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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 22  |  Issue : 2  |  Page : 129-131

Missed impacted tympanic membrane foreign body causing granulomatous myringitis


Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Web Publication11-May-2016

Correspondence Address:
Ahmed Hassan Sweed
Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Zagazig University, Zagazig
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.182273

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  Abstract 

The aim is to report an unusual site of aural foreign body (FB) and rare cause of granulomatous myringitis. We present the case of a 37-year-old male who presented with progressive radiation therapy otalgia, otorrhea, and aural fullness after unskillful aural FB removal, and diagnostic microscopic examination of the ear shows missed impacted transcendental meditation FB leading to granulomatous myringitis.

Keywords: Foreign body, Granulomatous myringitis, Tympanic membrane


How to cite this article:
Sweed AH, Saber IM, Abdelbary EM. Missed impacted tympanic membrane foreign body causing granulomatous myringitis. Indian J Otol 2016;22:129-31

How to cite this URL:
Sweed AH, Saber IM, Abdelbary EM. Missed impacted tympanic membrane foreign body causing granulomatous myringitis. Indian J Otol [serial online] 2016 [cited 2019 Nov 18];22:129-31. Available from: http://www.indianjotol.org/text.asp?2016/22/2/129/182273


  Introduction Top


Foreign body (FB) in the ear is relatively common in emergency medicine.[1] FBs in the external auditory meatus are most commonly seen in children who have inserted them into their own ears, whereas in adults cotton wool or broken matchsticks are most commonly seen as they have used them to clean or scratch the ear canal.[2]

FB in ear can be classified in many ways such as organic-inorganic, animate-inanimate, metallic-nonmetallic, hygroscopic-nonhygroscopic, regular or irregular, soft or hard, and so forth, according to their nature.[2]

The etiology of FB in the ear has been ascribed to general curiosity and whim to explore orifices in children, playful insertion of FB into others' body parts, accidental entry of FB, preexisting disease in ear causing irritation, and habitual cleaning of ear and nose with objects such as ear buds.[3]

The first attempt at removal is critical because success rates markedly decrease after the first failed attempt. Accordingly, complications increase as the number of failed removal attempts increases.[4]

It is essential to reexamine the ear canal and the tympanic membrane after removal of the FB, to assess any damage to the delicate skin of the ear canal and to document the state of the tympanic membrane.[5]

Granular myringitis (GM) is a special form of otitis externa, characterized by the development of granulation tissue over focal or diffuse areas of the tympanic membrane and adjacent external canal wall. GM was first described by Toynbee in 1860.[6]

It can be misdiagnosed as chronic suppurative otitis media complicated with granulations since intermittent purulent discharge is the most common symptom in both disorders. The wrong diagnosis may result in performance of middle ear surgery to treat the disorder.[7]

Pathogenesis of GM is presumed to be related to any trauma to the transcendental meditation (TM) that reaches the lamina propria and fails reepithelization.[8]

Symptoms are often mild, expressed by plugged ear and itching or aural discharge. It is commonly accepted that the middle ear is not involved in the disease. However, perforated ear drum was described in a few cases.[9]

The most accepted protocol of treatment includes recurrent meticulous cleaning of discharge, application of antibacterial or antiseptic solutions, and the use of topical caustic solutions. Mechanical removal of polypoid granulations has also been suggested.[7]


  Case Report Top


A 37-year-old man presented with a 2 months history of progressive RT otalgia, otorrhea, and aural fullness after unskillful removal of matchstick from his RT ear, 2 months ago in a Otorhinolaryngology private clinic. Several occasions during these 2 months, which he could not accurately recall. Only conservative treatment with topical antibiotic was given, and this was not effective.

On otoscopic examination, the patient showed RT GM with focal granulation tissue over the posterior compartment of TM.

On otoendoscopic examination, the same findings were existed with a white shadow within the granulations within the TM fibrous layer.

On microscopic examination (video), the same findings were confirmed [Figure 1], and removal of TM impacted FB was done under local anesthesia, first by disimpaction of this FB from the TM via Rosen Curette [Figure 2] then extraction via microscopic crocodile forceps leaving a small perforation surrounded by area of granular myringitis [Figure 3]. FB is proved to be broken matchstick [Figure 4].
Figure 1: Preoperative view of transcendental meditation where there is granulation tissue in the posterior part covering the impacted foreign body

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Figure 2: Disimpaction of the foreign body via round knife

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Figure 3: Transcendental meditation after removal of the foreign body with small tiny perforation

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Figure 4: Extracorporeal view of the missed broken matchstick (foreign body)

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This patient received systemic and local antibiotic with keeping his ear dry for 1 week when the tympanic membrane healed completely without intervention.


  Discussion Top


FB in the ear is relatively common in emergency medicine.[1] Attempts of aural FB removal made by untrained persons can result in complications of varying degrees.[2]

An aural FB can involve damage to tympanic membrane or middle ear by itself or by improper management during removal. The method of removal usually depends on the type of FB, its position, and co-operation of the patient.[2]

It is essential to reexamine the ear canal and the tympanic membrane after removal of the FB, to assess any damage to the delicate skin of the ear canal and to document the state of the tympanic membrane.[5]

Endoscopes have a great value in diagnostic otology due to their direct, natural, quick, and easy access to ear. However, because of their monocular vision, microscopic vision is superior in depth perception and important in the diagnosis of ear pathology.


  Conclusion Top


To the best of our knowledge, this is the first report of a purely impacted TM FB with secondary granular myringitis, and this TM FB was removed successfully under local anesthesia leaving a small perforation which healed with conservative therapy.

This case necessitates and emphasizes on the well-established otologic concept regarding use the facility of otoendoscopy and powered surgical microscope in ear examination in complicated, undiagnosed ear pathology also the importance of secondary look after aural FB removal to determine either complication of FB, e.g., TM perforation or another missed aural FB either TM FB or even middle ear FB.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Al-Juboori AN. Aural foreign bodies: Descriptive study of 224 patients in Al-fallujah general hospital, Iraq. Int J Otolaryngol 2013;2013:401289.  Back to cited text no. 1
    
2.
Kroukamp GR, Loock JW. Foreign bodies in the ear. In: Gleeson M, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS, et al., editors. Scott-Brown's Otorhinolaryngology: Head and Neck Surgery. 7th ed., Vol. 3. New York, USA: Hodder Arnold; 2008. p. 3370-2.  Back to cited text no. 2
    
3.
Das SK. Aetiological evaluation of foreign bodies in the ear and nose. J Laryngol Otol 1984;98:989-91.  Back to cited text no. 3
[PUBMED]    
4.
Heim SW, Maughan KL. Foreign bodies in the ear, nose, and throat. Am Fam Physician 2007;76:1185-9.  Back to cited text no. 4
    
5.
Kumar S. Management of foreign bodies in the ear, nose and throat. Emerg Med Australas 2004;16:17-20.  Back to cited text no. 5
    
6.
Toynbee L. The Diseases of the Ear: Their Nature, Diagnosis and Treatment. Philadelphia: Blanchard and Lea; 1860. p. 170-2.  Back to cited text no. 6
    
7.
Stoney P, Kwok P, Hawke M. Granular myringitis: A review. J Otolaryngol 1992;21:129-35.  Back to cited text no. 7
    
8.
Makino K, Amatsu M, Kinishi M, Mohri M. The clinical features and pathogenesis of myringitis granulosa. Arch Otorhinolaryngol 1988;245:224-9.  Back to cited text no. 8
    
9.
Khalifa MC, El Fouly S, Bassiouny A, Kamel M. Granular myringitis. J Laryngol Otol 1982;96:1099-101.  Back to cited text no. 9
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References
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