International Journal of Pediatric Otorhinolaryngology
Medial migration of tympanostomy tubes: An overlooked complication
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)
Post-surgical follow-up of children with tympanostomy tubes: results of the American Academy of Otolaryngology-Head and Neck Surgery Pediatric Otolaryngology Committee National Survey
Otolaryngol. Head Neck Surg.
(2000)- et al.
Meta-analysis of tympanostomy tube sequelae
Otolaryngol. Head Neck Surg.
(2001) - et al.
Follow-up of 366 ears after tympanostomy tube insertion: why is it draining?
Otolaryngol. Head Neck Surg.
(2003) - et al.
Late results and complications of tympanostomy tube insertion for prophylaxis of recurrent purulent otitis media in pediatric age
Int. J. Pediatr. Otorhinolaryngol.
(1984) Tympanostomy tubes
Otolarygol. Clin. N. Am.
(1999)A new treatment for chronic secretory otitis media
Arch. Otolaryngol.
(1954)- et al.
Complications of tympanostomy tubes
Arch. Otolaryngol.
(1974) - et al.
Myringotomy and tympanostomy tubes: a report of 1.568 ears
Laryngoscope
(1982) Long-term results of armstrong beveled grommet tympanostomy tubes in children
Laryngoscope
(2004)- et al.
Clinical results and complications of tympanostomy
Ann. Otol. Rhinol. Laryngol.
(1976)
Cited by (26)
Management of conductive hearing loss from otitis media in children operative techniques in otolaryngology
2024, Operative Techniques in Otolaryngology - Head and Neck SurgeryImaging of the Postoperative Temporal Bone
2022, Neuroimaging Clinics of North AmericaIn-office myringotomy and tympanostomy tube insertion
2021, Operative Techniques in Otolaryngology - Head and Neck SurgeryCitation Excerpt :Fortunately, such complications are exceedingly rare. Minor complications include tube loss into the middle ear requiring operative intervention, granulation, early extrusion, TM tears or persistent perforation after removal, tympanosclerosis, tube occlusion by blood or cerumen, temporary pain, as well as TTO (both temporary and chronic).6,27-28 Recalcitrant TTO may be a herald of biofilms seeding of the TT or (pre-existent or iatrogenic) cholesteatoma; iatrogenic cholesteatoma formation associated with TT occurs in up to 1.1% of operated ears.29,30
What to do with medialized tympanostomy tubes? A survey of pediatric otolaryngologists
2018, International Journal of Pediatric OtorhinolaryngologyCitation Excerpt :Medialized tympanostomy tube (MTT) is a rare occurrence whereby the tube migrates into the middle ear space as opposed to normal extrusion into the external auditory canal. Previous studies report a 0.5–1.1% rate of medial displacement of tympanostomy tubes [4,5]. Although not fully understood, the underlying mechanisms behind this complication are believed to be eustachian tube dysfunction, technical issue during insertion, and biofilm formation on the medial surface of the tubes [6].
To remove or not to remove: Review of cases of medial migration of tympanostomy tubes
2015, International Journal of Pediatric OtorhinolaryngologyCitation Excerpt :As seen by the present review, medial migration seems to be independent of tube type and occurs at various intervals after placement. One hypothesis is that the tube might migrate medially as a result of persistent negative middle ear pressure, as often the tube is initially seen in the correct position but later found medial to a healed intact tympanic membrane [2]. Some authors assume that an atypically long myringotomy incision would results in the outer rim of the tube lying partially inside the TM when inserted preventing keratin from being collected in its groove; the mechanism of the extrusion of tubes [10].
The clinical status of the eardrum: An inclusion criterion for the treatment of chronic secretory otitis media in children
2011, International Journal of Pediatric Otorhinolaryngology