Migration of T-tubes to the middle ear.
In the Otoscopic Clinic in the January 2008 issue of EAR, NOSE & THROAT JOURNAL, the authors reported otoscopic findings of a migrated tube into the middle ear space. (1) This article, by Abbarah and Abbarah, cites one reference and reports two additional cases. In the April 2008 EAR, NOSE & THROAT JOURNAL, Dr. Hamid comments on that article and reports an additional case of his own. (2)
Interestingly, we reported 4 cases of this problem back in 2002. (3) Our reference was obviously missed in searching the literature. Our impression of this problem was that the tube should be removed, and this was done in all 4 of our cases. Our concern about the persistence of a foreign body in the middle ear cleft stems from its potential to cause a reaction, including chronic otitis media with granulation tissue. This can easily be avoided with a small myringotomy and removal of the tube with an alligator forceps. The tympanic membrane usually will heal without further intervention.
(1.) Abbarah T, Abbarah MA. Migration of T-tubes to the middle ear. Ear Nose Throat J 2008;87(1):10-11.
(2.) Hamid M. Migration of T-tubes to the middle ear. Ear Nose Throat J 2008;87(4):186.
(3.) Roy S, Josephson GD, Lambert P. Retained tympanostomy tubes in the middle ear cleft: An uncommon complication of tube placement. In: Lim DJ, Bluestone CD, Casselbrant ML, et al, eds. Recent Advances in Otitis Media with Effusion. Proceedings of the Seventh International Symposium. Hamilton, Ont.: BC Decker; 2002:661-3.
Gary D. Josephson, MD, FACS, FAAP
Chief, Division of Pediatric Otolaryngology
Nemours Children's Clinic Jacksonville
Mayo Clinic School of Medicine
I would like to thank Dr. Josephson for his stimulating comments on our article regarding the migration of T-tubes to the middle ear and for providing a copy of his article, "Retained tympanostomy tubes in the middle ear cleft: An uncommon complication of tube placement." My reply is that we reported only on T-shaped ventilation tubes (modified Richards T-tube), and the reference we mentioned in our article also reported on T-shaped ventilation tubes (Goode T-tube). These tubes have large flanges, a long shaft, and are designed for long-term ventilation.
Dr. Josephson's article dealt with the migration of tympanostomy tubes in general. There are at least 50 kinds of tyrnpanostomy tubes. Migration of these tubes to the middle ear cleft is rare, but it was reported in the literature almost 30 years ago. (1)
I am in agreement with the removal of the tubes in the 4 cases reported in Dr. Josephson's article, since each case was associated with signs and symptoms requiring removal of the tube, but removal of a silent migrated tube without signs or symptoms is a matter of opinion, since there are no hard data to outline the management of this rare entity. However, there are some authors sharing Dr. Josephson's view in this regard. (2)
(1.) McLelland CA. Incidence of complications from use of tympanostomy tubes. Arch Otolaryngol 1980;106(2)97-9.
(2.) Groblewski JC, Harley EH. Medical migration of tympanostomy tubes: An overlooked complication, Int J Pediatr Otorhinolaryngol 2006;70(10):1707-14.
Thabet R. Abbarah, MD
Section of Otolaryngology
North Oakland Medical Center