A 15-year-old girl presented to the urgent care clinic complaining of hearing loss and a foul odor emanating from her left ear that had been present for 24 hours. She explains that she has just returned from a week-long trip to Florida where she participated in outdoor service projects. On the last day of the trip, the group visited the beach before the long bus ride home.

The patient describes taking part in typical beach activities such as swimming (including doing handstands in the water) and sunbathing. She recalls noticing many small, minnow-type fish in the shallow area of the water, and after getting out of the water, a minnow fell out of her left ear. The patient immediately noticed her hearing was muffled in that ear and assumed it was clogged with water. She attempted to dislodge the water but was unsuccessful. The patient was told by her counselor to sleep with her left ear down on the pillow to facilitate drainage of the water.

After an 8-hour bus ride home, the patient still could not hear out of the ear and said that she felt as if something was stuck. At this time, the patient noticed a foul smell coming from the ear.

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On examination, I found that the patient’s vital signs are normal: temperature of 98.7 °F, heart rate is 72 beats per minute, a respiratory rate of 16 breaths per minute, blood pressure of 116/68 mm Hg, and oxygen saturation of 95% on room air. Save for her hearing loss in the left ear, all other assessment findings are within normal limits. Foul odor was detected from the left ear, but no additional signs of drainage were noted.

After reviewing the history of events that led to her ear blockage, I examined her ear using an otoscope. The right ear had good visualization of landmarks without any redness, drainage, pain, or loss of hearing. The left ear canal displayed erythema, edema, and a shiny, silver object blocking the canal without drainage. I also noticed a foul, fishy odor coming from the left ear.

I tilted her head slightly toward the left shoulder and, using a warm water lavage, dislodged the object, which was an intact, small, dead minnow (Image).  The patient instantly cried out, “I can hear!” Another warm water lavage is applied and an examination of the left ear is conducted. The foul odor remains, although diminished, as well as the erythema and edema, but now the tympanic membrane can be visualized and is intact.

I prescribed polymyxin B/neomycin/hydrocortisone otic suspension (3 drops) to be administered into the ear 3 to 4 times per day for 7 days. I recommended that she refrain from swimming in a pool for 3 to 4 days, allowing the antibiotic drops time to take effect.  

The patient asked if she could have the fish, so I placed it in a specimen cup and gave it to her. I checked in on her a few days later and her prognosis was good: no fever, no further loss of hearing, no drainage from the ear, and no trace of odor.

Susan C Davidson, EdD, APRN, NP-C, is a  practicing family nurse practitioner and a coordinator for the Gateway RN-BSN Program at the University of Tennessee at Chattanooga School of Nursing.