Trick of the Trade: Insect removal from the ear

Trick of the Trade: Insect removal from the ear

2017-05-06T20:32:25+00:00

Insect FBInsect removal from the ear is a foreign body removal procedure with unique considerations. First, insects are friable. Have you ever squashed a house centipede? It’s like their 700 legs are spring-loaded to fall off instantly when touched. This characteristic makes mechanical removal by alligator forceps or cerumen loops less reliable. Second, they are alive which means they can move during your attempted extraction procedure.

Trick of the Trade

Use a Frazier suction device to remove the intra-aural critter.

Frazier Catheter

Prep for success: First achieve inner peace

The idea of having a critter in one’s ear can be very disconcerting. Consider sedation for the patient to optimize patient comfort and tolerance of the procedure. Although I am becoming a big fan of ketamine, I can only imagine that if any patient is going to have an emergence reaction, it’s the one who believes s/he is actively living out a horror movie… nonetheless it is recommended in Roberts and Hedges [1].

Prep for success: Prevent addition damage

Before extracting the insect, you must kill it or otherwise immobilize it to prevent ongoing intra-aural damage by the insect. Many providers drown the insect in viscous lidocaine. We used 1% NON-viscous lidocaine. Although a small 1993 study showed that microscope immersion oil killed cockroaches faster than lidocaine (27 vs 41 seconds), finding immersion oil in the today’s Emergency Department may be challenging [2]. There still remains much debate about which solution is the best to immobilize/kill the insect.

Frazier Suction Technique

The Frazier suction device, often found in your ENT kit, should be connected to low continuous suction. Once you are convinced that the insect is dead, slowly advance the suction catheter into the patient’s external ear canal. Be sure to inform the patient of each step to avoid accidental head movement. Occlude the insufflation port to suction out the contents of the patient’s ear canal. Once no more liquid returns, withdraw the catheter and hopefully you will be the proud owner of a dead insect.

Our team felt that this suction-based technique is superior to a manual extraction of the insect with forceps, because it would seem to cause less “shredding” of the insect into smaller debris pieces. Creating such debris should be avoided, according to Tintinalli [3].

References

  1. Roberts JR, Catherine BC, Todd WT, Jerris RH. Roberts and Hedges’ Clinical Procedures in Emergency Medicine. 6th edition. 2014. (pages 1316-7).
  2. Leffler S, Cheney P, Tandberg D. Chemical immobilization and killing of intra-aural roaches: an in vitro comparative study. Ann Emerg Med. 1993 Dec;22(12):1795-8. PMID: 8239097.
  3. Tintinalli, JE, J. Stephan S. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th edition. New York: McGraw-Hill, 2011 (page 1556).

 

For plastic bead removal from the ear, read another approach to intra-aural foreign body removal.

Mitchell Li, MD

Mitchell Li, MD

Emergency Medicine Resident
St. John Hospital
Detroit, MI
Mitchell Li, MD

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  • Gita Pensa, MD

    Nice post! The only thing I would add is to minimize using the otoscope light until the insect is dead. The patient’s discomfort increases exponentially as the insect moves in the canal or wings beat against the TM (ugh!!) Shining a light in the otherwise-dark canal often stimulates the insect, increasing the patient’s agony. So don’t pass the light around for everyone to take a turn looking–If you know it’s an insect, use the lidocaine/oil ASAP, then look to your heart’s content once it’s dead.

  • Ferdie

    Why not irrigate the ear? That’s is in my experience the most effective way of removing a foreign body in the ear…

    • Mitchell Li

      I’ve only used irrigation for cerumen, which it has worked well for. I don’t think it would be contraindicated in anyway as long as the insect was killed and immobilized prior to angering it with irrigation. That being said… this particular insect was pretty large and I imagined all of its sharp leg parts getting stuck if we attempted irrigation. Have you had luck with insects and irrigation specifically?

  • Ellen O’Connell, MD

    Thanks for the post. Specialized supplies can be difficult to come by in our county ED. I have had most success with using a catheter designed for trach suctioning.

  • Peter O’Hanley MD

    Why not smother the buggers? Mineral oil olive oil, both will quiet the bug, thus no sedation and its risks. I also doesn’t interfere with any extraction method used…

    • I believe that is what Mitchell recommends as the first step. The trick-of-the-trade discussion is focusing more on how to get the critter out after it’s smothered. It’s often part floating, part wedged in the ear after immersing it in whatever liquid you use (mineral oil, lidocaine jelly, saline).

  • Pik Mukherji

    Great tips. For stubborn extractions I’ve also used a drop of Dermabond on the wood end of the cotton swab and waited a few seconds for it to adhere to an insect body part, then withdraw and get insect on a stick.

  • Berenice Perez

    I have struggled in the past with alligator forceps placed through an otoscope and inevitably I extracted parts of the offending insect. Very unsatisfying. However, I used this technique on my shift yesterday and it worked beautifully! A whole insect at the end of the suction device without much hassle!

    • Terrific news! Thanks for sharing your successes with us. So awesome to hear these tricks making a difference in patient care!

  • Silmonster

    https://uploads.disquscdn.com/images/ce34b2d5eb73decaa7b86166a414468a85787898e3960bf5e36cb2a6d1e29655.png

    Just used this technique- but couldn’t find Frazier suction so used a 14Fr tracheal suction catheter that I cut to about 2 inches. Sucked the bugger up all the way into the canister!

  • Great tips. For stubborn extractions I’ve also used a drop of Dermabond on the wood end of the cotton swab and waited a few seconds for it to adhere to an insect body part, then withdraw and get insect on a stick.