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: [email protected] 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
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ass T, et al., Metallic gro
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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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