›Place a minimal drop of tissue adhesive on the blunt end of a cotton-tipped or wooden applicator, hold it against a dry smooth object for 30 to 60 seconds, then withdraw
›Only with a well-visualized object and a dry canal; a wet canal or excess glue bonds the applicator to canal skin or the drum
›Abandon the technique if the object is organic, deep, or against the drum
›Manual immobilization
›Papoose or caregiver-assisted hold for infants and toddlers for a single brief attempt
›If a hold sufficient for safety cannot be achieved, move to sedation or ENT
›Indications
›Small, non-organic, non-battery object in a patient with a known intact tympanic membrane and no tympanostomy tube
›Helpful for objects too deep or smooth to grasp, and to flush insect fragments
›Technique
›Body-temperature water or saline to avoid a caloric response and vertigo
›Direct the stream along the canal wall past the object with a 20 ml syringe and a soft catheter or a commercial irrigation tip, using low steady pressure
›Stop if the patient reports pain or vertigo, or if fluid does not return
›Absolute contraindications
›Button battery: irrigation completes the circuit and spreads alkaline injury
›Organic or vegetable matter and superabsorbent polymer beads: water causes swelling and a tighter impaction
›Known or suspected tympanic membrane perforation, or a tympanostomy tube in place: risk of middle-ear contamination, ototoxic exposure, and vertigo
›Penetrating object or an unexamined drum
›Immobilize or kill the insect before removal
›Movement drives pain and canal trauma; a still insect is far easier to extract
›Lidocaine 2% aqueous, preservative-free: fill the canal, about 1 to 2 ml, as a single application; it rapidly stuns and kills the insect and provides canal anesthesia
›Do not use if the tympanic membrane is known or suspected perforated: potential ototoxicity and severe vertigo; use mineral oil instead
›Mineral oil, or lidocaine 2% viscous: a few drops to fill the canal as a single application; preferred agent when perforation is possible
›Do not use alcohol or hydrogen peroxide; both are painful and injurious to canal skin
›Remove the dead insect
›Alligator forceps for the whole insect or wings; suction and body-temperature irrigation for fragments only if the drum is intact
›Examine for retained legs or head and for underlying canal abrasion
›ENT microscopy if the insect is fragmented and deep
›Aftercare
›Topical fluoroquinolone-steroid drops if the canal is abraded (dosing below)
›Analgesia; most discomfort settles within 24 to 48 hours
Button battery and magnet removal
›Button battery
›Emergent removal by ENT under microscopy, targeting within 1 to 2 hours of identification
›Dry techniques only: right-angle hook or micro-forceps and suction; never irrigate and never instill neutralizing or oily fluids
›If ENT is not immediately available and the battery is in the outer canal and clearly graspable, a single careful dry hook attempt is reasonable while arranging transfer
›After removal: magnified inspection for burn, perforation, and exposed bone; non-ototoxic topical fluoroquinolone; ENT follow-up within 24 hours with audiometry
›High-strength magnets
›Single magnet with no opposing metal: remove like any smooth object with a hook, avoiding ferromagnetic instruments that snap to it
›Two magnets, or magnet-plus-metal across tissue: urgent ENT removal, because separating them at the bedside risks tearing the trapped tissue
›Post-removal inspection for pressure necrosis and perforation, with interval ENT review
›Escalation
›Operating room with general anesthesia if the object cannot be removed safely awake, or if the drum or ossicles are involved
Analgesia, local anesthesia, and procedural sedation
›Systemic analgesia
›Acetaminophen 15 mg/kg PO or PR every 6 hours as needed; maximum single dose 1000 mg; maximum 75 mg/kg per day up to 4000 mg per day
›Ibuprofen 10 mg/kg PO every 6 to 8 hours with food, for age over 6 months; maximum 400 mg per dose and 40 mg/kg per day up to 1200 mg per day without prescription
›Intranasal fentanyl 1.5 mcg/kg, maximum 100 mcg per dose, for severe pain or as a bridge to a procedure; onset 5 to 10 minutes
›Verify against current pediatric guideline before use
›Topical and local anesthesia
›Lidocaine 2% aqueous preservative-free instilled to fill the canal for insect cases and for canal anesthesia; avoid with a perforated drum
›For repair of a canal or auricular laceration: lidocaine 1% infiltration or a four-point auricular block, maximum 4.5 mg/kg, which is about 0.45 ml/kg of 1%; avoid an epinephrine-containing solution in the pinna
›Procedural sedation for the uncooperative patient with a high-risk object
›Reserve for a battery, magnet, penetrating object, or a single failed gentle attempt when ENT is not readily available
›Ketamine IV 1 to 1.5 mg/kg over 1 to 2 minutes, or IM 4 to 5 mg/kg; repeat IV 0.5 mg/kg every 10 minutes as needed
›Verify against current pediatric guideline before use
›Have suction and airway equipment ready; treat laryngospasm with jaw thrust, positive pressure, and if needed succinylcholine 0.1 to 0.2 mg/kg IV or 4 mg/kg IM
›Verify against current pediatric guideline before use
›Intranasal midazolam 0.2 to 0.3 mg/kg, maximum 10 mg, for light anxiolysis in a cooperative-enough older child
›Verify against current pediatric guideline before use
›Nitrous oxide 50% inhaled, titrated to a maximum of 70%, for a brief minor procedure in a child who can hold a mask
›Avoid when a middle-ear or trans-tympanic object is present; nitrous oxide diffuses into and expands the air-filled middle ear and raises middle-ear pressure
›Monitoring: continuous pulse oximetry, waveform capnography, cardiorespiratory monitoring, and a dedicated provider recording sedation depth and vital signs every 5 minutes until the patient returns to baseline
›None of the agents above cause clinically relevant electrolyte shifts at these doses, so routine ECG monitoring is not required on that basis, though standard sedation cardiorespiratory monitoring still applies
Post-removal canal and tympanic membrane care
›Inspect after every removal
›The full canal circumference, tympanic membrane integrity, drum mobility on pneumatic otoscopy, and hearing
›Document any abrasion, laceration, granulation, or perforation
›Intact drum with canal abrasion, or after organic, insect, or battery contact
›Ciprofloxacin 0.3% with dexamethasone 0.1% otic suspension, 4 drops to the affected ear twice daily for 7 days
›Alternatively ofloxacin 0.3% otic solution, 5 drops once or twice daily for 7 days
›Keep the ear dry, with no swimming or water sports until re-checked
›Traumatic tympanic membrane perforation
›Use only a non-ototoxic preparation: ofloxacin 0.3% otic, which is labeled for use with a perforation, 5 drops (10 drops in adults) twice daily for 7 to 10 days, or ciprofloxacin with dexamethasone
›Do not use neomycin, polymyxin B, and hydrocortisone drops, or any aminoglycoside-containing drop, with a perforation, because of cochleovestibular toxicity
›Strict dry-ear precautions; most small traumatic perforations heal spontaneously in 6 to 8 weeks
›ENT follow-up with audiometry, and refer sooner for vertigo or sensorineural loss, which suggests ossicular injury or a perilymph fistula
›Tetanus
›Tdap 0.5 ml IM if there is a canal laceration and the patient is not up to date
Antibiotics, adjuncts, and complication management
›Systemic antibiotics only for tissue infection
›Simple canal abrasion does not need oral antibiotics; topical therapy suffices
›Auricular cellulitis: cephalexin 25 to 50 mg/kg per day PO divided every 6 hours, adult 500 mg four times daily, for 7 days
›Perichondritis, which must cover Pseudomonas: ciprofloxacin 500 to 750 mg PO twice daily in adults for 7 to 10 days; in children dose by weight with specialist input and arrange urgent ENT
›Mastoiditis or necrotizing otitis externa: admit for intravenous antipseudomonal therapy, for example piperacillin-tazobactam 4.5 g IV every 6 to 8 hours in adults, plus ENT
›Adjuncts with no supporting evidence
›Oral antihistamines and decongestants do not aid removal or recovery
›Systemic corticosteroids are not indicated for uncomplicated canal edema
›Follow the drug's cautions into every setting
›Fluoroquinolone otic drops: minimal systemic absorption, acceptable in pregnancy, lactation, and young children for this indication
›Systemic fluoroquinolone for perichondritis: weigh the tendinopathy signal and, in children, the arthropathy signal, and use only when Pseudomonas cover is genuinely needed
›NSAIDs: avoid after 20 weeks of pregnancy, in significant renal impairment, and in active peptic ulcer disease
Interventions with no role here (iatrogenic-harm check)
›Airway and breathing
›Intubation and mechanical ventilation have no role unless required for a separate injury or for operative removal under general anesthesia
›Supplemental oxygen is not therapeutic for an ear foreign body; give it only for hypoxemia or as part of sedation care
›Circulatory support
›Intravenous fluid loading, vasopressors, and mechanical circulatory support including an intra-aortic balloon pump are irrelevant to this condition and signal an alternative or additional diagnosis if they seem needed
›Hemostasis and clot-directed therapy
›Systemic anticoagulation and fibrinolysis have no role; if the patient is already anticoagulated, expect more canal oozing and favor gentle single attempts or ENT
›Canal-directed measures that harm
›Blind instrumentation without visualization lacerates the canal and drives the object against or through the drum
›Irrigation of a battery, of organic matter, or of an unexamined or perforated drum
›Cyanoacrylate in a wet canal or with excess glue, which bonds to canal skin or the drum
›Aminoglycoside or neomycin-containing drops with a perforation, causing cochleovestibular toxicity
›Nitrous oxide with a middle-ear or trans-tympanic object, causing middle-ear gas expansion and a pressure rise
›Repeated attempts past the second, since each pass compounds edema, bleeding, and pain