To the Editor: A recent case seen in an emergency department of a large urban hospital may have finally settled the tormenting and age-old question concerning the best method of removing Periplaneta americana, the common cockroach, from the ear canal. Numerous methods have been described in the medical literature, the most popular of which appears to be placement of mineral oil in the canal and subsequent manual removal of the creature. More recently, lidocaine spray has been suggested as a more effective approach to this problem.

A patient recently presented with a cockroach in both ears. The history was otherwise noncontributory. We recognized immediately that fate had granted us the opportunity for an elegant comparative therapeutic trial. Having visions of a medical breakthrough assuredly worthy of subsequent publication in the Journal, we placed the time-tested mineral oil in one ear canal. The cockroach succumbed after a valiant but futile struggle, but its removal required much dexterity on the part of the house officer. In the opposite ear we sprayed 2 per cent lidocaine solution. The response was immediate; the roach exited the canal at a convulsive rate of speed and attempted to escape across the floor. A fleet-footed intern promptly applied an equally time-tested remedy and killed the creature using the simple crush method.

However humble the method, and despite our small study population, we think we have provided further evidence justifying the use of lidocaine for the treatment of a problem that has bugged mankind throughout recorded history.

K. O'Toole, M.D.
P.M. Paris, M.D.
R.D. Stewart, M.D.
University of Pittsburgh School of Medicine

R. Martinez, M.D.
Louisiana State University

To the Editor: The excitement was unbearable. "There's a girl with a bug in her ear!" the nurse had exclaimed. "Looks like a cockroach to me!" It was all we could do to keep from running to the patient's bedside. "Grab the lidocaine!" we shouted. This was the moment we had been waiting for. We had seen the reports, but did it really work?

As we burst into the room, we could see the young woman writhing from the combined sensations of movement and pain in her ear canal. One of us tok a look, confirming the nurse's diagnosis, while the other filled a 3-cc syringe with 2 percent lidocaine solution. With hurried anticipation we sprayed the drug briskly into the ear canal and quickly jumped back, fully expecting the beast to come hurtling forth at first contact with the noxious substance.

Nothing. "Increase the dosage," we shouted, filling a 10-cc syring. Still nothing. "Get that sucker outa my ear!" the patient screamed. What a brilliant idea! We grabbed a 2-mm metal suction tip and attached it to a wall suction apparatus with a negative pressure of 120 cm of water. Then we gently passed the tip into the ear canal, taking care not to occlude the canal and risk tympanic-membrane barotrauma. Shloop! "Got him!" we exulted. Sure enough, there he was, plastered to the suction tip like a fly to flypaper. After a repeat examination of the canal and a few drops of Cortisporin solution, the patient was on her way.

We recommend suction as a safe and efficacious method for removing insects from the ear canal when other methods fail.

Jonathan Warren, M.D.
Leo C. Rotell, M.D.
State University of New York
Health Science Center

By using the appropriate international Signal flag or combination of international signal flags, different meanings can be communicated depending on the intentions of the wearer. For example, and individual could be wearing a covering garment (e.g. a jacket or Sweatshirt or the like) that prominently displays the international Signal flag "X-Ray', communicating the message "Stop carrying out your intentions and watch for my signals'. When the wearer sees someone with whom he or she would like to communicate with, the covering garment could be removed, revealing another article of apparel (e.g. a Swimsuit) displaying a Second international Signal flag "Kilo', communicating the message "I wish to communicate with you'.