What is the best course of action for a nurse practitioner to remove a foreign body, suspected to be a dried pea, from a child's external auditory canal near the tympanic membrane?

From the Guidelines

The best course of action for a nurse practitioner to remove a dried pea from a child's external auditory canal near the tympanic membrane is to refer the child to an otolaryngologist (ENT specialist) or emergency department. This type of foreign body removal requires specialized equipment and expertise, particularly due to its proximity to the tympanic membrane which could be damaged during removal attempts. The dried pea presents additional challenges as it may swell if irrigation is attempted, potentially causing more pain and making removal more difficult. While waiting for specialist care, the child should be kept calm and instructed not to manipulate the ear further. Parents should be advised against home removal attempts using cotton swabs or other instruments as these could push the object deeper or cause trauma to the ear canal or tympanic membrane, as noted in studies such as 1. If the child is experiencing significant pain, acetaminophen or ibuprofen at age-appropriate doses may be given for comfort. Prompt referral is essential as retained foreign bodies can lead to infection, hearing impairment, or tympanic membrane perforation if left untreated, highlighting the importance of specialized care as discussed in 1 and 1.

Some key points to consider in the management of this condition include:

• The potential for complications with irrigation, including tympanic membrane perforation and otitis externa, as discussed in 1 and 1
• The importance of avoiding the use of cotton-tipped swabs for ear canal cleaning, due to the risk of pushing the object further into the ear or causing trauma, as noted in 1 and 1
• The need for specialized equipment and expertise in the removal of foreign bodies from the ear, particularly in cases where the object is near the tympanic membrane, as highlighted in 1 and 1

From the Research

Removal of Foreign Body from External Auditory Canal

The nurse practitioner is faced with a situation where a child has a small, round object, suspected to be a dried pea, lodged in their external auditory canal near the tympanic membrane. The best course of action for removal depends on the type of object and its location.

Considerations for Removal

• The object is soft and irregularly shaped, which makes it a candidate for removal without referral to an otolaryngologist 2.
• However, the object is described as round, which may pose a challenge for removal, and referral to an otolaryngologist may be considered if previous removal attempts have failed or if there is ear trauma 2.
• The use of alligator forceps, small right angle hooks, and ear irrigation are common methods for removing aural foreign bodies in an outpatient clinic setting 2.
• Ear syringing is also an effective and easy way of removing most foreign bodies, and can be done with a disposable sterile kit and saline at body temperature 3.

Appropriate Action

• Given the object is suspected to be a dried pea, which is soft and irregularly shaped, the nurse practitioner may attempt to remove it using ear irrigation or alligator forceps 2, 3.
• However, if the object is difficult to remove or if there is ear trauma, referral to an otolaryngologist should be considered 2, 4.
• It is also important to note that patients with hard, spherical, or cylindrical objects should be referred to an otolaryngologist if previous removal attempts have failed or if there is ear trauma 2.

Available Options

• Refer the child to an otolaryngologist for removal (option a) may be considered if the object is difficult to remove or if there is ear trauma 2, 4.
• Irrigate the external auditory canal to flush out the object (option b) is a viable option for soft and irregularly shaped objects 2, 3.
• Use a bayonet forceps to grasp and remove the object (option c) may be considered, but the type of forceps used should be appropriate for the type of object and the location 2.
• Remove the object with a wire loop curette (option d) may not be the best option, as it is not specifically mentioned in the studies as a recommended method for removing aural foreign bodies.