Can prilocaine (a topical anesthetic) lidocaine (a local anesthetic) cream be used for anesthesia in a patient undergoing ear foreign body removal?

Lidocaine-Prilocaine Cream for Ear Foreign Body Removal

Yes, lidocaine-prilocaine cream (EMLA) can be used for ear foreign body removal, but it is NOT recommended as the primary anesthetic choice for the ear due to poor penetration and ototoxicity concerns. 1, 2

Critical Safety Contraindication

• The FDA explicitly states that lidocaine-prilocaine cream is NOT recommended in any clinical situation where penetration or migration beyond the tympanic membrane into the middle ear is possible due to ototoxic effects observed in animal studies. 1
• This is particularly relevant for foreign body removal where tympanic membrane perforation may already exist or could occur during the procedure. 3

Evidence Against Use on the Ear

• A prospective, randomized, double-blind study specifically evaluating EMLA for ear surgery found that EMLA cream is not a good first option for achieving full anesthesia on the ear because of its poor anesthetic effect, even when applied to both anterior and posterior surfaces for 120 minutes under occlusive dressing. 2
• The study concluded that EMLA is not clinically useful for major surgical attempts on the ear. 2

Alternative Anesthetic Approaches

For ear foreign body removal, consider these superior alternatives:

• Local infiltration anesthesia with lidocaine (with or without epinephrine) is the preferred method. 4, 5
• The American Academy of Dermatology confirms that epinephrine addition to local infiltrative anesthesia is safe and recommended for use on the ear, providing longer duration of anesthesia and improved hemostasis. 4
• Maximum safe dose of lidocaine without epinephrine is 4.5 mg/kg in adults; with epinephrine it increases to 7.0 mg/kg. 6, 5

When Topical Anesthesia Might Be Considered

If you still choose to use topical anesthesia despite the limitations:

• Apply for a minimum of 60 minutes under occlusive dressing for any meaningful effect, though this may still be insufficient for the ear. 7, 2
• Be prepared with infiltrative lidocaine as backup, as 13% of patients in the ear surgery study required supplemental anesthesia even after EMLA application. 2
• Never use if there is any possibility of tympanic membrane perforation or middle ear exposure. 1

Special Considerations for Foreign Body Removal

• Patients with a history of previous removal attempts should be referred directly to otolaryngology without further manipulation, as they universally fail direct visualization techniques and have higher rates of tympanic membrane perforation. 3
• For firm, rounded objects (beads, beans), direct otolaryngology consultation is strongly recommended as 72% of these cases require specialist intervention. 3
• Approximately 19% of otolaryngology referrals for ear foreign bodies require removal under general anesthesia. 3

Toxicity Monitoring

Watch for early signs of lidocaine toxicity during and after any local anesthetic use:

• Circumoral numbness, facial tingling, tinnitus, light-headedness, and slurred speech appear at plasma concentrations of 5-10 μg/mL. 6, 5
• Do not use lidocaine-prilocaine cream within 4 hours of any other local anesthetic intervention to prevent cumulative toxicity. 6