Destructive Otologic Foreign Body: Dangers of the Expanding Bead | Otolaryngology | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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Observation
September 2016

Destructive Otologic Foreign Body: Dangers of the Expanding Bead

Author Affiliations
  • 1Department of Otolaryngology, Children’s National Medical Center, Washington, DC
  • 2Department of Otolaryngology, Walter Reed National Military Medical Center, Bethesda, Maryland
  • 3Department of Diagnostic Imaging and Radiology, Children’s National Medical Center, Washington, DC
JAMA Otolaryngol Head Neck Surg. 2016;142(9):919-920. doi:10.1001/jamaoto.2016.1870

Foreign bodies of the external auditory canal (EAC-FB) are a common presentation to the emergency department (ED), with an estimated 280 000 visits from 2008 to 2012 in the United States.1 Cases are evaluated and treated with irrigation, suction, or surgical instrumentation. Otic drops are given if there is secondary canal trauma or inability to remove EAC-FB.2 One-third of patients require otolaryngology referral; 75% of these referrals consist of round or firm objects best removed under otomicroscopy and are seen on a less urgent basis. Expedient evaluation is indicated in cases associated with infection secondary to canal trauma from unsuccessful removal.3 Urgent referral is indicated for materials with potential for destruction, such as button batteries. Two patients were diagnosed with an EAC-FB that expanded within the ear canal leading to tympanic membrane (TM) perforation, ossicular erosion, and in a prolonged case, otic capsule erosion resulting in permanent auditory and vestibular loss. The FB in each case was identified as a water-expanding bead marketed as a children’s toy.

Report of Cases

Patient 1

A young girl presented to the clinic with a prolonged course (>10 weeks) of EAC granulation nonresponsive to oral antibiotics and ototopical drops. No foreign body was seen or reported as related to infection, and she denied EAC-FB on questioning during each visit to clinic or the ED. Computed tomography (CT) revealed bony erosion and subsequent biopsy was consistent with inflammatory tissue. Magnetic resonance imaging (MRI) revealed a 9.8-mm spherical FB (Figure 1). Surgical exploration was performed with removal of a green, gelatinous FB from the middle ear. Hypotympanic and otic capsule erosion was present with ossicular destruction. Profound sensorineural hearing loss was present on audiogram; labyrinthitis ossificans of the cochlea and semicircular canals was seen on imaging after surgery. Her facial nerve was intact and she did not exhibit vestibular symptoms.

Figure 1.  Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) of the Destructive Otologic Foreign Body
Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) of the Destructive Otologic Foreign Body

A, Axial CT images of the right temporal bone at initial presentation. Thickening of soft tissue within the external auditory canal (EAC) (asterisk). B, Axial CT images of the right temporal bone 10 weeks after initial presentation. There is erosion of the tympanic plate and anterior mastoid. A linear hyperdensity in the EAC (arrowhead) likely represents a displaced fragment of the tympanic plate. Axial (C) and Coronal (D) fat-saturated T2-weighted MRI of the same patient prior to biopsy. Both images demonstrate a 9.0 mm T2-hyperintense, spherical lesion suspicious for a foreign body and is found in the expected location of the middle ear cavity. The EAC measured diameter is 5.9-mm, indicating the foreign body had expanded after insertion. Imaging was obtained 10 weeks after initial presentation.

Patient 2

A young boy presented from the ED after unsuccessful removal of FB-EAC. He admitted to placing toy beads in his ears during play and was taken for removal in the operating room 4 days later. Findings revealed a blue, spherical 1 × 0.4 × 0.3-cm gelatinous FB that expanded within the canal causing subtotal TM perforation and partial ossicular chain erosion. Postoperative examination revealed a 40% residual perforation and mild conductive hearing loss. Toy beads belonging to his sister were brought to this visit; they were colorful, small, and after expansion in water, identical to the gelatinous material removed from his ear.

Discussion

A superabsorbent polymer (SAP) as an EAC-FB led to inflammation, erosion of the EAC, and in delayed diagnosis, migration into the middle ear space with cochlear erosion. Superabsorbent polymers, such as polyacrylamide, polymethylacrylate, or sodium polyacrylate, are commonly used in agriculture, fillers inside disposable diapers, and recently as a child’s toy. Superabsorbent polymer toys were previously marketed as 1- to 2-mm balls capable of expanding 400 times their size within 96 hours in water, and recalled after report of ingestion led to small bowel obstruction in an 8-month-old infant.4 Currently available SAP-toys are firm beads (0.1-0.2 cm in size) that expand in liquid medium to 0.67 to 1.09 cm (Figure 2).5 The source or brand of the SAP beads were unknown in the cases presented herein, but operative findings and history in case 2 was suggestive of a sibling’s SAP toy bead.

Figure 2.  Store-bought Superabsorbant Polymer Beads Before and After Exposure to Liquid Medium
Store-bought Superabsorbant Polymer Beads Before and After Exposure to Liquid Medium

Water beads or jelly beads are water expandable toys marketed to children for play, arts and crafts, and sensory play as well. When small (0.1-0.2 mm) the bead is hard and once exposed to water or liquid the bead grows to about 9 mm in diameter, becomes gel-like and breaks apart somewhat easily.

Conclusions

These cases highlight the danger of SAP beads as EAC-FB and the dramatic implications of a delayed diagnosis. We would not have anticipated the urgency of the second case, which resulted in a reversible hearing loss, without the initial case experience.

We conclude that in cases of persistent granulation in the ear, an FB reaction should remain on the differential diagnosis. Pediatric patients are not reliable historians and events are not typically witnessed. Care providers should consider SAP beads when managing EAC-FB and recognize their appearance. Malleable beads in the ear should not be treated with ototopical drops; patients should be instructed to keep the ear dry, and urgent otolaryngology evaluation is indicated.

In response to this case a formal report has been made to the Consumer Products Safety Commission (Report No. 20160125-B03A1-2147424341) and contact was made with the manufacturer/private labeler of the consumer product described in this report who report they are aware of the danger of inserting beads into the nasal cavity or ear canal and do carry a warning on the products. A report was also made to the American Academy of Pediatrics. We will continue to disseminate this known risk associated with SAP as aural FB, and cases may be reported at http://www.saferproducts.gov/, or contact the author at pmudd@cnmc.org.

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Article Information

Correction: This article was corrected online February 1, 2017, to fix an error in the byline.

Corresponding Author: Megan Sterling, DO, Department of Otolaryngology, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889 (Megan.sterling1@gmail.com).

Published Online: August 4, 2016. doi:10.1001/jamaoto.2016.1870

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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