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Bug in the Ear- What's your preferred treatment?

Discussion in 'Emergency Medicine' started by DropkickMurphy, 09.14.05.

  1. DropkickMurphy

    DropkickMurphy Removed

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    This was a topic of debate at work a while back, due to a patient we dealt with a few days prior who had a cockroach in her ear. After much fighting, kicking and screaming we finally got the med student calmed down....turns out she has a pathological fear of bugs....enough to get her to flood the patient's ear canal- or to use the technical term the patient used to describe the situation "ear hole"- with lidocaine to kill the bug which was then removed without incident. One of my coworkers said we should have used alcohol to kill the bug, another suggested plain old saline. Anyone else have an opinion or other suggestions on how to handle this common problem?
  2. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor

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    Viscous lido for 15 minutes, then pull it out with some very small ENT pickups under direct visualization with an otoscope (surprisingly, yes you can look in the ear with an otoscope and remove the bug at the same time).

    Taken out 10 of these things in my short career. I'm a bug magnet... (too bad not a babe magnet, but that's a story for another day).
  3. colforbinMD

    colforbinMD "Thanks, I'm very funny"

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    I like these cases. :) First thing I do is look. Premedicate the pt. with some happy juice if needed but then look and determine depth. If it's superficial enough and doesn't seem too entrenched i.e. no obvious death grip on canal wall with it's graspers. Then I will try to just grab it and remove with fine tip grasper. Only has worked once or twice I believe but I haven't seen the harm in trying every time. More often then not it has taken some chemical immersion of the bugs. I like to use Auralgan if available as it kills the critter and numbs the ear. If not I tend to use peroxide/saline mix probably just cause I am used to useing it for cerumen. Then I will still try and use the grasper to remove it because if it works it is less uncomfortable then washing it out is caveat being it's never a good idea to have to pull it out piece meal and never put the grasper in without full visualization. Last resort I use an 18g angiocath and the same saline peroxide mix. Or just saline
  4. jwilson.md

    jwilson.md Removed

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    Alcohol would have been a good choice. Saline would not kill nor drown a cockroach. Those things can survive a nuclear attack.
  5. DropkickMurphy

    DropkickMurphy Removed

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    As for the "happy juice" we should have given that to the med student. The patient was doing great (you have to love and respect some elderly black women for their composure at the oddest of times) in fact she was trying to calm the student down: "Dearie, it'll be alright. It's just a cock-a-ma-roach".

    Thanks for the suggestions....never thought about peroxide but I could see the reasoning behind it now. One of the residents suggested ether but that was quickly shot down because of the cooling produced by it probably producing excruciating pain (I believe the attending's exact words were "OK, let us put some in your ear and see how you like it").
  6. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    I love peroxide for wax but hate it for foreign bodies. It foams when it hits wax so it will often obscure the fb making it harder to grab.
  7. Sessamoid

    Sessamoid 1K Member

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    Ether? wtf? Who still has it around anyway? The cold could well give the patient severe vertigo as well as pain, so you'd have to be prepared to be vomited upon.

    I've always used lidocaine of some sort, viscous or regular 1% or 2%. I don't know if it kills the bug instantly, but it definitely paralyzes it instantly which is the important thing.
  8. Paws

    Paws

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    Wait a minute, I am still back on the 'cockroach in the ear part." Holy &*#, I think I would be through the roof on that one. Was it alive? I can hardly comprehend it ... :eek:

    Now I won't be able to sleep tonight thinking about that. I'll have to get my raid out ...
  9. DropkickMurphy

    DropkickMurphy Removed

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    They keep some around in the ED for maggot cases (works very well).

    And to answer the other question, yes it was still alive. The patient's exact words to the triage nurse were "Excuse me, but I think there's a cock-a-ma-roach crawling in my ear hole. I feel it moving around in there, sweetie."
  10. mikecwru

    mikecwru M.D. = Massive Debt

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    Yes, they're almost always alive. The roaches are smarter than most people I deal with on a daily basis and usually back in (you can see their heads). Then they get stuck in their and kick their little legs against the person's TM; what appears to be an excruciating experience.

    I kill the bug with lidocaine and the two options I've seen are (1) use alligator pickups and pull it out using the otoscope (2) use an 18g angiocath on a syringe and flood it out with lukewarm water.

    mike
  11. Gimlet

    Gimlet Cardiac Anesthesiologist

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    An EMT once told me about a call he got for this problem. Someone put in a call that their neighbor had gone crazy because he was running around in a circle in his front yard, smacking the side of his head. It turns out the cockroach in this guy's ear was pinching his ear canal/TM, causing him to basically go bonkers over the pain -- he couldn't think to do anything but run around in a circle and hit his ear because the pain was so bad. I think this should be the definition of 10/10 pain.
  12. DropkickMurphy

    DropkickMurphy Removed

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    Yes, that would be excruciating, but I think that would be best described as the definition of one of the levels of Hell.
  13. colforbinMD

    colforbinMD "Thanks, I'm very funny"

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    Peroxide and saline doens't foam as much as just peroxide and in my experience you leave the pt. for a few minutes to soak the bug so the foaming reaction is done by the time you are ready for extraction. That being said my next one I am going to try viscous lidocaine. Probably works alto lie araulgan but cheaper. I am curious about it's viscosity being an issue though.
  14. primadonna22274

    primadonna22274 Senior Member

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    The best thing I've found is Cerumenex or Tympagesic drops. The oil base makes it virtually impossible for the critter to latch on to anything in the canal and usually the bug just floats on out and you can grab it with alligator forceps.
    Last time I did this was with a 2 y/o with a spider in his ear. He kept saying "momma, I've got a bug in my ear" and she didn't believe him (thought he had an ear infection). He was so damn proud of that spider.
    Lisa PA-C
  15. mamadoc

    mamadoc Old Member

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    I can personally testify that peroxide can work. I got some sort of flying bug in my ear while camping, we happened to have peroxide in the first aid kit (honestly, I have no idea why) and it foamed the critter right out. And I can testify that I don't know that there is anything more excruciating than a bug's wings or legs or whatever beating up against your TM. I agree that it's a circle of hell. I've never screamed so much in my life.
  16. Sessamoid

    Sessamoid 1K Member

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    If the viscosity bothers you, there are several options. You can wash it out with warm water. The bug will stay dead/paralyzed. You can also use regular 2% lidocaine.
  17. ERMudPhud

    ERMudPhud Back for a visit

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    My personal favorite is to smear the opposite ear with bacon grease and wait for the bug to get hungry.

    My personal experience with this was many years ago. First you have to realize that it was the summer that Star Trek, Wrath of Kahn came out. Remember the scene where they put that bug in one of the crewman's ear and it crawls into his brain. I saw that just before leaving for the summer to do public health/sanitation work in rural Mexico. Very rural, no electricity, no phone, no water, no otoscope for hundreds of miles. For several weeks I had earaches with weird noises in my ear. Finally one morning the pain and noise got horrible and a black bug crawled out of my ear. I freaked and squashed the bug beyond recognition. Then I spent the rest of the summer wondering when the eggs were going to hatch and when the larva would start eating my brain.
  18. Sessamoid

    Sessamoid 1K Member

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    Lol! Great story! BTW, the eggs hatch VEEEEERY slowly.
  19. hyperbaric

    hyperbaric Cool under pressure.

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    It happened enough in the ED where I worked as a pre-med that one of the docs had standing orders for live roaches in the ear (regular 1 or 2% lidocaine using an angiocath). Sometimes they (the roaches) would run out when you squirted the lidoocaine in.

    Once I saw the a doc pull out a roach AND an egg case!!
  20. DrQuinn

    DrQuinn My name is Neo Moderator Emeritus

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    LMAO. :laugh:
  21. Jeff698

    Jeff698 Chief Resident

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    The real question, though, is if you suddenly found yourself understanding foreign languages.

    Take care,
    Jeff
  22. Oats

    Oats tempermental

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    :wow: :scared:
  23. bulgethetwine

    bulgethetwine Removed

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    Ah, the Babblefish...

    Known to arrive after a night of indulging in Absinthe. No ED visit required...
  24. youcandoit

    youcandoit Member

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    just a random question from a previous MS2 lurker:

    How does somebody get a bug in their ear without noticing that the bug is actively crawling in? Are they sleeping when it happens? Do you guys see this in patients of all "levels" of personal hygiene? Basically, what kind of patients do you this in?

    I have always wondered this (ever since I saw it on an ER episode long ago). Thanks for answering.
  25. DropkickMurphy

    DropkickMurphy Removed

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    Yes, normally it happens with a sleeping patient. Yes, we see it in all levels of hygeine (but the dirtier the patient the more common it is), but we had one of our ER residents (a damn hot little number) come in with a bug in her ear to give you some idea of occurence.
  26. stoic

    stoic best served chilled.

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    it's gotta be really common; before i started med school i saw 3 or 4 bugs in the ear while shadowing in the ER over the period of a couple years... and i wasn't there that frequently. the docs would always start telling war stories of what kind of bugs they've pulled. the winner was the black widow spider... the doc ID'd it with the otoscope, which he prompted DROPPED when he realized what it was. not wanting to scare the patient, he didn't tell them what it was and then drowned it with some lido.
  27. fedor

    fedor gunning like the NRA

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    I suggest you put a cockroach in each of your ears.

    In your left ear use lidocaine. In your right ear just flush with a water filled syringe.

    Repeat for 2 weeks to increase your n.

    And who said there's no room for research in emergency medicine?
  28. DropkickMurphy

    DropkickMurphy Removed

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    I have a question: If you're using yourself as the sole study study subject, do you still have to get IRB clearance and informed consent forms signed? :smuggrin:
  29. fedor

    fedor gunning like the NRA

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    No. There is no need to get clearance or consent. Get started with this project immediately. Don't let some young gunner beat you to the punch.
  30. DropkickMurphy

    DropkickMurphy Removed

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    What's really scary is there is another undergrad doing research on the uh, "ecology" (?) of cockroaches at our school... :idea: :laugh: :laugh:
  31. mustangsally65

    mustangsally65 Sally 2.0

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    OMG, a ROACH in your ear? :eek: I can put up with a lot of gross stuff, but bugs I cannot stand. How does a huge bug like a roach get in your ear and get far enough in to get stuck?

    I'm never working in an ER. I swear. Why do we have to have bugs anyway? the gross ones like roaches don't serve any purpose other than as the bottom of the food chain. And they crunch when you step on them.

    I'm gonna be that med student who passes out from the sighting of the roach. Not looking forward to that.
  32. primadonna22274

    primadonna22274 Senior Member

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    Haven't had a bug in an ear for a while.
    Working urgent care today, very slow...woman walks in with "fluttering" sensation in L ear x 2 d. More uncomfortable today.
    A: Bug in L ear, alive
    Instilled local anesthetic, flushed with 50% H2O2, a nice little creepy-crawly silverfish comes out. Ick!!! Pt's son (8 y/o or so) was fascinated, wanted to keep the souvenir.
    And Sally: the ecology of cockroaches is actually quite fascinating. How many other critters have survived millennia through scourge and famine and flood and fire to persist and thrive??? Read "The Beauty of the Beastly" by Natalie Angier.
    :)
    Lisa
  33. DropkickMurphy

    DropkickMurphy Removed

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    Yeah, cockroaches, while a bit disgusting do serve a purpose. Most just can't get past the "OMG" factor to see it.
  34. 12R34Y

    12R34Y

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    okay........had a patient a couple of days ago with a roach in her ear. My first personally.

    One attending says to put viscous lidocaine in her ear. So the nurse does it. I see the patient and grab an ENT tray that has alligator forceps. Look in and the roach was legs out sideways against the TM. bad position.

    I try 3 times to grab it and only get his soft underbelly and she freaks out each time.

    I get another attending and he freaks out because he says you should NEVER EVER use viscous lidocaine or mineral oil to drown it because it dissolves the body and you can't get it out then. I said "well, couldn't you just flush it out then if it is falling apart." He says no.

    He said that viscous lidocaine does NOT numb the ear canal. I asked him what he though about Auralgen and he says that numbs the TM which would be useless (in his words).

    After reading all of these posts it seems the consensus if viscous or regular lidocaine. How much viscous lidocaine do you use and how do you get it into the canal? The nurse said she put viscous lido in, but I didn't see any in the ear canal when I looked with the otoscope.

    later
  35. Apollyon

    Apollyon Screw the GST Lifetime Donor

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    As to the bolded, WRONG. The idea isn't to numb the ear canal, but the critter in the ear. It is true that the lidocaine (viscous or otherwise) does not numb the canal (unless the canal is lacerated) - that's why EMLA is used on intact skin.

    The point of the viscous lidocaine or mineral oil isn't to leave in until the bug "dissolves and is absorbed" - I mean, the carapace is chitin, which is a sugar - lidocaine or oils have no effect on it. The lidocaine works as a neuro effect without mechanical or chemical destruction. You numb it (the bug) for patient relief until you pull it out.

    My question is, what does this attending do, then? The bug stomping on the TM drives patients CRAZY - does he let them suffer? Then, trying to pull a bug out, while it's struggling, adds to the terror.

    As for how to get it in - use a 10cc syringe and put the lidocaine in a 30mL cup (or leave it in the brown container). Then, you just put the end of the syringe right in the canal and slowly inject it in.
  36. aphistis

    aphistis Moderator Emeritus

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    ...how would lidocaine dissolve anything?
  37. 12R34Y

    12R34Y

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    This attending says that anything that is oil based dissolves the body of the insect. He says that he doesn't use anything and just grabs it with alligator forceps and pulls it out. Sounds barbaric, but after watching him blindly grab at the roach with the alligator forceps I realized he wasn't joking.

    He's an old cowboy who trained in EM about 20 years ago. He's got interesting philosophies on lots of things. Very frustrating to sit there and read Rosen's and Tintanalli's chapters on foreign body removal and then hear him make no sense at all and have to do it his way.

    don't worry. I'll be using lidocaine to incapacitate the bug in my practice.

    thanks all

    later
  38. aphistis

    aphistis Moderator Emeritus

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    Gotcha. I forgot I'm not in Kansas anymore. Here in dental land, "lidocaine" means "2% aqueous solution." ;)
  39. ERMudPhud

    ERMudPhud Back for a visit

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    So chitin is a branched polysaccharide and insoluble in aqueos solutions except under conditions so acidic that it would also certainly digest your ear. Viscous lidocaine is not oil based it is aqueos lidocaine with carboxymethylcellulose for thickening. It won't dissolve chitin either. I'm pretty sure chitin is insoluble in mineral oil but next time I catch a roach or some other little bug I'll throw it in a tube of mineral oil for a few hours and let you know what happens. I'm betting nothing happens.

    As I said before my preferred method is to smear bacon grease outside the opposite ear, wait for the bug to get hungry and eat its way through to the bacon grease.

    If you can't find any bacon grease in the hospital cafeteria I find regular lidocaine easier to instill into the ear and it doesn't make the bug as slippery as oil or I guess viscous lido would.
  40. Oats

    Oats tempermental

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    Holy Mary Mother of God! :wow: :scared:
  41. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor

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    I have never had a problem grabbing bugs smothered in viscous lido.
  42. stoic

    stoic best served chilled.

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    do these critters ever scratch deep enough to plant any nasty microbes and cause infection?

    the docs i've been around all send the patient home w/an abx, though i often wonder if it's really needed. but keep in mind i'm in the middle of rural USA where a headache at 3am will still get you enough demerol and vistril to keep you quiet till the end of the shift... a little removed from the ideals of academic medicine, but effective to be sure

    anyway, what do you guys do?
  43. 12R34Y

    12R34Y

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    If there are abrasions in the ear canal I'll send them home with cortisporin drops (antibiotic plus steroid) ear drops.

    If TM is ruptured you can give PO antibiotics and ENT follow-up.

    later
  44. ERMudPhud

    ERMudPhud Back for a visit

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    I couldn't get the animal use committee to approve throwing a live roach in a tube of mineral oil but I did find a dead fly in the lab. I left him in a tube of mineral oil all morning and when I dumped him out I could still pick him up by a leg or wing and give him a good shake without anything falling apart. I would say mineral oil doesn't dissolve bugs. I'll write the experiment up and get it published as soon as I have time :D
  45. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    I used to have a job washing trucks. We used this special soap that was supposed to dissolve chitin to get the bugs out of the grills. You should do a study where you put that in pt's ears and compare it to mineral oil. Good luck with the IRB. :scared:
  46. AzMichelle

    AzMichelle Member

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    Oh crap. My nightmares should start in about 6 hours.
  47. DropkickMurphy

    DropkickMurphy Removed

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  48. oudoc08

    oudoc08 Please pass the gas...

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    Forget lidocaine, peroxide and all that noise.
    The key is succinylcholine. Yes, good old Anectine works everytime.
    First, you get a nice super high power ENT microscope, and a 82 gauge angiocath. You start an intraexoskeletal line on the roach, and shoot him full of sux (you can use a defasiculating dose of norcuron if you'd like to prevent the fasiculations from playing Wipeout on the pt's TM). Then simply remove the bug, intubate, and admit (the bug, not the patient).
  49. DropkickMurphy

    DropkickMurphy Removed

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    Would you be paging RT for a vent for the roach? I can tell you that they would LOVE you for that....especially at like 2 am.

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