What is the management approach for a patient with an insect inside their ear?

Management of Insect in the Ear

The primary goal is to immobilize and kill the live insect before removal to prevent further trauma to the ear canal, followed by gentle extraction and post-removal prophylactic topical antibiotics if any inflammation or minor trauma is present. 1

Immediate Immobilization of Live Insect

• Kill the insect first before attempting removal by instilling mineral oil, lidocaine, or 2% viscous lidocaine into the ear canal to immobilize it and prevent further trauma from the insect's movement 2
• Avoid using topical local anesthetics alone for certain arthropods (like centipedes), as this can paradoxically cause vigorous activity and increased harm 3
• The insect must be completely immobilized before any removal attempt to minimize risk of tympanic membrane perforation or canal trauma 2

Removal Technique

• Only attempt removal if the insect is clearly visualized and easily graspable with available instruments (forceps, alligator forceps, or suction) 2
• If the insect cannot be easily visualized or grasped, defer removal and refer immediately to an otolaryngologist rather than risk complications from blind instrumentation 2
• Irrigation can be used after the insect is dead, but only if the tympanic membrane is known to be intact 2
• In wilderness or austere settings, removal should only be attempted if the patient is acutely symptomatic AND the insect is visualized and graspable; otherwise, evacuation to definitive care is safer 2

Post-Removal Management

• Prescribe topical antibiotic drops (ofloxacin or ciprofloxacin-dexamethasone) for 5-7 days to prevent secondary infection in patients with inflammation or minor trauma after insect removal 1
• Examine the ear canal and tympanic membrane carefully after removal to assess for trauma, retained insect parts, or perforation 1
• Use non-ototoxic preparations if tympanic membrane integrity is uncertain 4

High-Risk Populations Requiring Immediate ENT Referral

• Immunocompromised patients require immediate otolaryngology referral due to high risk of rapidly progressive invasive ear infections, mastoiditis, or intracranial extension 1
• Diabetic or elderly patients are at increased risk for necrotizing otitis externa if secondary infection develops 4
• Any patient with signs of complications (facial nerve palsy, sensorineural hearing loss, vestibular symptoms, or signs of intracranial extension) requires emergent ENT consultation 5

Critical Pitfalls to Avoid

• Never attempt blind instrumentation or aggressive removal attempts, as this significantly increases risk of tympanic membrane perforation, canal laceration, ossicular damage, and secondary infection 5, 2
• Do not use water irrigation if tympanic membrane perforation is suspected or if the insect is still alive (as it may cause the insect to burrow deeper) 2
• Recognize that delayed presentation or complications from improper initial management carry a guarded prognosis, with reported cases of orbital apex syndrome, cavernous sinus thrombosis, and death 5
• Patients who develop progressive symptoms after initial intervention elsewhere should be assumed to have complications and require immediate specialist evaluation 5

When to Refer Immediately

• Inability to visualize or safely grasp the insect 2
• Any signs of infection, perforation, or middle ear involvement 1
• Immunocompromised status 1
• Failed removal attempt 2
• Development of neurological symptoms (facial palsy, hearing loss, vertigo) 5