Medial migration of tympanostomy tubes: An overlooked complication

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Summary

Background

Frequently encountered complications associated with tympanostomy tube placement have been well documented and are globally recognized. The medial migration of tympanostomy tubes into the middle ear space is a rare complication for which pathogenesis, natural history, and management have not been clearly delineated.

Objective

To describe our experience with the medial migration of tympanostomy tubes into the middle ear space. To propose a simple classification system and define management recommendations.

Methods

A retrospective chart review of all patients with medial tube migration seen in a Pediatric Otolaryngology practice at a tertiary care university hospital between 1995 and 2005.

Results

Six pediatric patients (ages 3–19) were found to have seven tympanostomy tubes within the middle ear space at various intervals following tube placement. One patient had a migrated tympanostomy tube deep to a large myringotomy incision. Five patients (six ears) had migrated tubes medial to intact, healed tympanic membranes. Fifty percent of the patients had symptoms attributable to the migrated tube. All six patients underwent middle ear exploration with successful removal of the migrated tube.

Conclusions

This process can be defined as primary, when the tympanostomy tube migrates due to a technical error, or secondary, when the tube is initially seen in the correct position but is later found medial to a healed, intact tympanic membrane. Medial migration is apparently independent of tube type and can occur at various intervals after placement. The process of secondary migration is most likely multifactorial but may in part be the result of persistent negative middle ear pressure. Migrated tubes should be removed surgically unless contraindicated.

Introduction

Since Armstrong reintroduced tympanostomy tube insertion for the treatment of chronic secretory otitis media [1], it has consistently been one of the most common procedures performed in children under general anesthesia. Although considered a routine procedure, tympanostomy tube placement has a significant morbidity. In fact, complications associated with this procedure are common, occurring in 17% of patients [2]. The most common complications, including otorrhea, tympanosclerosis, and permanent perforation, have garnered the greatest amount of attention in the literature. Cholesteatoma, a less frequently encountered but more serious complication, has also been widely discussed.

An additional complication with potentially serious ramifications is the medial migration of a tympanostomy tube into the middle ear space. This has been reported to occur at a rate of 0–1.1% [2], [3], [4], [5], [6], [7], [8], [9], but represents the fifth most common indication for tympanostomy tube removal [10]. In contrast to cholesteatoma, this complication has only been specifically addressed in the literature in two case series [11], [12]. Thorough descriptions of this phenomenon are therefore limited, and optimal management is not universally defined. Our goal is to utilize six individual cases of medial tube migration to illuminate the salient clinical features of, and better define, this clinical entity. A simple classification system is presented, possible etiologies are theorized, and treatment recommendations are discussed.

Section snippets

Methods

A retrospective review was conducted of all tympanostomy tube removal cases performed at our institution over a 10-year period (November 1995–2005). Patients were identified for this study when operative records indicated that a tube was removed from the middle ear space. Hospital records, patient charts, and, when applicable, records from outside institutions, were reviewed.

Various data were obtained for each patient, including: date of birth, age at tube insertion, type of tube inserted,

Results

During a 10-year period, six patients with medial tube migration in seven ears were encountered. Two of these patients (Cases 1 and 6) had tympanostomy tubes placed at our institution. The remainder of the patients had their tubes inserted at various outside institutions, all within the United States. The patients ranged in age from 3 to 19 years and included five males and one female. The patients with complete information available (5/6) were noted to have a medially migrated tube at

Case reports

Pertinent findings from the following patients are summarized in Table 1.

Discussion

Given the frequency of tympanostomy tube placement in General and Pediatric Otolaryngology practice, it is not difficult to understand why there is such a breadth of literature dedicated to the specific procedure, its indications, techniques, and equipment. While common but minor complications have been readily studied, there has been very little attention paid to the medial migration of tympanostomy tubes. Interestingly, this uncommon but real complication is often considered to be quite

Conclusions

While the medial migration of a tympanostomy tube is a rare phenomenon, it should be recognized by all Otolaryngologists as a potentially serious complication of tympanostomy tube placement. The rarity of this clinical entity precludes the acquisition of large amounts of data, and therefore we must rely on case series such as this for information. Nevertheless, when tubes have not been directly visualized during the extrusion process, the possibility of this complication should be considered if

References (21)

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