Ann 0101 86: 1977
IMPRESSION
~IATERIALS
FOR REMOVAL
OF AURAL FOREIGN BODIES SHAlUR RAZ,
MD
NEWARK, NEW JEHSEY
HAYMOND STASSEN,
DAVID
:MA
HILDlNG, ~ID
CHICAGO, lLLJI':OIS
NEWAHK, NEW JEHSEY
SUM~fARY - A new method for removal of aural foreign bodies is introduced, employing the injection of a semifluid impression material into the external auditory canal, and its removal after curing with the engulfed foreign matter. This technique obviated the need for a general anesthetic in some pediatric cases, while in others it was just a more pleasant experience.
The removal of an otic foreign object can occasionally present a formidable challenge even to the experienced Otolaryngologist.' It is the purpose of this report to add another method to the armamentarium of the practicing physician, for use primarily with children. A semifluid prepared impression material (1M) is introduced into the external auditory canal, filling it completely, thus encompassing the foreign body. Time is allowed for the 1M to harden, and it is then withdrawn with thc enclosed foreign object. The one important contraindication is the possibility of a tympanic membrane perforation that would allow penetration of fluid into the middle ear. A careful history is therefore obtained prior to therapy in each case. The procedure is usually avoided if the history suggests previous ear disease of any type. The external canal lumen is irregularly elliptic in outline. The meatus is somewhat constricted about midway in its course and also near the drum.P It is precisely these constricted areas, or isthmi, that present special difficulties should a foreign body be lodged deep
within them. Multiple methods have been described for removal of aural foreign bodies consisting mostly of water or alcohol irrigation or instrumental manipulation facilitated by microscopic control.v' Gluing the end of a small piece of tape or a small camel's hair brush to the surface of the object has also been advocated in difficult situations.v" Various reports on severe complications following nonprofessional instrumentation would imply that at times a general anesthetic is not only more agreeable, but also safer to the child. METHODS AND MATERIALS k'HMAL EXPERIMENTS
Eight canine ears in mongrel dogs weighing 1.5-20 kg were used. An artificial pearl was selected that would occlude most of the lumen, usually 4 mm or 5 mm in diameter, and pushed deep into the meatus. The two impression materials investigated were: polysulfide" rubber and SilastiC® elastomer."" Each canine ear was subjected to two tests, thus totaling 16 in all. Polysulfides and Silastic® were employed eight times each. CLINICAL STUDIES
Since November 1975, an attempt has been made to remove all aural foreign objects seen at the MartIand Medical Center Otolaryngol-
" Permlasticfs, low viscosity, Kerr Co., Romulus, MI. "" SilasticSl382, medical grade elastomer, Dow Corning Corp., Midland, MI. From the Section of Otolaryngology, New Jersey Medical School, Newark, New Jersey, and the Department of Otolaryngology, Abraham Lincoln School of Medicine, Chicago, Illinois.
396
Downloaded from aor.sagepub.com at CARLETON UNIV on July 10, 2015
REMOVAL OF AURAL FOREIGN BODIES
Fig. 1. SilastiC® polymer enclosing pencil lead. Child 2)~ years old.
If possible, a preliminary step of first painting the exposed surface of the foreign body with a special adhesivett may improve significantly the subsequent bond between the 1M and foreign object. A cotton tipped metal applicator immersed in the adhesive liquid served well. Polysulfide. Equal lengths of the base and accelerator are placed on the paper pad. A stiff stainless steel spatula is used for mixing, until a uniform color is obtained, i.e., no streaks of either the base or reactor are evident. A somewhat more liquid material than the comparable silicone 1M is obtained. A specific adhesive is also available, the preliminary application of which improves the bond of the 1M to the foreign object. Curing time is 6 to 12 minutes. RESULTS
ogy Service with 1M. A careful history regarding past ear disease or possible perforation was obtained in each case prior to the use of 1M.
ANIMAL EXPERIMENTS
At our institution the majority of foreign bodies are removed by the emergency room non-E.N.T. residents. Thus, the 25 patients reported comprise only a fraction of the total hospital experience, many being referred following an unsuccessful attempt elsewhere. Foreign bodies consisted of six artificial pearls, seven cockroaches and a variety of other objects. Silastic® was used in ten patients, acrylic in nine patients, polysulfides in four and alginate in two. Most of the materials chosen are routinely used in Dentistry.
CLINICAL STUDIES
Acrylic." Preparation and mixture of the 1M is as for syringe ear mold fabrication, except that 25% to 50% more than usual of the fluid component was added, in order to obtain a more fluid 1M. The patient is instructed to place the head horizontally, involved ear uppermost. The ear lobe is pulled backwards and laterally as the semiliquid 1M is slowly injected into the meatus. The external canal and conchae are filled with the 1M. Most cured 1M were ready for removal after 5 to 15 minutes. Dental Alginate. "'" Alginate powder is added to the water and mixed for one minute, until a smooth creamy semiliquid consistency is formed. The application into the ear canal is as described for acrylic. Silicone. t Silicone paste is dispensed on a mixing paper pad and liquid accelerator, then added according to the manufacturer's specifications. Spatula stirring up to one minute assures a homogenous mixture, ready for injection into the meatus. Curing time at body temperature is five to ten minutes (Fig. 1).
397
Fourteen pearls were recovered using the impression materials. In each group, Silastic® and polysulfide, there was only one pearl which could not be retrieved, and remained in the canal. The overall success rate of removal was 23 of 25 trials. The two failures occurred with the acrylic and alginate substances. We no longer use them for that reason. No untoward reactions or late complications were observed in any of the patients, and no pain was experienced. Some children were subjected to two or three attempts before a successful removal was achieved. There was no need to restrain the child as no discomfort was experienced. DISCUSSION
A variety of 1M are marketed. They differ in ease of handling, initial fluidity, working time, final tear resistance and elasticity.I-" Contrary to dental work, the precise final dimensional stability and permanent deformity of the 1M were considered unimportant. Light bodied polysulfide rubber is supplied in two collapsible tubes, one containing the mercaptan polymer and the other an accelerator or catalyst. The resultant
" Tru-Moldfs, Scientific Plastics Inc., N.Y., NY. "'" Jeltrate®; L.D. Caulk Co., Milford, DE. t Syringe elasticon, type II light body, Kerr Co., Romulus, MI. tt Silicone adhesive, Kerr Co., Romulus, MI.
Downloaded from aor.sagepub.com at CARLETON UNIV on July 10, 2015
398
RAZ ET AL.
polysulfide polymer cures relatively slowly, allowing ample working time, and the product is sufficiently firm to grasp most foreign bodies: resistance to tearing is 15.9 kg!2.5 em. Its main disadvantages are in handling: the mixture is somewhat difficult to handle. It has an unpleasant odor, and it may stain clothing permanently as it contains lead in the accelerator. It has a favorable shelf life. Silicone rubber base consists of polydimethyl siloxane which has reactive hydroxyl groups and a silica filler. Tin octoate and ethyl silicate combine with the semifluid base to form an elastic rubber-like 1M. Dental silicone is easier to mix than polysulflde 1M, lacks an objectionable odor and does not stain clothing. The end product is less flexible and exhibits lower tear resistance, 10.9 kg!2.5 ern, if compared with polysulfides. The adherence of silicone or polysulfide 1M to various objects can be enhanced by first coating the surface with the specific adhesive. A porous object may require several coats. The working time and curing time of silicone or polysulflde 1M may be extended by prechilling the elastomer base and mixin~ equipment.P The curing rate of silicone can further be regulated by reducing the accelerator to base ratio, without changing the 1M properties." Alginate 1M are inexpensive and extremely easy to handle. They manifest inadequate tear resistance: .9-1.8 kg! 2.5 em, Tru-Mold® 1M consists of acrylic powder and plasticizer liquids. Like most 1M its precise composition is a trade secret. The cured product has a soft rubbery consistency, not quite matching the strength of silicone or
polysulfide. The working time was usu-
ally shorter and often unpredictable. In certain instances children would not permit the insertion of any instrument whatsoever in their ear when they were referred to us after previous unsuccessful attempts elsewhere. The use of impression materials was then tolerated and clearly obviated the need for a general anesthetic. Because no attempt was usually made by our Otolaryngologists to remove aural foreign bodies first by a conventional method before resorting to an 1M, it would be difficult to assess the total number of general anesthetics prevented. There is no intention to suggest that all foreign objects can be removed by 1M. There will be an occasional impacted object, completely occluding the meatal lumen, which will not permit the fluid 1M to surround it to any degree, and in which case the adhesive bond may not be of sufficient strength for extraction. When a foreign body is coated by cerumen in the ear canal the removal is technically more difficult due to suboptimal contact of the 1M with the foreign object. Theoretically, external otitis should not be a contraindication. In practice we would not use 1M if there is any reason to believe that otitis media and a perforation are also present. Many of the smaller nonvegetal smooth aural foreign bodies can be removed best by irrigation. A wax curette can also be used frequently, particularly in a cooperative patient. Impression materials should probably be reserved for the more difficult situations as when a child is uncooperative or when the foreign body is deep. As with other techniques, experience is the key to success.
REFERENCES 1. Fernandez-Blasini N, Bunker RJ: Traumatic facial palsy. Arch Otolaryngol 90:4546, 1969 2. Anson BJ, Donaldson JA: Surgical Anatomy of the Temporal Bone and Ear, ed 2. Philadelphia, WB Saunders Co, 1975, p 156 3. Viring RP: Nontraumatic removal of
foreign bodies from the nose and ears of infants and children. Minn Med 55: 1123, 1972 4. Lederer FL: Diseases of the Ear, Nose and Throat, ed 4. Philadelphia, FA Davis Co, 1943, pp 107-110 5. Philips WC: Diseases of the Ear, Nose and Throat, ed 7. Philadelphia, FA Davis Co,
Downloaded from aor.sagepub.com at CARLETON UNIV on July 10, 2015
REMOVAL OF AURAL FOREIGN BODIES
1928, pp 163-167 6. Y. Ota: Statistical observations of foreign bodies in the external ear canal. Otolaryngology (Jap) 35 :205-208, 1963 7. Craig RG, O'Brien WJ, Powers JM: Dental Materials. St. Louis, CV Mosby Co,
399
1975, pp 128-150 8. Phillips RW: Elements of Dental Materials. Philadelphia, WB Saunders Co, 1971, pp 80-91 9. American Dental Association, Guide to Dental Materials, ed 6. 1972-3, pp 71-76
ACKNOWLEDGMENT-The authors acknowledge the kind advice and assistance of Drs. Vincent and Stackhouse from the Department of Dental Materials, N.J. Dental School. REPRINTS-S. Raz, MD, Section of Otolaryngology, Martland Hospital, Room 901, 65 Bergen St., Newark, NJ 07107.
Downloaded from aor.sagepub.com at CARLETON UNIV on July 10, 2015
IMPRESSION
~IATERIALS
FOR REMOVAL
OF AURAL FOREIGN BODIES SHAlUR RAZ,
MD
NEWARK, NEW JEHSEY
HAYMOND STASSEN,
DAVID
:MA
HILDlNG, ~ID
CHICAGO, lLLJI':OIS
NEWAHK, NEW JEHSEY
SUM~fARY - A new method for removal of aural foreign bodies is introduced, employing the injection of a semifluid impression material into the external auditory canal, and its removal after curing with the engulfed foreign matter. This technique obviated the need for a general anesthetic in some pediatric cases, while in others it was just a more pleasant experience.
The removal of an otic foreign object can occasionally present a formidable challenge even to the experienced Otolaryngologist.' It is the purpose of this report to add another method to the armamentarium of the practicing physician, for use primarily with children. A semifluid prepared impression material (1M) is introduced into the external auditory canal, filling it completely, thus encompassing the foreign body. Time is allowed for the 1M to harden, and it is then withdrawn with thc enclosed foreign object. The one important contraindication is the possibility of a tympanic membrane perforation that would allow penetration of fluid into the middle ear. A careful history is therefore obtained prior to therapy in each case. The procedure is usually avoided if the history suggests previous ear disease of any type. The external canal lumen is irregularly elliptic in outline. The meatus is somewhat constricted about midway in its course and also near the drum.P It is precisely these constricted areas, or isthmi, that present special difficulties should a foreign body be lodged deep
within them. Multiple methods have been described for removal of aural foreign bodies consisting mostly of water or alcohol irrigation or instrumental manipulation facilitated by microscopic control.v' Gluing the end of a small piece of tape or a small camel's hair brush to the surface of the object has also been advocated in difficult situations.v" Various reports on severe complications following nonprofessional instrumentation would imply that at times a general anesthetic is not only more agreeable, but also safer to the child. METHODS AND MATERIALS k'HMAL EXPERIMENTS
Eight canine ears in mongrel dogs weighing 1.5-20 kg were used. An artificial pearl was selected that would occlude most of the lumen, usually 4 mm or 5 mm in diameter, and pushed deep into the meatus. The two impression materials investigated were: polysulfide" rubber and SilastiC® elastomer."" Each canine ear was subjected to two tests, thus totaling 16 in all. Polysulfides and Silastic® were employed eight times each. CLINICAL STUDIES
Since November 1975, an attempt has been made to remove all aural foreign objects seen at the MartIand Medical Center Otolaryngol-
" Permlasticfs, low viscosity, Kerr Co., Romulus, MI. "" SilasticSl382, medical grade elastomer, Dow Corning Corp., Midland, MI. From the Section of Otolaryngology, New Jersey Medical School, Newark, New Jersey, and the Department of Otolaryngology, Abraham Lincoln School of Medicine, Chicago, Illinois.
396
Downloaded from aor.sagepub.com at CARLETON UNIV on July 10, 2015
REMOVAL OF AURAL FOREIGN BODIES
Fig. 1. SilastiC® polymer enclosing pencil lead. Child 2)~ years old.
If possible, a preliminary step of first painting the exposed surface of the foreign body with a special adhesivett may improve significantly the subsequent bond between the 1M and foreign object. A cotton tipped metal applicator immersed in the adhesive liquid served well. Polysulfide. Equal lengths of the base and accelerator are placed on the paper pad. A stiff stainless steel spatula is used for mixing, until a uniform color is obtained, i.e., no streaks of either the base or reactor are evident. A somewhat more liquid material than the comparable silicone 1M is obtained. A specific adhesive is also available, the preliminary application of which improves the bond of the 1M to the foreign object. Curing time is 6 to 12 minutes. RESULTS
ogy Service with 1M. A careful history regarding past ear disease or possible perforation was obtained in each case prior to the use of 1M.
ANIMAL EXPERIMENTS
At our institution the majority of foreign bodies are removed by the emergency room non-E.N.T. residents. Thus, the 25 patients reported comprise only a fraction of the total hospital experience, many being referred following an unsuccessful attempt elsewhere. Foreign bodies consisted of six artificial pearls, seven cockroaches and a variety of other objects. Silastic® was used in ten patients, acrylic in nine patients, polysulfides in four and alginate in two. Most of the materials chosen are routinely used in Dentistry.
CLINICAL STUDIES
Acrylic." Preparation and mixture of the 1M is as for syringe ear mold fabrication, except that 25% to 50% more than usual of the fluid component was added, in order to obtain a more fluid 1M. The patient is instructed to place the head horizontally, involved ear uppermost. The ear lobe is pulled backwards and laterally as the semiliquid 1M is slowly injected into the meatus. The external canal and conchae are filled with the 1M. Most cured 1M were ready for removal after 5 to 15 minutes. Dental Alginate. "'" Alginate powder is added to the water and mixed for one minute, until a smooth creamy semiliquid consistency is formed. The application into the ear canal is as described for acrylic. Silicone. t Silicone paste is dispensed on a mixing paper pad and liquid accelerator, then added according to the manufacturer's specifications. Spatula stirring up to one minute assures a homogenous mixture, ready for injection into the meatus. Curing time at body temperature is five to ten minutes (Fig. 1).
397
Fourteen pearls were recovered using the impression materials. In each group, Silastic® and polysulfide, there was only one pearl which could not be retrieved, and remained in the canal. The overall success rate of removal was 23 of 25 trials. The two failures occurred with the acrylic and alginate substances. We no longer use them for that reason. No untoward reactions or late complications were observed in any of the patients, and no pain was experienced. Some children were subjected to two or three attempts before a successful removal was achieved. There was no need to restrain the child as no discomfort was experienced. DISCUSSION
A variety of 1M are marketed. They differ in ease of handling, initial fluidity, working time, final tear resistance and elasticity.I-" Contrary to dental work, the precise final dimensional stability and permanent deformity of the 1M were considered unimportant. Light bodied polysulfide rubber is supplied in two collapsible tubes, one containing the mercaptan polymer and the other an accelerator or catalyst. The resultant
" Tru-Moldfs, Scientific Plastics Inc., N.Y., NY. "'" Jeltrate®; L.D. Caulk Co., Milford, DE. t Syringe elasticon, type II light body, Kerr Co., Romulus, MI. tt Silicone adhesive, Kerr Co., Romulus, MI.
Downloaded from aor.sagepub.com at CARLETON UNIV on July 10, 2015
398
RAZ ET AL.
polysulfide polymer cures relatively slowly, allowing ample working time, and the product is sufficiently firm to grasp most foreign bodies: resistance to tearing is 15.9 kg!2.5 em. Its main disadvantages are in handling: the mixture is somewhat difficult to handle. It has an unpleasant odor, and it may stain clothing permanently as it contains lead in the accelerator. It has a favorable shelf life. Silicone rubber base consists of polydimethyl siloxane which has reactive hydroxyl groups and a silica filler. Tin octoate and ethyl silicate combine with the semifluid base to form an elastic rubber-like 1M. Dental silicone is easier to mix than polysulflde 1M, lacks an objectionable odor and does not stain clothing. The end product is less flexible and exhibits lower tear resistance, 10.9 kg!2.5 ern, if compared with polysulfides. The adherence of silicone or polysulfide 1M to various objects can be enhanced by first coating the surface with the specific adhesive. A porous object may require several coats. The working time and curing time of silicone or polysulflde 1M may be extended by prechilling the elastomer base and mixin~ equipment.P The curing rate of silicone can further be regulated by reducing the accelerator to base ratio, without changing the 1M properties." Alginate 1M are inexpensive and extremely easy to handle. They manifest inadequate tear resistance: .9-1.8 kg! 2.5 em, Tru-Mold® 1M consists of acrylic powder and plasticizer liquids. Like most 1M its precise composition is a trade secret. The cured product has a soft rubbery consistency, not quite matching the strength of silicone or
polysulfide. The working time was usu-
ally shorter and often unpredictable. In certain instances children would not permit the insertion of any instrument whatsoever in their ear when they were referred to us after previous unsuccessful attempts elsewhere. The use of impression materials was then tolerated and clearly obviated the need for a general anesthetic. Because no attempt was usually made by our Otolaryngologists to remove aural foreign bodies first by a conventional method before resorting to an 1M, it would be difficult to assess the total number of general anesthetics prevented. There is no intention to suggest that all foreign objects can be removed by 1M. There will be an occasional impacted object, completely occluding the meatal lumen, which will not permit the fluid 1M to surround it to any degree, and in which case the adhesive bond may not be of sufficient strength for extraction. When a foreign body is coated by cerumen in the ear canal the removal is technically more difficult due to suboptimal contact of the 1M with the foreign object. Theoretically, external otitis should not be a contraindication. In practice we would not use 1M if there is any reason to believe that otitis media and a perforation are also present. Many of the smaller nonvegetal smooth aural foreign bodies can be removed best by irrigation. A wax curette can also be used frequently, particularly in a cooperative patient. Impression materials should probably be reserved for the more difficult situations as when a child is uncooperative or when the foreign body is deep. As with other techniques, experience is the key to success.
REFERENCES 1. Fernandez-Blasini N, Bunker RJ: Traumatic facial palsy. Arch Otolaryngol 90:4546, 1969 2. Anson BJ, Donaldson JA: Surgical Anatomy of the Temporal Bone and Ear, ed 2. Philadelphia, WB Saunders Co, 1975, p 156 3. Viring RP: Nontraumatic removal of
foreign bodies from the nose and ears of infants and children. Minn Med 55: 1123, 1972 4. Lederer FL: Diseases of the Ear, Nose and Throat, ed 4. Philadelphia, FA Davis Co, 1943, pp 107-110 5. Philips WC: Diseases of the Ear, Nose and Throat, ed 7. Philadelphia, FA Davis Co,
Downloaded from aor.sagepub.com at CARLETON UNIV on July 10, 2015
REMOVAL OF AURAL FOREIGN BODIES
1928, pp 163-167 6. Y. Ota: Statistical observations of foreign bodies in the external ear canal. Otolaryngology (Jap) 35 :205-208, 1963 7. Craig RG, O'Brien WJ, Powers JM: Dental Materials. St. Louis, CV Mosby Co,
399
1975, pp 128-150 8. Phillips RW: Elements of Dental Materials. Philadelphia, WB Saunders Co, 1971, pp 80-91 9. American Dental Association, Guide to Dental Materials, ed 6. 1972-3, pp 71-76
ACKNOWLEDGMENT-The authors acknowledge the kind advice and assistance of Drs. Vincent and Stackhouse from the Department of Dental Materials, N.J. Dental School. REPRINTS-S. Raz, MD, Section of Otolaryngology, Martland Hospital, Room 901, 65 Bergen St., Newark, NJ 07107.
Downloaded from aor.sagepub.com at CARLETON UNIV on July 10, 2015
