Marin, Trainor 2003).

References

Isaacson A, Aderonke O. Diagnosis and management of foreign bodies of the outer ear. In: UpToDate, Stack A, Wiley J (Ed), UpToDate, Waltham, MA. (Accessed on January 13, 2017.)

Marin J, Trainor J. Foreign Body Removal from the External Auditory Canal in a Pediatric Emergency Department. Pediatric Emergency Care 2006;22(9):630-634.

Thompson SK, Wein RO, Dutcher PO. External Auditory Canal Foreign Body Removal: Management Practices and Outcomes. Laryngoscope 2003;113:1912-1915.

Check out this great review of pediatric UTIs from the PEM Playbook

Tim Horeczko over at the excellent Pediatric Emergency Medicine Playbook just posted his latest monthly review (including podcast) – this time on urinary tract infections. I love the approach – simple, straightforward and focused on common questions in the ED. Some highlights;

  • The risk factors for UTI include age ≤12 months, fever ≥39C, fever >24 hours and absence of another source of infection.
  • Always cath – unless you want to do a suprapubic bladder aspiration – which is totally a viable way to get urine
  • Per the AAP the “standard definition of a urinary tract infection is the presence of BOTH pyuria AND at least 50,000 colonies per mL of a single uropathogen.” It is interesting that a recent study by Shaikh called into question the utility of pyuria in certain uropathogens.
  • Bactrim is acquiring resistance, therefore consider other treatment options in the well appearing child including cephalexin or cefdinir.
  • Generally admit anyone under 2 months with a febrile UTI

Tim also highlights the Urine Rule of 10s, which I think is a neat way to conceptualize things.

  • 10% of young febrile children without a source will have a UTI
  • 10% of UAs will show no evidence of pyuria
  • Routine urine culture in all children with suspected or confirmed UTI up to about age 10

Finally, he makes the following salient points – which I couldn’t agree more with;

  • If a child over 3 months of age is well, has no comorbidities, has a low grade fever “in the 38s” (38-38.9 °C) without a source, especially if less than 24 hours, you are very safe to do watchful waiting at home without obtaining urine.
  • An otherwise well child with an obvious upper respiratory tract infection has a source of his fever.
  • If your little patient has risk factors for UTI, or you are otherwise concerned, send the UA and send the culture.  You can opt out of the culture by middle school in the otherwise healthy child.
  • Make sure the child follows up with their primary care doctor.

Oh, and the title was a pun, and you know how much I love puns!

Check out all of the great content at PEMPlaybook.org

References

Urine Trouble. PEMPlaybook.com Tim Horeczko

Shaikh N, et al. Association Between Uropathogen and Pyuria. Pediatrics. 2016.

Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011 Sep;128(3):595-610.

A podcast episode on serum sickness

What does the combination of erythema multiforme, fever and swollen joints equal? If you answered a visit to the Emergency Department you’re only partially correct. Serum sickness like reaction is a delayed type hypersensitivity reaction that often occurs 7-10 days after starting a course of antibiotics. Learn how you can recognize it and differentiate it form more serious illness like Stevens Johnson Syndrome in this episode of PEM Currents, the Pediatric Emergency Medicine Podcast.

PEM Currents on iTunes

 

Stream it right here

 

Or download the mp3 – Serum Sickness

Briefs: Peritonsillar abscess

A 14 year old male presents with a very sore throat and fever. The symptoms have been present for 4 days. His PMD saw him 2 days ago and performed a rapid strep test, and it was negative. Since then he has gotten worse and it is hard for him to open his mouth fully. Per his mother it sounds like he just ate really hot food when he tries to speak. It is also quite painful to swallow, and he is having trouble swallowing all of his saliva. The RN caring him had already collected a rapid strep and it was negative.

On exam you note an ill appearing teenager with fever, HR in the 100-110 range and normal BP. He has tries us on exam, and it is somewhat difficult to understand what he is saying. When you examine his pharynx you see this.

What is the diagnosis?

This is a peritonsillar abscess (PTA). The hallmark clinical findings of which include:

  • Severe unilateral throat pain and possibly ear pain
  • Fever > 103F (39°C), malaise, rigors
  • Difficulty swallowing saliva
  • Muffled/hot-potato voice
  • Trismus
  • Unilateral redness and edema of the tonsillitis area with palpable fluctuance
  • Unilateral anterior cervical lymphadenopathy
  • Uvula deviated towards the contralateral side

A PTA is a complication of tonsillitis and is usually caused by beta hemolytic group A strep. Staph app. And Haemophilus spp. Are also known etiologies. It is more rare in preschool age children, as the lymph tissue is predominantly located in the retro pharynx, thus accounting for the prevalence of retropharyngeal abscesses. Most cases in pediatrics will be seen in teens.

What is the management?

The management includes needle aspiration or incision and drainage and antibiotics. Procedures should be performed in a center with an experienced practitioner with appropriate resources. Check out the embedded video from Anand Swaminathan as well as this post from Academic Life in Emergency Medicine for the more on the technique.

Even if the rapid strep is negative the pus cultured from head infections is often polymicrobial. Thus, beta lactamase coverage (including consideration for anaerobes) is reasonable. Ampicillin/Sulbactam as IV and Amoxicillin/Clavulanate as oral are reasonable choices. Cephalexin +/- Metronidazole or Clindamycin are options for Penicillin allergic patients. Patients that have moderate dehydration and are unable to tolerate PO, or those that are ill appearing should be admitted. Outpatient follow up is necessary in the next 48-72 hours.

Dexamethasone may reduce and hasten recovery pain in patients with PTA. Ozbek et al noted that a series of 62 hospitalized adolescents with PTA had faster resolution when they got Dexamethasone prior to the antibiotic course. Other studies have not shown as large of a benefit. I do tend to give a single dose in the ED at 0.6 mg/kg (max 10mg).