Sedation-Assisted, Non-sedated, and Escalated Removal of Pediatric ENT Foreign Bodies in Emergency Settings: A Systematic Review.

Pediatric ear, nose, and throat (ENT) foreign bodies are among the most common procedural challenges in emergency medicine. Substantial uncertainty exists regarding the optimal approach to removal, including sedation-assisted versus non-sedated techniques, and the appropriate thresholds for escalation to otolaryngology or the operating room. A systematic literature search was conducted in PubMed, the Cochrane Library, Web of Science, and Scopus (search date: June 2026). Studies were included if they reported outcomes of ENT foreign body removal in pediatric or predominantly pediatric emergency and acute care settings. Risk of bias was assessed using domain-specific methodological appraisal. Meta-analysis was not performed because of substantial clinical and methodological heterogeneity. Eight studies published between 2004 and 2022 were included from the United States, Singapore, Australia, and Israel, representing 2,332 patients and 2,336 removal attempts or study-level encounters. The difference reflects one study that reported 254 removal attempts involving 250 children. Removal success varied according to clinical setting and case complexity. In one pediatric ED cohort, successful removal was achieved in 204/254 (80.3%) ear foreign body attempts, while another study reported first-attempt success of 82.4% for pediatric emergency physicians and 96.1% for ENT physicians. Sedation was used in 1/254 (0.4%) to 71/312 (22.8%) of cases and was generally reserved for difficult or uncooperative patients or after failed non-sedated attempts, precluding causal comparison between strategies. Reported complication rates varied substantially because of differences in definitions and patient selection; one study reported complications in 30/254 (11.8%) cases, whereas another reported complications in 40/380 (10.5%), including tympanic membrane perforation in 1/380 (0.3%). Referral and escalation also varied according to clinical setting and case complexity. In one study, 38/275 (13.8%) patients were referred to ENT after previous removal attempts, while in another study, 44.8% were referred to an ENT clinic for further assessment. In one study, operative intervention was required in 2/44 (4.6%) patients initially managed by ENT and 13/38 (34.2%) patients referred to ENT after previous unsuccessful attempts; whereas in another study, 51/380 (13.4%) underwent removal in the operating theatre under general anaesthesia. ED procedural sedation demonstrated a safety profile comparable to operating-room management while substantially reducing costs. Repeated removal attempts and difficult foreign body characteristics were consistently associated with failure, complications, or escalation of care. Overall, emergency physicians can successfully remove most pediatric ear and nasal foreign bodies, although success varies substantially according to clinical setting and case complexity. Sedation appears to be a useful escalation strategy for uncooperative children or after failed initial attempts, although current evidence does not support a causal comparison with non-sedated approaches. Early otolaryngology referral is appropriate after failed attempts, for difficult foreign bodies, suspected tympanic membrane involvement, or button battery exposure. High-quality prospective comparative studies using standardized outcome definitions are needed to strengthen the evidence base.