This week we welcome Ross Roeser as a guest with very useful information for those of us looking in ear canals every day. Ross Roeser, PhD, is Professor and Head of the Doctor of Audiology Program at the University of Texas at Dallas/Callier Center for Communication Disorders, and Executive Director Emeritus of the Callier Center. He is also Editor-in-Chief of the International Journal of Audiology, and was the founding Editor of Ear & Hearing.
It was a typical Tuesday at my audiology practice: two routine diagnostic evaluations and a hearing aid check for a patient who I had fit about 3-4 months earlier. The patient, a 62-year-old female with a mild-to-moderate sloping sensorineural hearing loss (does that sound familiar?) had been fit with binaural premium receiver-in-the-ear instruments that used 312 batteries. She was seen for a two-week check with real-ear measures, the COSI and subjective evaluation, all indicating very good benefit.
Her three-month recheck was supposed to be a routine, but turned out to be much more than that. “How are things going hearing-wise?” was my remark when we sat face-to-face in my exam room. Her response was overall positive, but she said that she had not worn the instrument in the right ear for “a few days” because she had a “funny feeling” in that ear; she didn’t call me because she was scheduled for her recheck appointment.
My initial impression was that she might have inadvertently left a dome in the ear, but upon otoscopic inspection I noted a foreign object that I couldn’t exactly identify because it was deep in the ear canal and covered with cerumen.. “Ah ha!” I proclaimed to her, “I expect that you must have lost a dome in your canal, so I’ll take care of it.” However, upon palpation I noted that the object was solid–it would not move and it was firmly affixed to the wall of the ear canal. Closer examination with a higher resolution light source revealed the object to be silver in color, my first indication that it was not a dome, but perhaps, hmmmm, AH HA, a hearing aid battery!
At first my inclination was to attempt to wash it out with aural irrigation, but better judgment prevailed: otological referral. Upon contacting the local ENT office, an appointment was made IMMEDIATELY. “Drive to my office ASAP,” my ENT colleague advised. A hearing aid battery in the ear canal is an otological emergency, not because of simple obstruction or skin growth surrounding the object. Cerumen has a high electrical conductivity that results in a low-voltage electrical current being created when it comes into contact with the battery, causing exudation of the tissue and fluids. Battery electrolytes can spontaneously leak, resulting in caustic chemical hydroxide and liquefaction necrosis, or what I have termed hydrolytic necrosis of the canal wall and surrounding tissues.
Complications of a battery in the ear canal can include erosion of the tympanic membrane, ossicular erosion, erosion of the medial wall of the middle ear, and, in extreme cases, possibly sensorineural hearing loss and damage to the vestibular labyrinth. A battery in the ear canal that cannot be extracted by simple mechanical removal with forceps or a magnet is an emergency otological referral. Treatment is forced mechanical removal with forceps or a scalpel, or removal with suction. When the battery is firmly adhering to the canal wall, cyanoacrylate glue can be applied to the wooden blunt end of a cotton swab to force removal. Irrigation is an absolute contraindication because the fluids can result in leakage of the corrosive electrolyte solution further exacerbating the problem.
Any removal technique that causes bleeding must be avoided. As audiologists routinely performing otoscopy on many patients we encounter a variety of foreign objects in ear canals – I have my list and most other audiologists have theirs. My patient was fortunate that she had no resulting complications. There are reports in the literature on patients who were not so fortunate (See references).
- Ansley, J.F., & Cunningham,M.J. (1998). Treatment of Aural Foreign Bodies in Children. Pediatrics, Volume 101, Number 4 pp. 638-641 Olajide, T.G., Ologe, F.E., & Arigbede, O.O. (2011). Management of foreign bodies in the ear: A retrospective review of 123 cases in Nigeria. ENT Journal, Volume 90, Number 11 pp. E16-E19.
- Premachandra, D., & McRae, D. (1990). Severe tissue destruction in the ear caused by alkaline button batteries. Postgrad Med J, 52-53. Singer, J.I., Edwards, D., VanDeHoef, S., & Winograd, S.M. (2009). ‘There’s Something in my Ear’: Tools of the Trade for Foreign Body Entrapment and Retained Penetration. The Practical Journal of Pediatric Emergency Medicine, Volume 14, Number 8, pp. 97-108.
- Wolter, N.E., Cushing, S. L., Das-Purkayastha, P. K., & Papson, B.D. (Jan 2012). Non-accidental caustic ear injury: Two cases of profound cochleo-vestibular loss and facial nerve injury. International Journal of Pediatric Otorhinolaryngology, Vol. 76 Issue 1, p145-148.