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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 28  |  Issue : 3  |  Page : 255-257

Impacted eustachian tube foreign body mimicking chronic otitis media: An extremely uncommon presentation


Department of Otorhinolaryngology, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India

Date of Submission15-May-2022
Date of Acceptance10-Aug-2022
Date of Web Publication21-Nov-2022

Correspondence Address:
Dr. Pradeepti Nayak
J-234, Sector 25, Greater Noida - 201 301, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.indianjotol_80_22

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  Abstract 


Foreign bodies in the ear are a common occurrence in medical practice. This is true for both adults and children. It is one of the most common causes of trauma to the external auditory canal, tympanic membrane, and middle ear. However, an impacted foreign body in the eustachian tube (ET) has been reported very rarely. Due to the anatomical orientation of the ET, entry of a foreign body in it is very improbable. After an extensive research, we found only 14 reported cases of foreign body in the ET. A high degree of suspicion, incisive clinical evaluation, appropriate radiological evaluation, and diligent preoperative planning are imperative to extract an artifact from the ET. Herein, we present a case of a forgotten, impacted foreign body in the ET of a 52-year-old woman presenting with recurrent, intermittent foul-smelling discharge, and decreased hearing on the left ear for 2 years. To our knowledge, our case is the first, presenting with a foreign body in the ET after an inadvertent self-inflicted trauma.

Keywords: Endoscopy, eustachian tube, foreign body, otitis media, trauma


How to cite this article:
Chaudhary R, Khanna V, Nayak P, Pathak VK. Impacted eustachian tube foreign body mimicking chronic otitis media: An extremely uncommon presentation. Indian J Otol 2022;28:255-7

How to cite this URL:
Chaudhary R, Khanna V, Nayak P, Pathak VK. Impacted eustachian tube foreign body mimicking chronic otitis media: An extremely uncommon presentation. Indian J Otol [serial online] 2022 [cited 2022 Nov 27];28:255-7. Available from: https://www.indianjotol.org/text.asp?2022/28/3/255/361646




  Introduction Top


Foreign bodies in the ear are a common occurrence in both adults and children. It is one of the most common causes of trauma to the external auditory canal (EAC), tympanic membrane, and middle ear. However, an impacted foreign body in the  Eustachian tube More Details (ET) has been reported very rarely. It was more common earlier when ET dilatation was a common practice.[1],[2],[3] Even after the practice was discontinued at beginning of the 20th century, broken dilator tips in the ET were occasionally discovered by physicians years later. Accidental insertion of a foreign body, however, is very rare due to the anatomical orientation of the ET with respect to the EAC. To our knowledge, this is the first case presenting with a foreign body in the ET after an inadvertent self-inflicted trauma.


  Case Report Top


A 52-year-old woman presented to the outpatient department with a history of left-sided ear discharge for 2 years. She gave a preceding history of self-inflicted trauma to the ear with a “matchstick” following which the discharge started. She did not visit a doctor immediately following the trauma.

The discharge was intermittent, purulent, foul-smelling, occasionally blood-stained, and associated with a progressive hearing loss in the same ear. She also complained of intermittent pain in the left ear. There were no other associated aural or nasal complaints. The patient had no significant comorbidities like diabetes mellitus or immunocompromised status.

On examination of the left ear, there was purulent discharge in the EAC which was mopped and sent for culture sensitivity. The tympanic membrane was intact with Grade IV retraction (adhesive) and profuse granulations, leading to a differential diagnosis of granular myringitis or squamosal chronic otitis media (COM). The right ear was normal. Pure-tone audiometry showed a moderate conductive hearing loss of 33 dB. She was instituted local antibiotic and steroid ear drops with a course of oral antibiotics for a week which settled the acute inflammation and cleared the granulations. The patient, being of a lower socioeconomic class, was then lost to follow-up. However, the patient presented again within a month with similar complaints. High-resolution computed tomography temporal bone was done immediately and showed a distinct linear, opacity in the left ET with soft-tissue attenuation in the middle ear suggestive of COM [Figure 1].
Figure 1: High-resolution CT image showing linear opacity in the eustachian tube. CT: Computed tomography

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The patient was taken up for tympanomastoid exploration. Postaural Wilde's incision was given, and an inferior-based tympanomeatal flap was elevated keeping the tympanic membrane intact. Profuse granulations were seen in the middle ear, which were carefully excised revealing a sharply projecting object at the ET opening. Canaloplasty was done to improve visualization. A 4-mm 0° endoscope was introduced to assess the field with a better clarity and magnification [Figure 2]. Under endoscopic vision, the foreign body was carefully delineated by removal of the surrounding granulation. It was then extracted using a fine, curved micropick and crocodile forceps with a minor trauma and bleeding, revealing a 1.6-cm sliver of wood, the forgotten foreign body inserted by the patient 2 years previously [Figure 3]. Apart from the granulations, the middle ear was completely normal with an intact ossicular chain. Type 1 tympanoplasty was then done, and the postaural incision was sutured in layers. Postoperative period was completely uneventful.
Figure 2: Endoscopic view of the foreign body embedded in granulations

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Figure 3: Extracted foreign body: Matchstick

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Her symptoms were completely resolved with an almost complete air-bone gap closure (5 dB) and an intact tympanic membrane at the 6-month follow-up.


  Discussion Top


ET is an osseocartilaginous tube, linking the nasopharynx and protympanum. It assists in ventilation of the middle ear cleft and equalization of pressure. ET dysfunction is a major cause of middle ear disease. Majority of the causes of the inadequacy of ET function are easy to assess. However, the mechanical obstruction of ET is extremely rare and requires a high degree of suspicion, and is often confirmed only on radiological evaluation.[4] Weber and Rosner reported a case of a 12-year-old boy with a pressure-equalizing tube obstructing the ET, causing an atelectatic eardrum and conductive hearing loss after a myringotomy at 2 years.[5] Foreign bodies may also cause a granulomatous reaction presenting with foul-smelling, recurrent or persistent ear discharge mimicking or causing secondary COM. Shui Hong reported a case of an ET foreign body-induced middle ear cholesteatoma and EAC granuloma formation.[6]

The most common reported cause of ET foreign body is iatrogenic. Middle ear prostheses such as stapes piston and ventilation tube[5] may migrate to the ET if dislocated. Rato et al.[4] reported a case of a migrated stapes piston in the ET of a 63-year-old female presenting with COM 30 years after the surgery. Auriculotherapy is another source of ET foreign body as seen in the cases reported by Igarashi et al. and Morita et al.[7],[8] Jung reported a case with the insertion of molding material into the ET during a hearing-aid fitting.[9] Other accounts of ET foreign body include metal shards from welding[10],[11],[12] and assault.[13]

The position of EAC with respect to ET is defined by two parameters: the angle between Reid's plane and ET and the tubotympanic angle [Figure 4]. Reid's plane is defined as the horizontal plane at the level of bilateral inferior orbital walls and superior walls of the EAC. It was observed that the angle between Reid's plane and ET in normal individuals is between 27° and 28°.[14] As it is evident, the anatomical situation, orientation, and curvature of the ET make the insertion or entry of a foreign object or artifact in it very improbable. The same anatomical arrangement, however, makes the extraction of an ET foreign body equally challenging. Consequently, the microscopic approach has been reported to be inadequate for exposure. The endoscopic approach has been found to be more suitable as it provides a better field of vision.[10],[15] It also allows for a more accurate instrumentation, avoiding trauma to the surrounding structures. Conversely, a 4-mm endoscope may reduce the space available for manipulation. 2.7-mm endoscopes may be used for a wider field along with room for maneuvering. In case these do not suffice, flexible instruments like sialendoscopy may be utilized. However, due to the rarity of such cases, there is no literature to assess the efficacy of the same.[15]
Figure 4: Angle between the Reid's plane and the axis of the eustachian tube and the tubotympanic angle. ET: Eustachian tube

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Medially displaced or impacted foreign bodies in the ET may be very difficult to remove. Parelkar et al. reported a case where they were unable to remove the ET foreign body due to an extreme medial displacement, even after a canal-wall-down mastoidectomy. Consequently, they fashioned a cartilage graft with an inserted Goode's tube to provide ventilation to the middle ear.[15] Morita et al. reported a similar case where they were unable to extract an acupressure metallic bead from the ET.[8] Long-standing, corrosive, or sharp foreign bodies may also cause trauma to the ET or severe complications like erosion of the carotid canal.[5],[13]

Despite the anatomical impediment, it is possible in some circumstances for foreign bodies to get lodged in the ET. A high degree of suspicion, an accurate history, incisive clinical examination, and appropriate radiological evaluation are imperative to cinch the diagnosis. Once confirmed, a detailed plan should be formulated preoperatively to access and extract the foreign body. Any accompanying complication due to foreign body reaction should be evaluated and anticipated, and a plan of management for the same should also be devised before the surgery. Intraoperatively, if the foreign body remains inaccessible, an alternative should be planned to preserve the middle ear function.[15]

Declaration of the patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hastings H. XXIV A piece of gold bougie (twenty years in situ) removed from the distal half of the eustachian tube during a radical mastoid operation. Ann Otol Rhinol Laryngol 1937;46:248-51.  Back to cited text no. 1
    
2.
Mangiaracina A. Foreign bodies in the eustachian tube. Arch Otolaryngol 1940;32:517-9.  Back to cited text no. 2
    
3.
Compere WE Jr. Eustachian tube foreign body; report of a case. Laryngoscope 1959;69:90-3.  Back to cited text no. 3
    
4.
Rato C, Lopes G, Duarte D, Oliveira N. Foreign body in the eustachian tube: A challenging diagnosis and management. Turk Arch Otorhinolaryngol 2021;59:80-3.  Back to cited text no. 4
    
5.
Weber PC, Rosner D. An unusual cause of eustachian tube dysfunction. Otolaryngol Head Neck Surg 1997;117:S142-4.  Back to cited text no. 5
    
6.
Shui-Hong Z, Qin-Ying W, Shen-Qing W. Middle ear foreign body causing cholesteatoma and external auditory canal granuloma: A case report. J Otol 2012;7:25-7.  Back to cited text no. 6
    
7.
Igarashi K, Matsumoto Y, Kakigi A. Acupressure bead in the eustachian tube. J Acupunct Meridian Stud 2015;8:200-2.  Back to cited text no. 7
    
8.
Morita A, Shimada H, Yagi A, Nagamine K, Nagai C, Ryu K, et al. Adverse event associated with auriculotherapy. Tradit Kampo Med 2017;4:55-7.  Back to cited text no. 8
    
9.
Jung JH, Paik JY, Kim ST, Cha HE. Middle ear foreign body induced by ear molding procedure: A case-report and a literature review. Int Adv Otol 2014;10:97-9.  Back to cited text no. 9
    
10.
Purnell PR, Bender-Heine A, Zalzal H, Tarabishy AR, Cassis A. Eustachian Tube Foreign Body with Endoscopic-Assisted Surgical RRemoval. Case Reports in Otolaryngology 2019. p. 1-4.  Back to cited text no. 10
    
11.
Savranlar A, Alkan A, Yiğitbaşı OG, Atabey F. Case report: Metalic foreign body in eustachian tube. Ann Med Res 2002;9:223-4.  Back to cited text no. 11
    
12.
Robertson MW, Morris DP. Welding injury to the ear: Looking beyond the perforation. J Otolaryngol Head Neck Surg 2011;40:E15-8.  Back to cited text no. 12
    
13.
Ribeiro Fde A. Foreign body in the eustachian tube: Case presentation and technique used for removal. Braz J Otorhinolaryngol 2008;74:137-42.  Back to cited text no. 13
    
14.
Nemade SV, Shinde KJ, Rangankar VP, Bhole P. Evaluation and significance of eustachian tube angles and pretympanic diameter in HRCT temporal bone of patients with chronic otitis media. World J Otorhinolaryngol Head Neck Surg 2018;4:240-5.  Back to cited text no. 14
    
15.
Parelkar K, Shere D, Wallic A, Dave V, Rao K. Impacted incus foreign body in the eustachian tube. Iran J Otorhinolaryngol 2019;31:123-6.  Back to cited text no. 15
    


    Figures

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



 

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