Embedded earrings are a common pediatric emergency department presentation that can usually be managed quickly and safely without procedural sedation. This episode reviews why earrings become embedded, how to distinguish uncomplicated earlobe cases from higher-risk cartilage piercings, step-by-step removal techniques, pain control strategies, and appropriate wound care, antibiotics, and follow-up.

Learning Objectives

1. Recognize the evaluation and management of embedded earlobe earrings, including indications for local anesthesia, incision, and removal techniques.
2. Differentiate uncomplicated earlobe piercings from cartilage piercings that require additional concern for perichondritis, Pseudomonas infection, and possible ENT consultation.
3. Apply evidence-based post-procedure care, including appropriate wound management, antibiotic selection, and counseling to help prevent future embedded earrings.

References

1. Timm N, Iyer S. Embedded earrings in children. Pediatr Emerg Care. 2008;24(1):21-24.
2. Muntz HR, Pa-C DJ, Asher BF. Embedded earrings: a complication of the ear-piercing gun. Int J Pediatr Otorhinolaryngol. 1990;19(1):73-76.
3. Kim MM, Goldman RD. Ear-piercing complications in children and adolescents. Can Fam Physician. 2022;68(9):661-663.

Transcript

This transcript was generated using Descript and subsequently reviewed and lightly edited for spelling, grammar, and clarity. Minor inaccuracies may remain, and the audio recording should be considered the definitive version of this content.

Welcome to PEM Currents: The Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski. Today, we’re continuing our new series on minor procedures. These are the procedures we perform all the time in pediatric emergency departments. They’re not the subject of giant multicenter trials or big keynote lectures, but they are the procedures that families remember.

If you make them quick, comfortable, and maybe even a little less scary, families and patients will remember that. And if the procedure turns into a wrestling match with three people trying to hold down a screaming child while you’re searching for an earring backing, they’re gonna remember that too.

Today’s topic is embedded earrings. A kid walks into the emergency department holding one ear. The earlobe is swollen and red, and the parent says, “I can’t find their earring.” It didn’t disappear. The ear basically swallowed it, and the parents almost always feel bad. They think they did something wrong or they waited too long.

Honestly, this happens all the time. The first one can be a little intimidating because the hardware isn’t always where you expect it to be, but after you’ve removed a few of these, you’ll realize they’re actually pretty straightforward. Most can be managed right in the emergency department or a well-resourced urgent care.

One of the best studies on the topic actually came from Cincinnati Children’s. Tim and Iyer reviewed over 100 children who presented to our emergency department with embedded earrings over about a four-and-a-half-year period. The median age was eight years, and about 60% of the children were younger than 10.

That fits with most of our clinical experience. Younger children are more likely to sleep on new piercings, play with their earrings, forget the aftercare instructions, or simply not notice that the backing has become too tight. Nearly 90% of embedded earrings involve the earlobe rather than the cartilage, and in about two-thirds of patients, it wasn’t the decorative front of the earring that got stuck, it was the posterior backing or clasp.

That’s helpful because I, um, almost always start looking on the back of the ear, ‘cause usually they’ve taken off the front. About one-third of children had evidence of a localized infection when they presented. Usually, that meant tenderness, erythema, swelling, and maybe a little purulent drainage or crusting around the piercing.

Doesn’t necessarily mean they need oral or systemic antibiotics, but it does mean they shouldn’t wait another week hoping the earring somehow works itself out. So why does this happen? It’s really a pressure injury. The backing gets tightened against the earlobe, either because it was applied too snugly when the ears were pierced or because the ear swells afterward and suddenly there’s no room for the tissue to expand.

That constant pressure decreases blood flow, produces local inflammation, and eventually the skin begins to grow around the earring hardware. Kids speed the whole process along by twisting the earrings, playing with them, sleeping on them, bumping them during play, and not cleaning the piercing consistently while it’s healing.

One thing that probably contributes as well is the spring-loaded ear piercing gun. These devices place the earring and immediately snap on the backing, and sometimes that backing ends up much tighter than it should be. If swelling develops over the next day or so, the backing can quickly become buried beneath the skin.

It’s one of the reasons I generally recommend families avoid piercing guns and instead use a method that leaves just a little room for post-procedure swelling. When these patients show up in the emergency department, they almost always complain of pain, swelling, redness, and tenderness around the piercing site.

Sometimes there’s drainage. Sometimes the parent says they can’t unscrew the backing anymore. Sometimes they tell you they can feel the earring in the earlobe, but you can’t actually see it. Now, I’ll get to the procedure technique in just a minute. But before I start talking about that, I do wanna separate earlobe piercings from cartilage piercing, ‘cause they’re really different problems.

Once cartilage is involved, the stakes go up considerably. Cartilage has relatively poor blood supply, making it much more susceptible to perichondritis, chondritis, cartilage necrosis, and permanent cosmetic deformity. The bacteria may be different as well. We’ll come back to that later. For now, though, let’s stay with the earlobe because, frankly, that’s where almost all of these procedures occur.

All right. Before you start any procedure, you wanna have everything ready. So I’ll have local anesthetic, so lidocaine or lidocaine with epi. Epi is totally fine in the earlobe. At least two mosquito hemostats, stuff to grab the earring, an 11 blade, gauze, saline, and a good light source. I think if there’s any chance I’ll need to make a small incision, I’ll prep the ear before I do anything with, uh, betadine or chlorhexidine.

Once the ear starts bleeding a little or the child starts moving around, everything gets just a little harder to see and grab. Absolutely bring your child life specialist if you’ve got them and someone to hold, like a medic or a PCA. One of the interesting things about the Cincinnati study is that none of the 100 children required procedural sedation. None.

And honestly, that fits with my experience. The overwhelming majority of these can be managed with local anesthesia alone. For the earlobe, I usually perform a small field block using one percent lidocaine with epinephrine, using a twenty-seven or thirty-gauge needle. Epi is perfectly safe in the earlobe and gives you a little hemostasis while you’re working.

One thing I probably do differently from some people is I actually wait for the anesthetic to work a little longer. I don’t just block and immediately start. I’ll wait at least five minutes. Honestly, it’s usually closer to seven to ten minutes. During that time, I’m talking with the family, keeping child life involved, making sure all my equipment is ready, and just letting everybody settle down a bit.

Those extra few minutes make the whole procedure a lot easier. And again, this is pediatrics, so never underestimate distraction. You’ve got videos, music, you know, stuffed animal, a toy. Parents should be there holding the child’s hand. You gotta coach the parents as well. And sometimes that’s really all you need, a good block and some distraction.

Of course, some kids do need more. For an anxious child, you can use intranasal midazolam or oral midazolam. If your department has nitrous oxide, this is a great procedure for it because it’s usually pretty quick. You’re often treating anxiety more than pain. I have used ketamine a handful of times, and not because something went wrong, but just because you have an extremely anxious child, and you’re not gonna accomplish the procedure safely any other way.

First, figure out what you can see and what you can feel. Sometimes both the decorative front and backing are still visible, but the ear is simply too swollen to separate them normally. Those are the easy ones. I’d grab each side with a mosquito hemostat, disengage the backing from the post, and remove the earring.

More commonly, the backing is buried beneath the skin. The decorative front may still be attached, or the parents may have already removed it and left the backing sitting in the earlobe. I’ll gently compress the earlobe from the front while looking at the back. That pressure tents the skin enough to expose a few millimeters of metal through the original piercing hole, and that may be all that I need to grab the backing and remove it.

If you still can’t see it, keep palpating. Usually, I can feel the hardware through the swollen tissue. Once you localize it, I’ll make a tiny incision on the back of the earlobe directly over it. And when I say tiny, I mean tiny, like a couple millimeters, just enough to expose the metal. But don’t be afraid of making that incision.

It’s honestly usually the difference between wrestling with the earring for ten minutes and having it out within sixty seconds. From there, the rest is pretty straightforward. Whether the front is buried, the backing is buried, or neither side is visible, I gently spread the tissue with a mosquito hemostat until the hardware comes into view.

Notice that I said spread, not dissect. You’re not hunting for the earring. You’re simply opening the tissue until you see the hardware, enabling yourself to grab it. Once you can see metal, you’re almost done. Hold one side steady and separate the backing from the post. Don’t just grab one piece and pull because the whole earring will usually rotate within the earlobe instead of coming apart.

I also keep gauze or a surgical towel underneath the ear while I’m working. The little backings seem to launch themselves across the room every single time you let go, and I’d rather catch one than spend five minutes looking under the stretcher.

Occasionally, you’ll inherit a child who’s already had one or two unsuccessful attempts. Maybe the parents tried at home, maybe the pediatrician tried, maybe another emergency department tried. Every failed attempt makes the next one more difficult. If you’re not making progress, ask yourself, “Am I pulling in the right direction? Do I actually know where the backing is, or am I just fishing for it? Would a tiny posterior incision solve this? Do I need another pair of hands or somebody more experienced?”

Most of the time, changing your approach works better than just yanking harder. Once the earring’s out, I always look at both pieces. Is the backing intact? Is the decorative front intact? Is the post complete?

If something doesn’t look right, especially when you compare it, hopefully, to the other earring that they brought or at least a picture of it, I’ll go back and explore the wound. The last thing you want to do is leave a small piece of metal behind. Once I know everything is out, I put the earring and the backing into a specimen cup and hand it back to the family.

They almost always appreciate getting the jewelry back, especially if it has sentimental value. Then I’ll irrigate the wound with about one hundred to two hundred milliliters of saline. I’m not trying to pressure irrigate it like a contaminated laceration. I just want to wash away dry drainage, debris, and any small blood clots around the piercing tract.

After that, I make sure the bleeding is stopped and that the earlobe still has good color and perfusion before the child leaves. One other question that comes up pretty often, should you close the incision? Most of the time, I don’t. These are really small incisions, usually only a millimeter or two, and it’s okay to allow them to heal by secondary intention.

If there’s any contamination or early infection, I don’t want to trap that underneath a closed wound. Every once in a while, though, I’ll have to make a larger incision, maybe because the backing was deeply embedded or it’s larger or the tissue was particularly swollen. If that incision is more than two or three millimeters, I’ll have a conversation with the family about the trade-off between cosmesis and infection risk.

In some of those cases, I’ll loosely approximate the incision with one or two absorbable sutures, something like 5-0 fast-absorbing gut. If I do that, I’ll only close the incision I created. I still leave the original piercing tract open because I want any residual pus to have somewhere to go. That’s also one of the advantages of making the incision on the back of the earlobe.

If you decide to leave it open or even if you only loosely close part of it, any resulting scar is usually much less noticeable than it would be on the front. Whether I suture or not, I make sure we’ve got good hemostasis and that the earlobe still has good color and perfusion, and then I’ll put some antibiotic ointment and a bandage on it and call it a day.

Honestly, if there’s no cellulitis, no abscess, and the child is otherwise healthy, I generally don’t prescribe oral antibiotics. Topical antibiotic ointment and routine wound care are usually enough. Redness by itself does not equal infection. These ears are inflamed and swollen simply because the earring has been buried in the tissue.

If there’s expanding cellulitis, significant purulent drainage, an associated abscess, fever, or if the child is immunocompromised or has something like diabetes, then I’ll start some oral antibiotics. My first choice is usually cephalexin because these are uncomplicated skin and soft tissue infections caused by methicillin-sensitive staph or streptococci that cause common skin infections.

If the kid has a history of MRSA, there’s a high local prevalence of community-associated MRSA, the family’s had MRSA, or the infection is frankly purulent, then I’ll switch to clindamycin or trimethoprim-sulfamethoxazole, depending on local resistance patterns.

Let’s come back to cartilage one more time.

There, you’re primarily worried about perichondritis, where Pseudomonas aeruginosa is the major pathogen. These patients usually warrant ENT involvement, and antibiotic selection changes substantially, often requiring antipseudomonal coverage. That’s a separate entity from the routine embedded earlobe earring.

Families will also ask, “Can we just put it back in?” Eh, not so fast, right? That piercing tract isn’t really a piercing anymore. It’s a wound. Let it heal completely. If they decide to pierce it again, I’d recommend choosing a slightly different location once everything is healed. You should also talk to families about how to keep this from happening again.

Most of the time, this isn’t because the family did something wrong. Sometimes it just happened. But there are a few things that probably would help. Avoid spring-loaded piercing guns if possible. Don’t clamp the backing tightly against the earlobe. Leave just a little room for swelling. Keep new piercings clean while they’re healing.

And if they notice the backing start disappearing beneath the skin, don’t wait several days hoping the swelling will go down and it’ll just work itself out. These are much easier to remove when they’re only partially embedded than when the skin has completely grown over the hardware.

All right, a few take-home points.

First, figure out which part of the earring is actually embedded before you start yanking on anything. Give your local anesthetic, lido with epi, time to work. I usually wait at least five minutes, but more often seven to ten. And most uncomplicated earlobe piercings don’t need oral antibiotics after removal.

And again, this was really an episode about earlobe embedded earrings. If you’re dealing with cartilaginous piercings that get stuck or infected, think Pseudomonas, think perichondritis, and early ENT involvement.

Honestly, I really enjoy this procedure. It’s quick, it’s satisfying, and families are incredibly appreciative when you’re done. The ear looked terrible when they walked in, they thought their child might need surgery, and then 15 minutes later, they’re walking out with a Band-Aid, their earring in a specimen cup, and the popsicle color of their choice.

These are the fun procedures. So I hope you enjoyed this installment in our minor procedures series.

I’ve already got several more procedures on my list, and I’ll be working through them over time. If there’s one that you’d like me to cover, let me know. As the kids would say, like, rate, and review. If you leave a review on your favorite podcast platform, it really does help other clinicians discover the show, which I appreciate because it helps teach more people good stuff.

For PEM Currents: The Pediatric Emergency Medicine Podcast, this has been Brad Sobolewski. See you next time.