A living foreign body in the external auditory canal of a 65-year-old patient at the Buea Regional Hospital, Cameroon: A case report

A living foreign body in the external auditory canal of a 65-year-old patient at the Buea Regional Hospital, Cameroon: A case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF comment A living foreign body in the external auditory canal of a 65-year-old patient at the Buea Regional Hospital, Cameroon: A case report Christian Damien Tchuisseu Ngapjang, Emmanuel Choffor Nchinda, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7716464/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Foreign bodies (FBs) in the ear, nose, and throat (ENT) are frequently encountered in emergency departments (EDs), particularly in pediatric populations. In adults, common aural FBs include cerumen impactions, cotton swab remnants, and, less frequently, live insects. Case: We present a case of a 65-year-old female who was rushed to the ED of Buea Regional Hospital with acute-onset left otalgia with intermittent paroxysms every 20-30 seconds, anxiety, and abnormal behavior. Otoscopic examination revealed a live insect within the left external auditory canal (EAC), later identified as a cockroach. Immediate extraction with forceps followed by EAC irrigation resulted in complete symptom resolution. The patient was discharged with recommendations for household pest control. This report highlights the appropriate management of live aural FBs and underscores the public health implications of domestic cockroach infestations. Conclusion: This case underscores the urgency of removing live external auditory canal foreign bodies, especially cockroaches which cause acute severe distress. The standard approach recommends immobilization prior to extraction while assessing tympanic integrity. Immediate extraction should be prioritized only in situations of severe distress. Public health measures prevent recurrence. Resource-limited settings may utilize adapted techniques (e.g., standard forceps) effectively when specialist care is inaccessible. Foreign body ear cockroach living insect public health Figures Figure 1 Figure 2 Introduction Foreign bodies represent a frequent presentation in the Emergency Department (ED), particularly within Ear, Nose, and Throat (ENT) emergencies. These cases often constitute a profoundly stressful experience for patients, caregivers, and occasionally the entire emergency room staff, depending on the nature and location of the foreign body. While the literature emphasizes the high prevalence of foreign bodies in pediatric populations, numerous cases have been reported in adolescents and adults. In adult populations, aural foreign bodies most commonly consist of cerumen impactions, cotton wool remnants, or other materials inserted for ear cleaning [1]. Less frequently, live insects may become lodged in the external auditory canal (EAC), often producing particularly distressing symptoms due to the audible noise and mechanical irritation caused by their movement within the confined space [2]. Among insect-related foreign bodies, cockroaches (Order: Blattodea) appear to be the most frequently reported [3]. The management of such ENT foreign bodies requires clinical experience, sound judgment, and excellent patient-provider communication. During extraction procedures, maintaining a calm demeanor, providing adequate reassurance, demonstrating precise technique, and possessing good manual dexterity are all critical determinants of successful outcomes [4]. We present a case of a large cockroach lodged in the left EAC of a 65-year-old female patient at Buea Regional Hospital in Cameroon. Case Report A 65-year-old female was rushed into the Emergency Department of Regional Hospital of Buea with acute-onset left otalgia. The symptoms developed abruptly at approximately midnight, 30 minutes after sleep onset, compelling the patient to awaken. The pain was characterized by severe intensity with superimposed paroxysmal exacerbations occurring at 20–30 second intervals, accompanied by ipsilateral tinnitus. The patient exhibited marked distress manifesting as vocalizations, psychomotor agitation, and disorganized behavior. Initial assessment revealed no significant medical history or predisposing psychological factors that might account for the acute behavioral manifestations. Otoscopic examination identified complete obstruction of the left external auditory canal by a mobile insect. Following appropriate patient stabilization and reassurance, the foreign body was successfully extracted using non-toothed dissecting forceps ( Fig. 1 ) , yielding a large adult cockroach (Blattodea order) measuring approximately 2 cm in length ( Fig. 2 , Video 1). Immediate post-procedural resolution of all symptoms was observed, with rapid normalization of the patient's affect and behavior. Post-extraction otoscopic reevaluation revealed residual insect debris in the left external auditory canal. Complete removal was achieved through therapeutic irrigation using normal saline at body temperature. The contralateral ear was examined, demonstrating normal anatomical findings. The patient was discharged with a prescription for paracetamol (1000 mg every 8 hours as needed for analgesia over 48 hours) and detailed discharge counseling emphasizing environmental hygiene measures, including proper sanitation practices and appropriate application of insect repellents to eliminate household infestations and prevent recurrence. At the 48-hour follow-up evaluation, the patient reported complete resolution of symptoms, with otoscopic examination revealing no evidence of inflammation or other abnormalities; physical examination remained unremarkable, and preventive hygiene measures were reiterated to ensure long-term prevention. Discussion Foreign body impaction in the ENT tract represents a frequent emergency presentation, with epidemiological studies by Adedeji et al. (2016) [5] demonstrating that insects - particularly cockroaches (Blattodea) - constitute the predominant foreign bodies in adult populations, a finding consistent with our case. Current management protocols describe multiple extraction modalities, with irrigation being the most commonly employed technique. Instrumental approaches utilizing forceps, hooks, or suction devices represent viable alternatives, while for live insects, initial immobilization through instillation of lidocaine or mineral oil followed by irrigation is widely recommended [6–8]. Our case presented several unique management considerations: Resource-limited setting : The procedure was successfully performed by emergency physicians without otolaryngology specialist support Equipment adaptation : Standard dressing forceps were effectively utilized despite not being specialized otologic instruments Technique modification : The conventional drowning protocol was omitted due to: the patient's extreme distress and pain severity, and also potential tympanic membrane compromise requiring verification. Attempting extraction of a struggling living foreign body like this was also risky, exposing the patient to significant harm to the external auditory canal and even to the tympanic membrane, including abrasions, lacerations, tympanic membrane perforation [9, 10]. Sequential approach : Direct mechanical extraction preceded irrigation, with tympanic membrane integrity confirmed prior to syringing. The patient was not sedated prior to the procedure because despite the intermittent agitation due to the cockroach movements, the patient was very cooperative, and the foreign body seemed easily graspable [11, 12]. This case highlights both the adaptability required in emergency ENT management and the importance of tailoring techniques to individual patient circumstances and available resources. Following extraction, otolaryngology consultation was arranged for comprehensive evaluation and specialist recommendations. Post-procedural otoscopy revealed no evidence of traumatic lesions or tissue damage in the external auditory canal, suggesting the patient's reported pain likely represented neurogenic discomfort secondary to mechanical irritation from the insect's movement rather than true somatic injury. This clinical presentation aligns with the International Association for the Study of Pain (IASP) classification of emotionally-mediated nociceptive responses [13], where psychological distress amplifies the perception of physical stimuli. The absence of visible pathology supported this interpretation, with the acute symptoms resolving immediately upon foreign body removal. This clinical presentation serves as an important sentinel event, indicating probable cockroach infestation in the patient's domestic environment, a significant public health concern. As nocturnal scavengers, cockroaches (Order: Blattodea) thrive on human organic waste and household debris [14]. Consequently, they are vectors of multiple bacteria, viruses, parasites and even fungi [15, 16]. Those cockroaches contaminate food by the pathogens that they transport and can also cause food poisoning [17]. In addition, many studies have proven cockroach sensitization as is an important risk factor for the development of asthma. [18, 19]. Given these substantial health risks, it was important to encourage the patient to actively fight the situation by planning and executing series of disinfestations in her household (regular targeted disinfestation protocols, proper food storage practices, structural pest-proofing measures, waste management optimization etc…). This multifaceted approach addresses both immediate infestation control and long-term prevention strategies. Conclusion The presence of a living foreign body in the external auditory canal constitutes a profoundly distressing otologic emergency. The intermittent budging of the insect triggers an unbearable type of pain and discomfort to the patient. Efficient management should encompass safe extraction, cleaning, as well as the patient counselling on good health measures and household disinfestation. Declarations Ethic consent : In accordance with the Declaration of Helsinki, Verbal informed consent was obtained from the patient of which the anonymity was preserved, and the ethical clearance was obtained from Buea Regional Hospital. Competing interests : The authors declare that they have no competing interests. Authors’ contributions: All the authors contributed to the design of the manuscript, extraction of data, literature review. They all approved the final version of the manuscript. Funding Declaration: This scientific work received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Acknowledgements: The contribution of the medical staff of Buea Regional Hospital is acknowledged. References Dadá MSAC, Lay WY, Dadá ZMS, Dadá AHM. Foreign bodies in otorhinolaryngology among teenagers and adults observed in reference hospital in Mozambique. Brazilian Journal of Clinical Medicine and Review. 2024 Jul-Sep;02(3):12-21 Kroukamp G, Londt JGH. Ear-invading arthropods: a South African survey. S Afr Med J. 2006;96(4):290–292. Antonelli PJ, Ahmadi A, Prevatt A. Insecticidal activity of common reagents for insect foreign bodies of the ear. Laryngoscope 2001;111:15-20. Yadav R, Yadav DK. Foreign Bodies in Ear:s A Descriptive Study. Indian J Otolaryngol Head Neck Surg. 2022 Dec;74(Suppl 3):4077-4080. doi: 10.1007/s12070-021-02826-z. Epub 2021 Aug 25. PMID: 36742603; PMCID: PMC9895142. Adedeji TO, Sogebi OA, Bande S. Clinical spectrum of ear, nose and throat foreign bodies in North Western Nigeria. Afr Health Sci. 2016 Mar;16(1):292-7. doi: 10.4314/ahs.v16i1.38. PMID: 27358644; PMCID: PMC4915433. Fasunla J, Ibekwe T, Adeosun A: Preventable Risks in the Management of Aural Foreign Bodies in Western Nigeria. The Internet Journal of Otorhinolaryngology. 2007 7(1). DOI: 10.5580/18fe Ette VF. Pattern of Ear, Nose and Throat Foreign Bodies seen in Uyo Nigeria. Ibom Medical Journal. 2012; 5(1). DOI: 41.203.67.54 Ogunleye AOA, Sogebi ROA. Otic foreign bodies in children in Ibadan, Nigeria. Nigerian Journal of Surgical Research 2005; 7(3): 305-308 Lotterman S, Sutton AE, Hohman MH. Ear Foreign Body Removal. [Updated 2025 Jan 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459136/ Olajuyin O, Olatunya OS. Aural foreign body extraction in children: a double-edged sword. Pan Afr Med J. 2015;20:186. Published 2015 Feb 27. doi:10.11604/pamj.2015.20.186.5218 Mingo K, Eleff D, Anne S, Osborne K. Pediatric ear foreign body retrieval: A comparison across specialties. Am J Otolaryngol. 2020 Mar-Apr. 41 (2):102167. Kwong A O-K, Provataris J, Meyers A. (Updated Aug 08, 2023). Ear Foreign Body Removal Procedures. Consulted on Medscape on September 24 th , 2025. Available at: https://emedicine.medscape.com/article/80507-overview#a1 Raja, S. N., Carr, D. B., Cohen, M., Finnerup, N. B., Flor, H., Gibson, S., Keefe, F. J., Mogil, J. S., Ringkamp, M., Sluka, K. A., Song, X. J., Stevens, B., Sullivan, M. D., Tutelman, P. R., Ushida, T., & Vader, K. (2020). The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain, 161(9), 1976–1982. https://doi.org/10.1097/j.pain.0000000000001939 Uçkay I., Sax H., Pietro S. L.-D., et al. Cockroaches (Ectobius vittiventris) in an intensive care unit, Switzerland. Emerging Infectious Diseases. 2009;15(3):496–497. doi: 10.3201/eid1503.071484 Solomon, F., Belayneh, F., Kibru, G. & Ali, S. Vector potential of Blattella germanica (L.) (Dictyoptera: Blattidae) for medically important bacteria at food handling establishments in Jimma town Southwest, Ethiopia. Biomed. Res. Int. 2016 , 3490906. https://doi.org/10.1155/2016/3490906 (2016). Atiokeng Tatang RJ, Tsila HG, Wabo Poné J. Medically Important Parasites Carried by Cockroaches in Melong Subdivision, Littoral, Cameroon. J Parasitol Res. 2017;2017:7967325. doi: 10.1155/2017/7967325. Epub 2017 Aug 20. PMID: 28912965; PMCID: PMC5585542. Adenusi, A. A., Akinyemi, M. I. & Akinsanya, D. Domiciliary cockroaches as carriers of human intestinal parasites in lagos metropolis, Southwest Nigeria: Implications for public health. J. Arthropod-Borne Dis. 12 , 141–151 (2018). Tatfeng Y. M., Usuanlele M. U., Orukpe A., et al. Mechanical transmission of pathogenic organisms: the role of cockroaches. Journal of Vector Borne Diseases. 2005;42(4):129–134 Do DC, Zhao Y, Gao P. Cockroach allergen exposure and risk of asthma. Allergy. 2016 Apr;71(4):463-74. doi: 10.1111/all.12827. Epub 2016 Feb 4. PMID: 26706467; PMCID: PMC4803579. Additional Declarations No competing interests reported. Supplementary Files Video1LivingCockroachintheEACCopie.mov Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7716464","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"comment","associatedPublications":[],"authors":[{"id":525117812,"identity":"e5744516-5413-4bdf-825e-a197b6ff81c4","order_by":0,"name":"Christian Damien Tchuisseu 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Cameroon\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7716464/v1/93581eb3b6f6f3ffbb978bf0.jpg"},{"id":93025072,"identity":"39b9b0dc-2a24-4fac-8afc-ef0574f4e693","added_by":"auto","created_at":"2025-10-08 09:22:20","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":77837,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eA large adult cockroach (Blattodea order) measuring approximately 2 cm in length, extracted from the left external auditory canal of a 65-year-old patient at Buea Regional Hospital, Cameroon\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7716464/v1/227dcbe3e0b023674f2fae4a.jpg"},{"id":93027121,"identity":"03c25836-f7d6-4a05-9a88-97cf2c5ff2bd","added_by":"auto","created_at":"2025-10-08 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report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eForeign bodies represent a frequent presentation in the Emergency Department (ED), particularly within Ear, Nose, and Throat (ENT) emergencies. These cases often constitute a profoundly stressful experience for patients, caregivers, and occasionally the entire emergency room staff, depending on the nature and location of the foreign body. While the literature emphasizes the high prevalence of foreign bodies in pediatric populations, numerous cases have been reported in adolescents and adults. In adult populations, aural foreign bodies most commonly consist of cerumen impactions, cotton wool remnants, or other materials inserted for ear cleaning [1]. Less frequently, live insects may become lodged in the external auditory canal (EAC), often producing particularly distressing symptoms due to the audible noise and mechanical irritation caused by their movement within the confined space [2]. Among insect-related foreign bodies, cockroaches (Order: Blattodea) appear to be the most frequently reported [3]. The management of such ENT foreign bodies requires clinical experience, sound judgment, and excellent patient-provider communication. During extraction procedures, maintaining a calm demeanor, providing adequate reassurance, demonstrating precise technique, and possessing good manual dexterity are all critical determinants of successful outcomes [4]. We present a case of a large cockroach lodged in the left EAC of a 65-year-old female patient at Buea Regional Hospital in Cameroon.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eA 65-year-old female was rushed into the Emergency Department of Regional Hospital of Buea with acute-onset left otalgia. The symptoms developed abruptly at approximately midnight, 30 minutes after sleep onset, compelling the patient to awaken. The pain was characterized by severe intensity with superimposed paroxysmal exacerbations occurring at 20\u0026ndash;30 second intervals, accompanied by ipsilateral tinnitus. The patient exhibited marked distress manifesting as vocalizations, psychomotor agitation, and disorganized behavior. Initial assessment revealed no significant medical history or predisposing psychological factors that might account for the acute behavioral manifestations. Otoscopic examination identified complete obstruction of the left external auditory canal by a mobile insect. Following appropriate patient stabilization and reassurance, the foreign body was successfully extracted using non-toothed dissecting forceps \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e, yielding a large adult cockroach (Blattodea order) measuring approximately 2 cm in length \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cb\u003eVideo 1).\u003c/b\u003e Immediate post-procedural resolution of all symptoms was observed, with rapid normalization of the patient's affect and behavior.\u003c/p\u003e\u003cp\u003ePost-extraction otoscopic reevaluation revealed residual insect debris in the left external auditory canal. Complete removal was achieved through therapeutic irrigation using normal saline at body temperature. The contralateral ear was examined, demonstrating normal anatomical findings.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe patient was discharged with a prescription for paracetamol (1000 mg every 8 hours as needed for analgesia over 48 hours) and detailed discharge counseling emphasizing environmental hygiene measures, including proper sanitation practices and appropriate application of insect repellents to eliminate household infestations and prevent recurrence. At the 48-hour follow-up evaluation, the patient reported complete resolution of symptoms, with otoscopic examination revealing no evidence of inflammation or other abnormalities; physical examination remained unremarkable, and preventive hygiene measures were reiterated to ensure long-term prevention.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eForeign body impaction in the ENT tract represents a frequent emergency presentation, with epidemiological studies by Adedeji et al. (2016) [5] demonstrating that insects - particularly cockroaches (Blattodea) - constitute the predominant foreign bodies in adult populations, a finding consistent with our case. Current management protocols describe multiple extraction modalities, with irrigation being the most commonly employed technique. Instrumental approaches utilizing forceps, hooks, or suction devices represent viable alternatives, while for live insects, initial immobilization through instillation of lidocaine or mineral oil followed by irrigation is widely recommended [6\u0026ndash;8].\u003c/p\u003e\u003cp\u003eOur case presented several unique management considerations:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eResource-limited setting\u003c/b\u003e: The procedure was successfully performed by emergency physicians without otolaryngology specialist support\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eEquipment adaptation\u003c/b\u003e: Standard dressing forceps were effectively utilized despite not being specialized otologic instruments\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eTechnique modification\u003c/b\u003e: The conventional drowning protocol was omitted due to: the patient's extreme distress and pain severity, and also potential tympanic membrane compromise requiring verification. Attempting extraction of a struggling living foreign body like this was also risky, exposing the patient to significant harm to the external auditory canal and even to the tympanic membrane, including abrasions, lacerations, tympanic membrane perforation [9, 10].\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSequential approach\u003c/b\u003e: Direct mechanical extraction preceded irrigation, with tympanic membrane integrity confirmed prior to syringing. The patient was not sedated prior to the procedure because despite the intermittent agitation due to the cockroach movements, the patient was very cooperative, and the foreign body seemed easily graspable [11, 12].\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThis case highlights both the adaptability required in emergency ENT management and the importance of tailoring techniques to individual patient circumstances and available resources.\u003c/p\u003e\u003cp\u003eFollowing extraction, otolaryngology consultation was arranged for comprehensive evaluation and specialist recommendations. Post-procedural otoscopy revealed no evidence of traumatic lesions or tissue damage in the external auditory canal, suggesting the patient's reported pain likely represented neurogenic discomfort secondary to mechanical irritation from the insect's movement rather than true somatic injury. This clinical presentation aligns with the International Association for the Study of Pain (IASP) classification of emotionally-mediated nociceptive responses [13], where psychological distress amplifies the perception of physical stimuli. The absence of visible pathology supported this interpretation, with the acute symptoms resolving immediately upon foreign body removal.\u003c/p\u003e\u003cp\u003eThis clinical presentation serves as an important sentinel event, indicating probable cockroach infestation in the patient's domestic environment, a significant public health concern. As nocturnal scavengers, cockroaches (Order: Blattodea) thrive on human organic waste and household debris [14]. Consequently, they are vectors of multiple bacteria, viruses, parasites and even fungi [15, 16]. Those cockroaches contaminate food by the pathogens that they transport and can also cause food poisoning [17]. In addition, many studies have proven cockroach sensitization as is an important risk factor for the development of asthma. [18, 19]. Given these substantial health risks, it was important to encourage the patient to actively fight the situation by planning and executing series of disinfestations in her household (regular targeted disinfestation protocols, proper food storage practices, structural pest-proofing measures, waste management optimization etc\u0026hellip;). This multifaceted approach addresses both immediate infestation control and long-term prevention strategies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe presence of a living foreign body in the external auditory canal constitutes a profoundly distressing otologic emergency. The intermittent budging of the insect triggers an unbearable type of pain and discomfort to the patient. Efficient management should encompass safe extraction, cleaning, as well as the patient counselling on good health measures and household disinfestation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eEthic consent\u003c/u\u003e\u003c/strong\u003e\u003cu\u003e:\u003c/u\u003e In accordance with the Declaration of Helsinki, Verbal informed consent was obtained from the patient of which the anonymity was preserved, and the ethical clearance was obtained from Buea Regional Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eCompeting interests\u003c/u\u003e\u003c/strong\u003e\u003cu\u003e:\u003c/u\u003e The authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAuthors’ contributions:\u003c/u\u003e\u003c/strong\u003e All the authors contributed to the design of the manuscript, extraction of data, literature review. They all approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFunding Declaration:\u003c/u\u003e\u003c/strong\u003e This scientific work received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAcknowledgements:\u003c/u\u003e\u003c/strong\u003e The contribution of the medical staff of Buea Regional Hospital is acknowledged.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDad\u0026aacute; MSAC, Lay WY, Dad\u0026aacute; ZMS, Dad\u0026aacute; AHM. Foreign bodies in otorhinolaryngology among teenagers and adults observed in reference hospital in Mozambique. Brazilian Journal of Clinical Medicine and Review. 2024 Jul-Sep;02(3):12-21\u003c/li\u003e\n\u003cli\u003eKroukamp G, Londt JGH. Ear-invading arthropods: a South African survey. S Afr Med J. 2006;96(4):290\u0026ndash;292.\u003c/li\u003e\n\u003cli\u003eAntonelli PJ, Ahmadi A, Prevatt A. Insecticidal activity of common reagents for insect foreign bodies of the ear. Laryngoscope 2001;111:15-20.\u003c/li\u003e\n\u003cli\u003eYadav R, Yadav DK. Foreign Bodies in Ear:s A Descriptive Study. Indian J Otolaryngol Head Neck Surg. 2022 Dec;74(Suppl 3):4077-4080. doi: 10.1007/s12070-021-02826-z. Epub 2021 Aug 25. PMID: 36742603; PMCID: PMC9895142.\u003c/li\u003e\n\u003cli\u003eAdedeji TO, Sogebi OA, Bande S. Clinical spectrum of ear, nose and throat foreign bodies in North Western Nigeria. Afr Health Sci. 2016 Mar;16(1):292-7. doi: 10.4314/ahs.v16i1.38. PMID: 27358644; PMCID: PMC4915433.\u003c/li\u003e\n\u003cli\u003eFasunla J, Ibekwe T, Adeosun A: Preventable Risks in the Management of Aural Foreign Bodies in Western Nigeria. The Internet Journal of Otorhinolaryngology. 2007 7(1). DOI: 10.5580/18fe \u003c/li\u003e\n\u003cli\u003eEtte VF. Pattern of Ear, Nose and Throat Foreign Bodies seen in Uyo Nigeria. Ibom Medical Journal. 2012; 5(1). DOI: 41.203.67.54 \u003c/li\u003e\n\u003cli\u003eOgunleye AOA, Sogebi ROA. Otic foreign bodies in children in Ibadan, Nigeria. Nigerian Journal of Surgical Research 2005; 7(3): 305-308\u003c/li\u003e\n\u003cli\u003eLotterman S, Sutton AE, Hohman MH. Ear Foreign Body Removal. [Updated 2025 Jan 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459136/\u003c/li\u003e\n\u003cli\u003eOlajuyin O, Olatunya OS. Aural foreign body extraction in children: a double-edged sword. Pan Afr Med J. 2015;20:186. Published 2015 Feb 27. doi:10.11604/pamj.2015.20.186.5218 \u003c/li\u003e\n\u003cli\u003eMingo K, Eleff D, Anne S, Osborne K. Pediatric ear foreign body retrieval: A comparison across specialties. Am J Otolaryngol. 2020 Mar-Apr. 41 (2):102167.\u003c/li\u003e\n\u003cli\u003eKwong A O-K, Provataris J, Meyers A. (Updated Aug 08, 2023). Ear Foreign Body Removal Procedures. Consulted on Medscape on September 24\u003csup\u003eth\u003c/sup\u003e, 2025. Available at: https://emedicine.medscape.com/article/80507-overview#a1 \u003c/li\u003e\n\u003cli\u003eRaja, S. N., Carr, D. B., Cohen, M., Finnerup, N. B., Flor, H., Gibson, S., Keefe, F. J., Mogil, J. S., Ringkamp, M., Sluka, K. A., Song, X. J., Stevens, B., Sullivan, M. D., Tutelman, P. R., Ushida, T., \u0026amp; Vader, K. (2020). The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain, 161(9), 1976\u0026ndash;1982. https://doi.org/10.1097/j.pain.0000000000001939 \u003c/li\u003e\n\u003cli\u003eU\u0026ccedil;kay I., Sax H., Pietro S. L.-D., et al. Cockroaches (Ectobius vittiventris) in an intensive care unit, Switzerland. Emerging Infectious Diseases. 2009;15(3):496\u0026ndash;497. doi: 10.3201/eid1503.071484\u003c/li\u003e\n\u003cli\u003eSolomon, F., Belayneh, F., Kibru, G. \u0026amp; Ali, S. Vector potential of \u003cem\u003eBlattella germanica\u003c/em\u003e (L.) (Dictyoptera: Blattidae) for medically important bacteria at food handling establishments in Jimma town Southwest, Ethiopia. \u003cem\u003eBiomed. Res. Int.\u003c/em\u003e \u003cstrong\u003e2016\u003c/strong\u003e, 3490906. https://doi.org/10.1155/2016/3490906 (2016).\u003c/li\u003e\n\u003cli\u003eAtiokeng Tatang RJ, Tsila HG, Wabo Pon\u0026eacute; J. Medically Important Parasites Carried by Cockroaches in Melong Subdivision, Littoral, Cameroon. J Parasitol Res. 2017;2017:7967325. doi: 10.1155/2017/7967325. Epub 2017 Aug 20. PMID: 28912965; PMCID: PMC5585542.\u003c/li\u003e\n\u003cli\u003eAdenusi, A. A., Akinyemi, M. I. \u0026amp; Akinsanya, D. Domiciliary cockroaches as carriers of human intestinal parasites in lagos metropolis, Southwest Nigeria: Implications for public health. \u003cem\u003eJ. Arthropod-Borne Dis.\u003c/em\u003e \u003cstrong\u003e12\u003c/strong\u003e, 141\u0026ndash;151 (2018).\u003c/li\u003e\n\u003cli\u003eTatfeng Y. M., Usuanlele M. U., Orukpe A., et al. Mechanical transmission of pathogenic organisms: the role of cockroaches. Journal of Vector Borne Diseases. 2005;42(4):129\u0026ndash;134\u003c/li\u003e\n\u003cli\u003eDo DC, Zhao Y, Gao P. Cockroach allergen exposure and risk of asthma. Allergy. 2016 Apr;71(4):463-74. doi: 10.1111/all.12827. Epub 2016 Feb 4. PMID: 26706467; PMCID: PMC4803579.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Foreign body, ear, cockroach, living insect, public health","lastPublishedDoi":"10.21203/rs.3.rs-7716464/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7716464/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction: \u003c/strong\u003eForeign bodies (FBs) in the ear, nose, and throat (ENT) are frequently encountered in emergency departments (EDs), particularly in pediatric populations. In adults, common aural FBs include cerumen impactions, cotton swab remnants, and, less frequently, live insects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase: \u003c/strong\u003eWe present a case of a 65-year-old female who was rushed to the ED of Buea Regional Hospital with acute-onset left otalgia with intermittent paroxysms every 20-30 seconds, anxiety, and abnormal behavior. Otoscopic examination revealed a live insect within the left external auditory canal (EAC), later identified as a cockroach. Immediate extraction with forceps followed by EAC irrigation resulted in complete symptom resolution. The patient was discharged with recommendations for household pest control. This report highlights the appropriate management of live aural FBs and underscores the public health implications of domestic cockroach infestations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThis case underscores the urgency of removing live external auditory canal foreign bodies, especially cockroaches which cause acute severe distress. The standard approach recommends immobilization prior to extraction while assessing tympanic integrity. Immediate extraction should be prioritized only in situations of severe distress. Public health measures prevent recurrence. Resource-limited settings may utilize adapted techniques (e.g., standard forceps) effectively when specialist care is inaccessible.\u003c/p\u003e","manuscriptTitle":"A living foreign body in the external auditory canal of a 65-year-old patient at the Buea Regional Hospital, Cameroon: A case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-08 09:14:15","doi":"10.21203/rs.3.rs-7716464/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2505e0f5-4daa-4e5e-92dd-689d5a90660b","owner":[],"postedDate":"October 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-08T09:14:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-08 09:14:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7716464","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7716464","identity":"rs-7716464","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}