Letters to the Editor

Options for Removing Foreign Bodies from Ear, Nose, and Throat

TO THE EDITOR: The excellent review on foreign bodies in the ear, nose, and throat will be of much interest to any family physician who has wrestled with these mischievous and far-too-common objects. However, there are a couple of additional techniques that may be useful for office-based physicians that I have previously published in American Family Physician (AFP).1,2

The easiest way we have found to remove these foreign bodies is to apply a small drop of strong bonding glue to the end of a cotton-tipped applicator. Taking care not to touch the mucous membranes, the applicator is then touched to the foreign body for as long as it takes the seal to harden (usually 15 to 20 seconds). Then, the applicator and foreign body can be easily removed. Because the nose generally has hair on the sides, we are more comfortable using this method for nasal foreign bodies than for foreign bodies in the ear.1

To remove nonoccluding foreign bodies from the ear, one can use dental impression material, which may be obtained from a local dentist. The semifluid dental impression material is injected into the external auditory canal, then removed after curing, with the foreign body attached. Dental amalgam comes with two substances in separate tubes connected by a hand-held pump device that empty through a single nipple. The method is painless, easy, and fun! This technique should not be used with a tympanostomy tube in place.2

Walter L. Larimore, MD

Monument, Colo.
E-mail: waltlarimore@aol.com

Author disclosure: Nothing to disclose.

REFERENCES

1. Larimore WL, Hartman JR. Diary from a week in practice. Am Fam Physician. 1992;46(2):437-438.

2. Larimore WL, Hartman JR, Shupe TB, Frisbie SE, Ries JS, Griffin CA. Diary from a week in practice. Am Fam Physician. 1998;58(8):1762-1763.

Diagnosis and Treatment of Otitis Media

TO THE EDITOR: The cover illustration on the December 1, 2007, issue of AFP unfortunately demonstrates poor technique in the use of the otoscope to examine the child's external ear canal and tympanic membrane. As illustrated, the technique risks irritation and injury to the external ear canal from the tip of the otoscope speculum if the child moves her head toward the examiner. The examiner should apply a small amount of traction to the ear lobe with the right hand to straighten the external canal. The otoscope should be held in the left hand with the fifth finger stabilizing it against the head to maintain proper position when the child moves her head, as they almost always do. The hands should be switched when examining the right ear, but stabilizing the instrument against the child's head is mandatory.

I have seen too many students, residents, and nurse practitioners examine children's ears using the technique illustrated on the cover and on the first page of this article. I would conclude that they are not being taught how to use an otoscope safely and correctly. Certainly a high quality journal such as AFP that is being read by thousands of physicians should not compound this problem.

Lawrence M. Markman, MD, FAAFP

New Castle, Del.
E-mail: lawrence.markman@state.de.us

Author disclosure: Nothing to disclose.

editor's note: Dr. Markman's critique of the inappropriate ear examination technique depicted in the December 1, 2007, cover illustration was echoed by several other readers. We agree that in this case artistic license should not have been taken with an important examination maneuver and we apologize for the oversight.

Kenny Lin, MD

Assistant Editor

Correction

The article "Diagnosis and Treatment of Otitis Media," (December 1, 2007, page 1650) contained an error in Table 5 on page 1654. The dosage for acetaminophen was incorrectly listed as 1 mg per kg every six hours; the correct dosage is 15 mg per kg every six hours. The corrected Table 5 is reprinted below.

Table 5. Agents Used in the Treatment of Otitis Media
Agent	Dosage	Comments
Antimicrobials*
Amoxicillin	80 to 90 mg per kg per day, given orally in two divided doses	First-line drug. Safe, effective, and inexpensive
Amoxicillin/clavulanate (Augmentin)	90 mg of amoxicillin per kg per day; 6.4 mg of clavulanate per kg per day, given orally in two divided doses	Second-line drug. For patients with recurrent or persistent acute otitis media, those taking prophylactic amoxicillin, those who have used antibiotics within the previous month, and those with concurrent purulent conjunctivitis
Azithromycin (one dose; Zithromax)	30 mg per kg, given orally	For patients with penicillin allergy. One dose is as effective as longer courses
Azithromycin (three-day course; Zithromax Tri-pak)	20 mg per kg once daily, given orally	For patients with recurrent acute otitis media
Azithromycin (five-day course; Zithromax Z-pak)	5 to 10 mg per kg once daily, given orally	For patients with penicillin allergy (type 1 hypersensitivity)
Cefdinir (Omnicef)	14 mg per kg per day, given orally in one or two doses	For patients with penicillin allergy, excluding those with urticaria or anaphylaxis to penicillin (i.e., type 1 hypersensitivity)
Cefpodoxime (Vantin)	30 mg per kg once daily, given orally	For patients with penicillin allergy, excluding those with urticaria or anaphylaxis to penicillin (i.e., type 1 hypersensitivity)
Ceftriaxone (Rocephin)	50 mg per kg once daily, given intramuscularly or intravenously. One dose for initial episode of otitis media, three doses for recurrent infections	For patients with penicillin allergy, persistent or recurrent acute otitis media, or vomiting
Cefuroxime (Ceftin)	30 mg per kg per day, given orally in two divided doses	For patients with penicillin allergy, excluding those with urticaria or anaphylaxis to penicillin (i.e., type 1 hypersensitivity)
Clarithromycin (Biaxin)	15 mg per kg per day, given orally in three divided doses	For patients with penicillin allergy (type 1 hypersensitivity). May cause gastrointestinal irritation
Clindamycin (Cleocin)	30 to 40 mg per kg per day, given orally in four divided doses	For patients with penicillin allergy (type 1 hypersensitivity)
Topical agents†
Ciprofloxacin/hydrocortisone (Cipro HC Otic)	3 drops twice daily	-
Hydrocortisone/neomycin/polymyxin B (Cortisporin Otic)	4 drops three to four times daily	-
Ofloxacin (Floxin Otic)	5 drops twice daily (10 drops in patients older than 12 years)	-
Analgesics
Acetaminophen	15 mg per kg every six hours	-
Antipyrine/benzocaine (Auralgan)	2 to 4 drops three to four times daily	-
Ibuprofen (Motrin)	10 mg per kg every six hours	-
Narcotic agents	Variable	May cause gastrointestinal upset, respiratory depression, altered mental status, and constipation
*-These drugs should be given for 10 days, unless otherwise indicated. A five- to seven-day course is an option for patients six years and older. These agents may cause diarrhea, vomiting, abdominal pain, rash, anorexia, and dermatitis. †-These drugs should be used for seven to 10 days in patients with chronic suppurative otitis media. Information from references 1, 5, and 25.

Send letters to Kenny Lin, MD, Assistant Editor, American Family Physician, e-mail: afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680.

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