|Year : 2017 | Volume
| Issue : 2 | Page : 128-130
Migrated guidewire: An unusual cause for recurrent aural polyps
Kong Yew Liew1, Aun Wee Chong2
1 Otorhinolaryngology Unit, Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia
2 Department of Otorhinolaryngology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
|Date of Web Publication||14-Jun-2017|
Kong Yew Liew
Otorhinolaryngology Unit, Department of Surgery, Faculty of Medicine and Heath Sciences, Universiti Putra Malaysia, 43400, UPM Serdang, Selangor
Source of Support: None, Conflict of Interest: None
Aural polyps are secondary to multiple ear pathologies, most commonly inflammatory or cholesteatoma related. Here, we present a rare case of recurrent aural polyps caused by guidewire migration into the middle ear with serious systemic complications and our attempts at removal.
Keywords: Aural polyp, bacteremia, computed tomography, guidewire
|How to cite this article:|
Liew KY, Chong AW. Migrated guidewire: An unusual cause for recurrent aural polyps. Indian J Otol 2017;23:128-30
| Introduction|| |
Aural polyps occur as a result of multitude of underlying ear pathologies, for which the most common are either inflammatory or cholesteatoma related. Here, we present a case of an aural polyp caused by a migrated foreign body with systemic complications, which has not been reported on in the past to the best of our knowledge.
| Case Report|| |
A 63-year-old male presented with a 1-week history of right ear fullness and otorrhea. He has had several episodes of right-sided otorrhea associated with aural polyps over the past 2 years, but each episode had resolved with application of topical medications prescribed by various sources before his presentation to us. Physical examination revealed turbid secretions within the external auditory canal and an underlying aural polyp occluding the entire canal. He was initially treated with a combination of antibiotic/steroid topical drops which resolved the polyp, revealing a dull red tympanic membrane with a white mass visible behind the tympanic membrane at the anterior–inferior quadrant [Figure 1]. He was planned for a computed tomographic (CT) scan for further evaluation.
|Figure 1: Endoscopic view of the patient's tympanic membrane after completion of local therapy, immediately and 2 weeks after|
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While waiting for his CT, he returned with complaints of generalized lethargy associated with high fever and rigors and was admitted for investigation. Blood work showed a raised white cell count with marked leukocytosis and raised erythrocyte sedimentation rate and C-reactive protein. Blood cultures grew methicillin-sensitive Staphylococcus aureus(MSSA). Urine biochemistry and microscopy did not suggest a urinary tract infection; however, the chest X-ray showed a linear foreign body running from the neck downward until below the diaphragm.
We proceeded with the planned CT scan but extended it to include the thorax and abdomen to try to find a cause for the MSSA bacteremia and further investigate the chest X-ray findings. The CT showed a metallic foreign body extending from the middle ear cavity, piercing the jugular bulb and styloid process, and running down the length of the neck into the superior vena cava and inferior vena cava with the coiled tip within the right common iliac vein [Figure 2],[Figure 3],[Figure 4]. Other significant findings on the CT were that of 2 thick-walled cavitating lesions in the right lower lobe of the lung.
|Figure 2: Coronal computed tomographic film showing the guidewire in the middle ear space (arrow)|
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|Figure 3: Axial computed tomographic film showing the guidewire within the right styloid process (arrow)|
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|Figure 4: Coronal computed tomographic film showing the guidewire running down the thorax with the coil visible inferiorly (arrows)|
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On review of the patient's past medical records, there was a previous admission to another state general hospital 12 years ago for intracranial bleeding postmotor vehicle accident, for which the patient had undergone a decompressive craniectomy followed by a titanium cranioplasty as well as a lengthy intensive care unit (ICU) stay. However, we were unable to obtain the details of that admission. Other significant medical history was a previous blood culture of MSSA 6 months before his current presentation. At the time, the source was attributed to otitis media and the patient was given a 2-week course of intravenous (IV) cloxacillin and then discharged.
After a multidisciplinary team meeting, the patient was planned for 6 weeks of IV cloxacillin for complicated S. aureus bacteremia (SAB) likely secondary to a retained central venous catheter guidewire with a planned removal afterward. Transesophageal echocardiography reveals no valvular vegetations.
Removal of the guidewire was attempted by interventional radiology under fluoroscopy, but the foreign body was completely encapsulated within the vessel, and the procedure was abandoned. The patient was subsequently discharged with lifelong oral cephalexin for prophylaxis.
| Discussion|| |
Retained guidewires are a recognized complication of the insertion of central venous catheters. There are several reports in the literature detailing the discovery and removal of such foreign bodies but none to our knowledge of any which have been discovered secondary to an aural polyp. Our hypothesis is that the guidewire was left in situ during central venous catheterization during his previous ICU stay 12 years ago and over time has migrated superiorly (likely due to the action of bending over and sitting down), piercing exactly through the styloid process and through into the middle ear cavity.
Retained guidewires are a serious complication and can be fatal in up to 20% of cases. The majority of retained foreign bodies following intravascular procedures are fragments from the catheters with Egglin et al. reporting only 2 of 32 being lost guidewires. However, Williams et al. showed that from a series of reported incidents, 74% involved the entire length of the guidewire. About one-third are discovered and removed on the same day, roughly one-third are discovered and removed within the same hospitalization period and the remainder months to years later. The causes of guidewire retention are attributed to inattention during the procedure, distractions, inexperience, defective equipment, and fatigue., Retained guidewires can be removed either intravascularly with a basket or snare or as an open surgical procedure.,, Unfortunately, in our case, removal of the guidewire failed, likely due to the fact that it had been retained for 13 years and as such was well encapsulated with the vessel wall.
Aural polyps are fleshy masses found within the external auditory canal which originate either from the external auditory canal itself or from the middle ear through a perforation in the tympanic membrane. Almost all patients with aural polyps present with otorrhea. The most common etiology for aural polyps is inflammation secondary to external or middle ear infections, with about 40% of aural polyps found to be inflammatory polyps on histopathological examination. Underlying cholesteatoma is a well-recognized cause of aural polyps and is the cause in around 24% of cases., Other causes found include nonspecific inflammation, granulomatous conditions, and malignancy among others., In cases of infection/inflammation, the majority of cultures were either Pseudomonas sp., coliforms, or Staphylococcus sp. In our patient, the polyp resolved with topical therapy, but his prior recurrent otorrhea was likely due to otitis media secondary to the foreign body within the middle ear cavity, with or without polyp formation. The exposure of the foreign body to the external environment through the middle ear cavity likely provided the entry route for the S. aureus into the bloodstream.
In our patient, the SAB was complicated by lung abscesses but not endocarditis. Risk of metastatic foci in SAB is quoted between 14% and 31% with lung involvement at 15% and heart valves at 8%. Clinical features for SAB can be nonspecific with low-grade fever and myalgia which can then progress to septic shock. In about one-third of cases, no apparent source can be found. Other commonly affected sites of secondary infection in SAB in descending order are the joints, kidneys, central nervous system, intervertebral discs, liver/spleen, and bone. Treatment should be culture directed and for at least 4 weeks if complicated by metastatic spread.
| Conclusion|| |
Foreign body reaction within the middle ear is a possible cause for recurrent aural polyps, however to find it secondary to a migrated guidewire is rare. Removal should be attempted as retention of the foreign body will lead to multiple long-term systemic complications such as SAB.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]