Metallic grommet in the Eustachian tube

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Case Report

Metallic grommet in the Eustachian tube

T. Ramadass a,b,*, Rochita Venkatraman c,e, Raees Abdurahiman d,f

a Prof., Apollo Hospitals, 21, Greams Lane, Off Greams Road, Chennai 600006, Tamilnadu, Indiab Senior Consultant Otorhinolaryngology and Head and Neck Surgery, Apollo Hospitals, Chennai, Indiac Consultant Radiologist, Apollo Heart Centre, Chennai, Indiad DNB Trainee in ENT, Apollo Hospitals, India

a r t i c l e i n f o

Article history:

Received 21 November 2014

Accepted 3 February 2015

Available online xxx

Keywords:

Grommet

Eustachian tube

Foreign bodies

* Corresponding author. 29 Pycrofts GardenTamilnadu, India.

E-mail address: ramadassthota@yahoo.coe No. 34, Srinivasa Moorthy Avenue, Adyaf Ramseena Manzil, Near Co-op Bank, Ma

Please cite this article in press as: Ramaddx.doi.org/10.1016/j.apme.2015.02.004

http://dx.doi.org/10.1016/j.apme.2015.02.0040976-0016/Copyright © 2015, Indraprastha M

a b s t r a c t

Objective: 1. To highlight the rare presentation of a metallic grommet in the Eustachian

tube.

2. To highlight how the metallic grommet entered the Eustachian tube.

3. To suggest how the foreign body can be removed from the Eustachian tube if

symptomatic.

Case report: A 49 year old lady presented with symptoms of tinnitus and intolerance to loud

sounds in right ear after tympanoplasty. HRCT showed a metallic grommet in the left

Eustachian tube. We conjectured that the metallic grommet accidentally slipped into

middle ear and could not be retrieved by the treating surgeon. The foreign body migrated to

the Eustachian tube.

Conclusion: Metallic foreign body in the Eustachian tube is a rare presentation and it posed a

diagnostic dilemma how it entered the Eustachian tube. We discussed the possibilities and

the method to retrieve when the symptoms appear. A simple or a complicated surgical

procedure (Skull Base) may be undertaken if symptomatic.

Copyright © 2015, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

Metallic foreign body in the Eustachian tube accidentally

detected in an X-ray is a rare presentation. An extensive

search in English language literature revealed no incidence

of such foreign body of metallic grommet lodged in the bony

Eustachian tube. But cases of metallic objects in the Eusta-

chian tube are described in psychiatric patients. The foreign

Road, 2nd Floor, Door N

m (T. Ramadass).r, Chennai 20, India.nna, Taliparamba, Kannu

ass T, et al., Metallic gro

edical Corporation Ltd. A

bodies reported in such cases happened to be a sewing

needle which the patient pushed into the Eustachian tube1

and another case where the patient is an alcoholic psy-

chopathic patient had a barbeque wooden stick in Eusta-

chian tube.2 The metallic foreign body detected in this

patient's HRCT to rule out semicircular canal dehiscence,

reported as a metallic grommet by the radiologist, which is

extremely rare.

o. 2, Ambrosia Apartments, Nungambakkam, Chennai 600006,

r 670141, India.

mmet in the Eustachian tube, Apollo Medicine (2015), http://

ll rights reserved.

a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1e32

2. Case presentation

A 49 year old lady reported to my clinic for complaints of right

sided whistling tinnitus, intolerance to loud sounds and occa-

sional right sided headache. She has undergone right sided

tympanoplasty in the year 2010 elsewhere. She underwent

treatment forSleepDeprivationSyndromein1999atourhospital

and got cured. On examination, nose and throat were normal.

The right side ear showed intact graft with some sclerotic

changes. The Left ear showed thinned out tympanicmembrane

in the centre with myringosclerosis at the periphery and no

perforationcouldbemadeout.Shehasnoautophoniaandfistula

test was negative on either side. Audiogram showed in the right

ear slopingmixedhearing lossand in the left earmildconductive

hearing loss. Impedance tympanometry showed in the right ear

‘C’ type curve and in the left ear ‘B’ type curve. Otoendoscopy

confirmed our otoscopic findings and flexible fibreoptic nasal

endoscopy revealed normal eustachian tube openings and they

are not contributory. Taking into consideration intolerance to

loud sounds, a HRCT temporal bone was advised to rule out

dehiscence of the semicircular canals. To our surprise the radi-

ologist reported a metallic foreign body suggestive of a metal

grommet in the left bony Eustachian tube (Fig. 1).

3. Discussion

Asymptomatic grommet in the bony Eustachian tube is

extremely rare. Extensive search in English language litera-

ture failed to find one and perhaps this case report may be the

only one incidence worthwhile for documentation. The pa-

tient came for relief of tinnitus and intolerance to extraneous

sounds and defective hearing after having undergone tym-

panoplasty on the right ear. We suspected semicircular canal

dehiscence, though she had no classical signs and symptoms

of canal dehiscence, we advised the patient HRCT Temporal

bones. The radiologist reported metal object in the bony

Fig. 1 e A metallic foreign body is seen in the left eustachian tub

been scanned (B) to show the similarity in shape. (C) Panel C is a

tube.

Please cite this article in press as: Ramadass T, et al., Metallic grodx.doi.org/10.1016/j.apme.2015.02.004

Eustachian tube simulating metallic grommet in the left ear.

On questioning, the patient totally denied any surgery in the

left ear in the recent past or during childhood. So we conjec-

tured that during infancy or childhood she might have had

grommet insertion for secretory otitismedia and the grommet

might have slipped into the middle ear. The treating surgeon

could not retrieve the same and left it alone. Over years the

grommet might have so journed into the Eustachian tube and

lodged in the bony canal without any symptoms.

The radio-opaque grommets made of steel, gold and tita-

nium are rarely used now and radiolucent biocompatible

grommets made of teflon and silicon are extensively used in

the present day practice. In this case the retrieval of grommet

canbeattempted throughmiddleear routeafter tympanotomy

using a suitable instrument under C-arm guidance. In case of

failure, skull base approach to bony Eustachian tube is the only

feasible major invasive surgery with morbidity. Since the pa-

tient refused surgery and was asymptomatic, we deferred any

surgical intervention and advised periodic checkup.

4. Conclusion

Theradio-opaquegrommetsmadeofsteel, titaniumandgoldare

rarely used and biocompatible grommets made of teflon and

siliconareextensivelyused inchildrenandadults, inpresentday

practice. Asymptomatic metallic grommet in the Eustachian

tube is extremely rare. The patient consulted me for relief of

tinnitus and intolerance to loud sounds anddefective hearing in

the right ear after tympanoplasty. We suspected superior semi-

circular canal dehiscence though she had no classical signs. We

tookHRCTof the temporal bones. The radiologist reported amet

allic grommet in the bony Eustachian tube (Fig. 1).We supplied a

steel grommet for comparative study and after scrutiny the rad

iologist confirmed the shadow in the scan, a metallic grommet.

The migration of the grommet is discussed and also the

surgical management. The foreign bodies in the Eustachian

e within the bony canal (A). For comparison a grommet has

zoomed view of the foreign body in the left bony eustachian

mmet in the Eustachian tube, Apollo Medicine (2015), http://

a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1e3 3

tube described in the literature are grass, sewing needle and

barbeque sticks which are self induced by the psychiatric

patients.1,2 Our patient though suffered from depression

about 15 years ago, got treated in our hospital and cured. She

does not remember to have undergone left ear surgery. We

discussed in the text that the treating surgeon inadvertently

left the grommet during infancy and did not retrieve it. A

search in English language literature failed to find one and this

may be the only one case report worth documentation.

Conflicts of interest

All authors have none to declare.

Please cite this article in press as: Ramadass T, et al., Metallic grodx.doi.org/10.1016/j.apme.2015.02.004

Acknowledgment

We thank Apollo Hospital administration for using the hos-

pital records and the clerical assistants for this publication.

r e f e r e n c e s

1. Compere Jr WE. Eustachian tube foreign body: report of a case.Laryngoscope. 1959;69:90e93.

2. Ribeiro Fernando de Andrade Quintanilha. Foreign body in theEustachian tube: case presentation and technique used forremoval. Braz J Otorhinolaryngol. 2008;74:137e142.

mmet in the Eustachian tube, Apollo Medicine (2015), http://

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